Community Health Nursing

VII. Conceptual Approaches to Care


            The term ‘nursing model’ was probably introduced to you in your basic education, and used for assignment work. Nursing models are supposed to be used in practice but in reality they are generally not used well, and appear to serve more as checklists for care plans rather than to inform the direction of nursing care. You may now be questioning the value of models of nursing, if they are simply used as a theoretical exercise in nurse education and a checklist in routine practice, but nursing models can, properly used, facilitate thinking about care and the philosophy that underpins it.

            Most nurses have used one or more nursing models. You are likely to be familiar with the Activities of Living model (Roper, Logan and Tierney 1980, 2000) and the Self Care model (Orem 1971, 1991). There are many models that can inform nursing and health practice. Models are not simple; they have been very rigorously contemplated by experts and each one serves as a representation of nursing. An interesting point about nursing models is the way in which they vary quite considerably, so that the purpose and intention of one, and the way in which it informs nursing, is quite different from these aspects in another model, and each is helpful to different branches of nursing.This will be discussed as the chapter develops.


           It is unlikely that anyone has a blank sheet, mentally, when approaching patient care, and this indicates that professionals take a considered approach in this matter. There are several labels for these general approaches. One approach to nursing is known as task-orientated – referring to the clinical task being carried out in isolation from any other aspects that influence the patient’s condition. Thus the nurse dresses the wound and does not consider other factors that could influence the healing of the wound or the patient’s comfort. Most nurses have heard the term biomedical model, which refers to treating the medical condition of the patient in isolation from the patient as a person. For instance, the patient’s heart condition would be treated but their excess weight and sedentary lifestyle, and the anxiety they might have about their health, would be ignored. Pearson et al. (1996) consider that many nurses still use the biomedical model as the basis for their practice.

            A term that is often used in relation to a general philosophy of care is holistic. The holistic approach takes into account a range of physiological and personal considerations for each individual and also places them in the context of contemporary society and of current health care provision. Holism is concerned with balance, i.e. with balancing the physical, psychosocial, and economic relationships of the person, with the environment in which they live (Aggleton and Chalmers 2000). Some branches of nursing, for example the nursing of those with learning disabilities, are more likely to take a holistic approach, as clients are not perceived in terms of a medical condition.

          The underlying philosophy of our approach to nursing very much reflects our individuality. ‘Philosophy’ refers to the beliefs and values that shape the way each of us thinks and acts. You will certainly have heard the word used in the context of philosophy to life. Some common sayings exemplify such philosophies: Live now pay later; A short life but a good one; You reap what you sow. These sayings demonstrate our use of the term philosophy in this context: how our beliefs and values shape thinking and influence actions. It is to be expected that life experiences, education, professional  socialisation  and professional experience will shape a nurse’s philosophy of care. Thus our underlying philosophy of care says something about us as individuals with unique personal experience.


           Nurse theorists have examined the concept of nursing and have illustrated their ideas through nursing models. The full term is ‘conceptual model’, differentiating this kind of model from the sort that are exact miniatures of real objects – model cars, boats, buildings, for example. Each of these can be perfectly recreated as a working model. Is it possible to build such a model of nursing? The answer is, of course, No; and the reason for this is that nursing is a concept. A concept is a collection of images and ideas that help to classify things and it is not possible to build anything material from images and ideas. The notion of a concept can be explained through something that is familiar, for example the concept of spring. There are certain aspects that embody spring: lambs, daffodils, buds on trees, sunshine and warmer days. Put all these together and a set of images that creates a picture of the season of spring comes to mind. Nursing is a concept that is built around a set of images.

          Your concept may involve images about caring, knowledge about health and illness, prevention of ill  health, rehabilitation and enabling people to help themselves, partnerships with patients and other health workers, the list goes on. When nursing is viewed in this way it is easy to determine why models of nursing are conceptual. It would be impossible to build such a set of images into a visible working model.

       It is possible to see that models may differ quite considerably because nurses think differently and hold divergent views about the concept. The difference in views will also reflect the varied concepts that are embodied in the different specialities of nursing. Take, for example, the conceptual difference between mental health and acute nursing. The concepts that make up the two roles will vary because the nature of nursing is different in each role; mental health nursing treating psychological disorders and imbalances while acute nursing is concerned with physical illness or disability. As conceptual models are developed for the nursing role it is logical that they will differ in accordance with the differences between branches of nursing.

         Fawcett (1984) identified some common ground by analysing four key concepts that are embodied in all nursing models. These are: (1) the person or individual; (2) the environment in which nursing takes place; (3) health; and (4) nursing itself. Whatever other concepts make up a particular model, these four are found in all. Nurse theorists have attempted to build conceptual models that illustrate ‘systematically constructed, scientifically based, and logically related sets of concepts which identify the essential components of nursing practice’ (Riehl and Roy 1980: p. 6).

Building Nursing Models

         Models must be put down in writing/text to enable them to be shared and used by other nurses. It is in this state that you have probably encountered nursing models. You might imagine how difficult it is to represent a complex set of concepts in writing. All models require to be portrayed through the written word and with the use of diagrams.

        Before any model can be effectively used it must be interpreted and understood. It may take time to work through some of the terminology, but this is necessary if the is model to be used as intended. You can see that Orem’s model (1980) is based on the ability of people to care for themselves. The model represents a balance between what people need to be able to do, which Orem refers to as ‘universal self care needs’ and a person’s ability to perform their care, which Orem refers to as ‘self care’. The model also lists areas where, for various reasons, an individual may require nursing intervention and suggests, under methods of helping, the form that such intervention might take.

       The model proposed by Orem has several components that relate to self care, starting with the premise that individuals wish to be independent and listing areas where people normally meet their own self care needs. There are health-related reasons that interfere with people’s ability to be independent and to care for themselves. The model looks at general reasons why a person may need help and makes suggestions about ways in which a nurse may support a patient in their striving for self care. The overall philosophy is to support self care and independence, and this sets the tone of this particular model and the direction that nursing care will take.

       Representing this conceptual model is not easy and Orem supports the concepts embodied in the model with detailed explanatory text. To use any model well, the whole model should be applied, with all concepts captured, in its application to patient care. Nurses tend to take what they consider to be the useful ideas from models and apply them in isolation. A prime example of this is the use of the Activities of Living model (Roper, Logan and Tierney, 1980, 2000), where the list of daily living activities is used as a checklist against which care plans are developed. This action ignores the essence of the model.

       You should now have an understanding of the nature and purpose of a nursing model. One or more models should be used by a care team to guide the process of care, and the model(s) must be supported by all members. The team leader has responsibility to ensure that all team members are sufficiently knowledgeable to be able to use the chosen model(s) competently to follow through the planned programme of care. Effective caring using a nursing model is a team effort.

Models with Differing Philosophies

         You may not feel that a Self Care model is suitable for the patient that you have in mind or for your branch of nursing. There are other options to explore, some similar to the ideas expressed in Orem’s model, others very different. A similar model was developed by Roper, Logan and Tierney (1980, 2000), informed by earlier work from Henderson, who offered a definition of nursing based on 14 activities of daily living (Henderson 1966). The Activities of Living model is well known and much used in the British Isles. It approaches nursing care by considering the activities of living that are common to all people, and how these can be influenced by a range of factors, the origins of which might be physical, psychological, social, cultural, environmental, political or economic. Other aspects that come into the model are the age of the person and the degree to which they are able to lead an independent life. The model focuses strongly on the many factors that influence activities of daily living and requires nurses to take these into consideration in making judgements about nursing care.

          Self care and activities of living tend to be concerned with planning nursing care in order to meet physical health deficits, which is why these two models are widely used to nurse patients with acute and chronic illnesses. They are equally suitable for wider use. Aggleton and Chalmers (2000) illustrate this point by applying the Activities of Living model to bereavement.

        Other models take a very different philosophical approach. Roy (1976) proposed a model based on adaptation. It works from the premise that each person is constantly adapting to an ever-changing environment. Roy suggests that an altered state of health requires a person to adapt to cope with changed circumstances. She sees the role of the nurse as one of facilitating adaptation in the patient by adopting a systematic series of actions, directed towards the goals of adaptation. The role of the nurse in this model is to facilitate the patient to adapt to their altered health circumstances and through adaptation learn to cope with the change. This explanation is much over-simplified but it indicates yet another conceptual approach.

        Neuman’s Systems model (Neuman 1989) takes a very different conceptual approach, based on wellness. It is concerned with the patient’s response to stressors in the environment. Each person develops a range of responses to cope with normal circumstances, with some people appearing to cope better than others with everyday life. There are, however, situations that occur in the lives of all people that deviate from normal and produce stressors that are very difficult to cope with. Neuman defines stressors as inert forces that have the ability to impact on the patient’s steady state (Neuman 1989: pp. 12, 24). Some situations may be positive and enabling whilst others may be detrimental. This model views the nurse’s role as intervening to enable the patient to maintain an optimal state of wellness. There may be opportunities in primary care practice to capitalise on facilitation and enable the patient to manage stressors that face them in order to attain an optimum state of health. Such a model may be well suited for use in school nursing, health visiting and occupational therapy.

     In Peplau’s Interpersonal Relations model (Peplau 1988) the key components are the interpersonal process, nurse, patient and anxiety. Peplau considers that people are motivated towards self-maintenance, reproduction and growth by biological, psychological and social qualities. The model views the interpersonal relationship between nurse and patient as the focal point of interface that will produce benefits for the patient’s health. There are elements of adaptation and coping in this model with the main thrust of nursing intervention coming through the nurse–patient relationship as a therapeutic interpersonal process. A model such as this, based on interpersonal relationships, may be well suited to mental health and learning disability nursing.

        The conceptual models that have been mentioned in this chapter serve to illustrate the wide and varying approaches that contribute to the development of models of nursing. The differing approaches afford choice in decisions that are taken about delivery of care, and consideration should be given by the care team to the most suitable choice of model for the patient. The models are complex and to use any one effectively it will be necessary to refer to texts where the model under consideration is fully examined. It will also be necessary to make sure that others involved in the care know and understand the model in all its aspects.


          The vehicle for implementing a nursing model is the nursing process, a functional approach to the organisation of nursing care. Yura and Walsh (1967) identified a number of stages in nursing care with which all nurses have some familiarity: assess, plan, implement, evaluate. The four stages of the process are used in conjunction with a nursing model and its philosophy. Using Orem’s model as an example, the four stages of the nursing process could be applied as follows.

The assessment stage of the nursing process would take into consideration:

• the philosophy that people are normally self caring

• the ability of people to care for themselves, using universal self-care needs to guide the assessment

• recognition of the reasons an individual may require nursing intervention

• recognition of the way in which lifestyle and the patient’s environment influence the situation.

The care plan would detail:

• the actions that need to be taken to meet identified needs in relation to the patient’s normal lifestyle and wishes

• interventions that could be used to achieve self care, whether they are the responsibility of the nurse, the patient or others

• the type of intervention needed: for example, teaching how to carry out care, or giving care, and providing aids to living that enable the patient to regain independence

• ways in which the planned actions would be evaluated.

The planned care would then be given (implemented), bearing in mind that:

• planned care is given according to good practice;

• current knowledge that is evidence-based underpins the care

• lifestyle and the environment are accommodated in the provision of care

• care given is evaluated against changes in the patient’s physical, psychological and socio- economic condition.

Evaluation of care takes place to determine its effectiveness. This is:

• carried out as an ongoing practice at each visit

• includes, at regular predetermined intervals, an objective review of the care with reference to changes in condition, treatment effectiveness,

introduction of new treatments

• leads to an adjustment of the care plan, if necessary, updating it in accordance with the evidence of the review.

     Thus the nursing process, systematically applying a model, connects theory to what is done on a practical level; and the nursing process and model(s) of care offer a care team a more supportive structure than can be provided by a task-oriented approach to nursing. They enable systematic, logical organisation of care to be developed around a philosophical focus.

     Though we are here referring to ‘nursing process’, in fact the four-stage process outlined above can be applied to any situation that requires organizing. It is a tool that can be just as useful for organizing a charity walk or planning a teaching session.

       Through the use of models of nursing and the nursing process there is good support on which to base nursing and health care practice, in a well  planned manner. All nurses must be thoroughly conversant with models and process, but although these provide a philosophy of care and give structure to care, what else is needed to provide sound practice? Evidence from patient surveys suggests that patients would want competent and caring practitioners (Carey and Posovac 1982) and the next part of this chapter is concerned with competent practice.


          You are taught in formal and informal situations. You read professional journals, books, literature from medical suppliers and drug companies. You observe those who you work with, some of whom you admire as role models. As you progress through your career you gain from experience. Many things that you have done have worked well and the patient has had positive outcomes from your care. These positive outcomes are sources of learning: you learned from something that went well. Learning can also take place following a poor experience. If something did not work well or went wrong a great deal can be gained from reflecting on the event, identifying what went wrong and considering measures that could be taken to improve the situation.

Objectivity in Nursing Practice

         Learning takes place in a variety of ways and everyday work provides a mixture of objective and subjective learning experiences. Information that is evidence-based has been based on research studies, and this is objective knowledge, gained from systematically established evidence. Subjective knowledge is gathered from observations made in practice, from conversations with colleagues and sometimes from teaching sessions. The problem with knowledge gained in this way is that it may not be reliable, and could even be unsound and dangerous. It is important that care is planned on the basis of objective evidence, and this means that knowledge that is gained subjectively must be checked to see that it supported by evidence.

     EBP, a key concept in modern health care, is one element of clinical governance (DOH 1999), a framework for the continual improvement of services and quality in the NHS, the purpose of which is to ensure that clinical decisions are based on the most up-to-date evidence and that clear national standards are set to reduce local variations in access to and outcomes of health care. Clinical governance has the following key elements:

• To set national standards for health services through development of national service frameworks and the National Institute for Clinical Excellence (NICE).

• To provide mechanisms for assessing local delivery of high-quality services, reinforced by a new statutory duty to quality.

• To provide support for life-long learning.

• To develop effective systems for monitoring the delivery of quality standards in the form of the Commission for Health Improvement, the NHS Performance Framework and surveys of patient/user experience (DOH 1999).

All health professionals are accountable for their individual practice and are responsible for making sure that their knowledge and skills are current. This implies that any care given is based on the most up-to-date knowledge available.

         EBP forms an essential element in the quality of health care and is directly related to clinical care in that clinically effective practice is based on national standards, frameworks and research.

A Systematic Approach to Acquiring Evidence

        Systematic acquisition of evidence provides the information from which standards and protocols for care are developed. Standards and protocols related to the provision of care are written by employers to guide the process of care. Health trusts use national guidelines based on the work of the National Institute for Clinical Excellence (NICE) and evidence from research as the basis for protocols. Each employee has a duty to keep up-to-date with, and refer to, guidelines that are supplied by their employer to inform their specific area of care, and to work to protocols.

       Research is the means of gathering evidence, and thus the source of guidelines and protocols. Nurses should have a working knowledge of the research process to enable them to appraise and understand the evidence that is presented as the basis for care, and be able to make a judgement on validity.

        McInness et al. (2001) suggest that evidence is not easily integrated into practice. The reasons that they offer for this are that research literature can be poorly organised and not easy to read, making it particularly hard for busy practitioners to access. The same authors also acknowledge the poor quality of some research. These comments make it clear that evidence is not always easy to access/understand, neither is it always sound. Health professionals must be able to interpret the information that is given to them to enable them to question evidence when it is unclear or unconvincing. The application of EBP lies with each health professional who must exercise judgement about the applicability of knowledge, whether it is evidence-based or subjective. Senior members of the team should have sufficient knowledge to support less experienced nurses, but all registered nurses should have a working knowledge that equips them to question the soundness of practice.

     A part of professional life must be the acquisition of knowledge that informs patient/client care. Access to information through electronic journals and websites makes information readily accessible. Most health trusts have access points for internet searches and this makes it so much easier for nurses to keep informed and current in their practice.

Evidence-based care or patient preference?

       There may be some instances where a treatment or practice, even though based on evidence, may not be appropriate for a patient. Thought and consideration are required to be given by practitioners at each care intervention. This makes the argument for evidence-based practice turn on itself. You may reasonably ask why objective evidence cannot be applied in all cases when it is likely to be effective. The response to this rests in the nature of health care practice, which is described by McCormack et al. (2002) as practice that takes place in a variety of settings, communities and cultures. To add to this complexity, there are other relevant influences, for example psychosocial and economic factors. Taking all these factors into account it is reasonable to assume that thought needs to be given to the application of practice. While practice should be based on evidence, it is also important to establish that the patient is suited to this care, and willing to accept the proposed treatment.

Informed decisions and patient choice

       One example of advocated treatment being found unacceptable to the patient, would arise in the case of a family who do not wish to have their child vaccinated with the triple measles, mumps and rubella (MMR) vaccine. The family might hold strong views about the safety of triple vaccine. Here the parents’ wishes might conflict with those of professionals, who have convincing reasons why children should be protected from childhood infections. There are no easy answers to this type of problem, and decisions taken must be carefully considered in the light of evidence that is presented from a range of sources. The patients’, or in this case the parents’, wishes are vital. When decisions about care are to be made the nurse’s role is to provide information that can enable the patient to make an informed decision, but in the end the choice rests with the patient.

     Planning decisions about care are normally considered by the care team, and a long-term treatment plan, though initially developed by one nurse, would not rest with a single individual. The plan would be discussed by the team to ensure that it was suitable and allow all team members to understand the goals and process of care. Daily evaluation of circumstances would, however, rest with an individual and would rely on informed decision making.

      Professional practice relies on nurses being competent in a range of specified outcomes (UKCC 2001), successful achievement of which equips nurses to practice. Practice requires that decisions are made, and that implies that each professional should be knowledgeable in their subject area and have the ability to translate their knowledge to support practice. Knowledge in itself has only limited value if it is used without due consideration of the effect that it might have on a situation. Thus a key aspect of professional practice is the ability to interpret and apply knowledge in widely varying circumstances. It is around the varying circumstances that decisions must be made that assure that care is appropriate and each nurse is accountable for the decisions that they make about patient care (NMC 2002).


       Many of the issues raised in this chapter illustrate the complexity of nursing practice and demonstrate how thinking skills and decision making are essential to good practice. Not only is nursing practice complex it is also dynamic, and changes with developments in health policy and scientific knowledge. For nurses this means that every patient contact is unique and that over a period of time a great deal of experience is generated from nursing practice. Nursing practice, taken in its widest sense, means working with other health and social care practitioners to provide the assessment, organisation and management of holistic care for patients.

     Reflection is a great way to learn. It enables nurses to capitalise on what they do well and see how to improve the aspects of care that did not go so well. Taylor (2000) stresses this by stating how the unconsidered life is transformed, through the process of reflection, into one that is consciously aware, self-potentiating and purposeful. All recently qualified nurses will have been taught to use reflection as a method of learning, for just as EBP is a key concept in current nursing practice, so is reflection. Reflection has particular value to learning in nursing because of the richness of experience in practice and the direct observation that nurses are able to make about how the care that they and the health care team give affects patients.

Reflection and practice

       Reflection can and should take place during the process of practice. Schon (1983) refers to this as ‘reflection in action’. It also takes place after the event, which Schon refers to as ‘reflection on action’. Sometimes reflection is private, at other times it is shared with colleagues or may even form part of a team meeting.

       The exercise that you have undertaken is an illustration of reflecting on practice, learning from it and using the learning to inform and develop future practice. This is why reflection is so beneficial in nursing. In part it is explained because of the uniqueness of each situation demands new thinking and reasoning and this accumulates over time as experience increases.

      Reflecting on action is a deliberate event. It can be a very effective learning experience for the individual nurse or for the team. Each nurse should regularly take time to reflect on their practice, considering their knowledge and skills, the evidence base from which care is given and the many influences that impinge on care.

     Group reflection probably occurs informally in many teams at hand-over meetings when care is discussed. Reflection by the team in a more formal sense provides opportunity for review of patient care on a planned and regular basis. Like the individual nurse, the care team considers their knowledge and skills, the evidence base from which care is given, the influences on care, that are raised in models of nursing, and take a general reflective view of the care provided for each patient. Group thinking can be productive, with each member contributing an individual perspective, and everyone learning from the others in the group. Shaw (1981) suggests that groups make better- quality decisions than individuals, which has particular significance when so much is at stake for patients. However, some caution needs to be exercised when a group reflects, on account of a phenomenon known as groupthink, whereby pressures for conformity and for keeping within the boundaries of accepted practice stifle creative thinking (Robbins 1986).

     Learning often occurs when something happens that is disappointing or does not turn out the right way. It is this type of experience that most frequently makes people think about what they have or have not done and how it could have been more effectively achieved. It is not enough only to reflect and recognise where things went wrong: that is evaluation of the incident. Reflection is more than evaluation – it involves new learning. For learning to occur it is first necessary to identify what, in the case of a negative experience, went wrong. It is then essential to take the necessary steps to remedy the deficit and put it right. It may be as simple as recognising that work has been done without sufficient thought and that corners have been cut. In this instance the practitioner knows what should be done but has failed to do it correctly. The learning will be in the nature of accepting that however great the pressures, sufficient time must be given to each patient and procedure. It may, however, be that new learning needs to take place, perhaps a new skill needs to be learned, maybe from a colleague who has the necessary expertise. Sometimes knowledge is out of date and must be updated by reading or by attending study days. Very often in primary care nurses come across health problems that are new to them and they have to find the information that is needed to enable them to provide effective care. As you can see, learning involves taking some action. The purpose of reflective practice is to actively enable learning so that it becomes integral to routine practice. If a nurse constantly reflects on practice, learns from it and changes practice in response to learning, practice will not become static and out of date.

Aids to reflection

A number of frameworks have been designed to help the process of reflection. Many nurses are introduced to reflection by using the staged process advocated by Gibbs (1988). Gibbs’s model offers a cycle to guide nurses through the reflective process:

• describe what happened

• explore the thoughts and feelings that occurred as part of the experience

• evaluate what was good and bad about the experience

• analyse the experience in order to better understand it

• consider what else could have been done, and finally

• make an action plan to determine how the situation would be handled should it occur again.

       This cycle of steps gives an easy-to-follow process, guiding the nurse through reflection. There are other frameworks that facilitate the reflective process, for example Burnard (1991), Boud, Keogh and Walker (1985) and Goodman (1984). Goodman’s approach focuses on levels of reflection, suggesting three levels of increasing complexity. The first level consists of a simple approach that involves considering how the job was done with regard to technical efficiency and effectiveness, and in terms of accountability. The second level takes a wider view, looking at the implications and consequences of the nurse’s actions and beliefs, which includes the underlying rationale for practice. The third, most complex, level draws on all the considerations in levels one and two, and adds ethical and political considerations and developments.

       There are distinct differences between the approaches that are taken by Gibbs and Goodman. Gibbs offers a framework to facilitate structured thinking while Goodman pushes the boundaries of thinking to levels of considerable complexity. Examination of different approaches helps nurses to choose the one most suited to the situation. As with models of nursing the most suitable approach to reflection may vary with differing experiences and so it is beneficial to have a range of approaches to draw upon.


        This chapter has covered some of the key factors that influence and inform professional practice in nursing. This should create awareness of sources of nursing knowledge and reinforce earlier learning that introduced the nature and purpose of nursing models. There is no doubt that practice is complex and nurses can only truly attempt to meet the needs of patients if they are able to understand and manage complexity. The value of models of nursing is that, in representing the complex nature of practice, they act as prompts. Because each model is presented in diagrammatic form it enables the same detailed process of assessment, planning, implementation and evaluation to take place for every patient. Professional skill comes into play as infinitely variable information is analysed and interpreted into personal and individual plans of care that take account of very differing needs. The skill of the nurse is needed to manage patient information and translate it, with the patient’s collaboration, into meaningful and appropriate delivery of care. Nurses must therefore be knowledgeable and skilful. The dynamic nature of health care means that new knowledge is constantly emerging, and health practitioners are obliged to keep up to date with the latest developments.

         Knowledge and the validity of information are requirements for planning effective, economic care. Quality in care is high on the government agenda for improving the National Health Service (DOH 2000). Receiving care that is based on objective information is an essential part of provision; application of care without thought or consideration of the individuality of people would go against the ethos of professional practice (Norman and Cowley 1999). Norman and Cowley state that knowledge based on evidence is valuable and should underpin protocols and guidelines. Information that is collated and current greatly assists practitioners. Blind acceptance of evidence is not, however, consistent with professional practice, one criterion of which is autonomy. Reflective practitioners who are constantly learning on the job are fundamental to the profession – nurses who can plan appropriate care on an individual basis, with the patient, and are able to be justify their decisions.



Community Health Nursing

V. Therapeutic Relationships


           The recognition of the importance of the therapeutic relationship is not a new phenomenon. Peplau’s (1952) theory of nursing is based upon the importance of the relationship between the nurse and the patient, and she asserts this is the way in which all nursing care is delivered. The importance of this relationship has continued to be widely acknowledged and indeed McMahon and Pearson (1998) suggest that it is central to patient health, well-being and recovery. Since a therapeutic relationship is so important, it is essential to consider what features characterise such a relationship. In reviewing various definitions it becomes apparent that the important factors are:

  • appropriate boundaries are maintained
  • meets the needs of the patient
  • promotes patient autonomy
  •  positive experience for the patient

Appropriate boundaries are maintained

      A boundary, as defined in the dictionary (Chamber, 1993) is: ‘a limit, a border, termination or final limit’. Within the therapeutic relationship, boundaries define how far the nurse is willing to go to meet the needs of the patient and his family.

       Therefore it is important that the nurse, patient and family are clear regarding their relationship and what is reasonably expected of each party. This will protect all those involved in the relationship. A publication from the UK Central Council (1999: p.5) on this subject states that: ‘boundaries define the limits of behaviour which allow a client and practitioner to engage safely in a therapeutic, caring relationship’. The practitioner has the responsibility to maintain appropriate professional boundaries at all times (UKCC 1999). However, the process of finding the boundaries of care is far from automatic (Totka 1996), as will be discussed later in this chapter.

Meets the needs of the patient

       The purpose of the relationship between the nurse and patient is to meet the nursing needs of that patient. It is therefore important that the nursing needs of the patient are discussed at the outset of the relationship in order that mutually identified goals can be set and each person within the relationship can be clear as to their role in the achievement of those goals. This might include the nurse, patient, family members, other professionals and carers. This will require expert communication skills on the part of the nurse in order that a relationship of trust can develop. Whilst the relationship exists to meet the needs of the patient it is likely that the nurse will experience satisfaction in helping the patient to meet those needs. This is entirely appropriate. However, it is important that nurses do not allow their personal needs for positive self-esteem, control and belonging to undermine the professional relationship (Jerome and Ferraro- McDuffie 1992). This requires the nurse to be self- aware and open to seeking support from others when the need arises.

Promotes patient autonomy

          Autonomy is the right to self-determination. Self- determination can be defined as an ability to understand one’s own situation, to make plans and choices and to pursue personal goals (McParland et al. 2000). This further supports the need for excellent communication skills on the part of the nurse in order to assist the patient to understand their own situation. Within a relationship that promotes patient autonomy the patient will contribute to the achievement of personal goals and will move towards independence.

Positive experience for the patient

        The experience of participating in a therapeutic relationship will be positive for the patient as nursing needs will be met, in a way that is most appropriate to the patient and their family. Truly therapeutic relationships can empower the patient, the family and the nurse.

  These features are embodied in the Code of Professional Conduct, which states:

             You must at all times, maintain appropriate professional boundaries in the relationships you have with patients and clients. You must ensure that all aspects of the relationship focus exclusively upon the needs of the patient or client. (NMC 2002: Clause 2.3)


          Having considered the features of a professional relationship, some of the challenges of achieving such a relationship in the community setting will be discussed. Professional relationships with the patient are influenced by a number of factors.

          The delivery of care within the home can provide a feeling of security for the patient and his carer/s as they are on familiar territory. This can make it easier to develop a good relationship, such that they are able to share their concerns and worries. It is also probable that patients and carers will be able to learn new skills more readily as they are likely to feel more relaxed within their ‘normal’ environment.

           In this example the benefits of home visiting are apparent. These opportunities could be lost if health visitors change their mode of practice to give more care in clinic settings, as has been reported by Normandale (2001). However, caring in the home environment can leave the nurse feeling vulnerable. A nurse who has recently left a hospital-based job to work in the community can feel very isolated. Despite the use of mobile phones and pagers it is more difficult to seek the advice of a colleague, and help may not be instantly at hand. A nurse who feels vulnerable and isolated will find it more difficult to inspire the confidence of patients.
Working in the relative isolation of the home can provide challenges to nurses in maintaining standards of care. If the relationship is not ‘therapeutic’ it can be difficult for the nurse to identify this herself, particularly if the situation has developed over time. The support and guidance of colleagues is essential, as is the willingness of the nurse to be open to that support. Totka (1996) notes that peers often recognise unhealthy situations before the nurse involved, but find it difficult to discuss the situation with their colleague.
Care given by the nurse within the workplace will also be different from the more traditional hospital setting. The occupational health nurse works within a three-way relationship between the employer, employee and the nurse (Atwell 1996).

        Developing therapeutic relationships may also be affected by a clinic or surgery setting, where the patient may gain the impression of busy workloads inhibiting the time they spend with the nurse. Paterson (2001) identified lack of time as a major inhibitor in developing a participatory relationship between professional and patient, and although the nurse is likely to be as busy, if not more so, when undertaking home visits the interaction may be less distracted than in a busy clinic.

           In other cases the relative anonymity the surgery or clinic provides may be of benefit in facilitating the development of a therapeutic relationship. Initial assessments are often the first point of contact between community nurse and patient and the nurse must develop skills to enable a conducive environment in order to establish the start of a therapeutic relationship (Bryans and McIntosh 1996).

        Working in the community, many nurses find that not wearing a uniform removes an unnecessary barrier, which makes the development of a therapeutic relationship an easier task. It does, however, require skills on the part of the nurse to gain access to the patient’s home, gain the patient’s trust and explain her nursing role, since a symbol, which for many carries some degree of status, has been lost.
For those community nurses who do wear a uniform other challenges arise. Wearing of a uniform can enable almost instant entry to some homes, but may present a barrier to acceptance by some people. This may be especially apparent with children, who have perhaps learnt to associate uniforms with pain and discomfort. In these situations it will take time to address prior conceptions before a therapeutic relationship can be established.
If nurses do not wear a recognised uniform it is particularly important to consider the appropriateness of the clothing that is worn. Entering a home inappropriately dressed may cause offence and prevent establishment of a relationship. Perhaps this might require the nurse to cover her arms and legs if visiting Asian families, or maybe to remove shoes prior to entry into some homes. In order to meet the needs of individual families the nurse must enquire as to family preferences and be willing to adapt behaviours to respect values different from her own, in order to facilitate good relationships.
A final point about dress code: whether wearing uniform or not, it is essential to carry identification at all times in order to protect the wellbeing of patients.

Nature of care

       A key element in the nature of the therapeutic relationship with all patient groups is the duration of the relationship. Morse (1991) describes three appropriate relationships. Firstly, she describes the one-off clinical encounter that, for example, a practice nurse may have with a patient in a travel clinic. There are also encounters that last longer but focus on a specific need, such as maintenance of hormone replacement therapy. Both of these relationships are mutual and appropriate to certain situations but Morse argues that within a much longer-term nurse–patient relationship there should be a different focus, with the development of what Morse terms as a connected relationship. Morse suggests that the key characteristic of a connected relationship is that the nurse views the patient as a person first rather than a patient.

       Whilst for many families and professionals this can only be positive, there is a potential to step over the professional boundary and it is essential to maintain the appropriate balance within the therapeutic relationship. The consequences of not maintaining the balance will be explored later in the chapter.

        In the home environment the patient and his carer could be perceived to have greater control within the relationship. Should the patient decide not to concur with recommended treatment, this may not be immediately evident as the nurse is
spending only a short period of time within the home environment. Parkin (2001) notes that professionals are unable to control the home environment. If, unbeknown to the nurse, the patient has not adhered to the recommended treatment, the therapeutic relationship is threatened, since a relationship based on trust no longer exists. Within a therapeutic relationship the patient should be able to tell the nurse of his intentions. This might allow treatment to be modified such that the patient feels able to follow the regimen, but even if this is not the case at least the nurse is aware of the true situation and can modify her nursing care accordingly.

Patient expectations

         Expectations of the nurse and of the community nursing service may also impact on the relationship between the nurse and adult patient. Over the past 25 years there has been a rapid rise in consumerism (May and Purkis 1997), with a corresponding rise in expectations of the Health Service. In community nursing this can be seen by the use of time bands in allocating home visits and the proliferation of charters and mission statements displayed on clinic and surgery walls.

      Many patients have clear ideas on the service they expect from community nurses with a consequential detrimental effect on the therapeutic relationship when these expectations are either not met or are unrealistic.
However, despite trends in healthy ageing and participation in health care (Lorig et al. 1996), many older adults were bought up in a society where medicine was seen to have all the answers and the public was expected to be the passive recipient of care (Dukes Hess 1996). There is some evidence that not all adult patients wish to be an active partner in the therapeutic relationship (Waterworth and Luker 1990) and there may be a significant number of patients who feel more comfortable with the paternalistic model of care (Roberts 2001). The nurse ‘doing for’ the patient rather than enabling them to self-care contradicts the current trend towards empowerment (Copperman and Morrison 1995), which is a central theme in the National Service Framework for Older People (DOH 2001a). The community nurse may find a challenge in helping some patients in developing the confidence and ability to self care, and again the therapeutic relationship will be focused on trust and the facilitation of realistic independence.

Patient needs

        The main purpose of the nursing or health visiting intervention may also have a significant impact on the therapeutic relationship. The patient within the relationship may have significant physical and emotional needs, such as happens in palliative care. The relationship in such cases may be based on intensive input by the nurse (Goodman et al.1998). In contrast, the practice nurse or occupational health nurse may see a person for health screening with less obvious health needs as the focus of the intervention.
The substantial shift of care from hospitals to the community for those with mental health needs (Brooker and Repper 1998) has resulted in a rapidly developing role for community nurses in supporting this group. With approximately one in six people at any one time suffering from mental illness in the United Kingdom (DOH 1999a) the role is constantly evolving. The National Service Framework for Mental Health (DOH 1999a) is firmly underpinned by a patient focus. However, empowering patients with mental health needs is often challenging, not least because of concerns from society and professionals as to whether some patients have the capability of making decisions over their care and treatment (Feenan 1997).

Table 5.1 Responses to caring role:

Response to caring role – Features of Response

  • Engulfment mode
  1. Cannot articulate needs as a carer
  2. No other occupation
  3. Generally female spouse
  4. Total sense of responsibility and duty
  • The balancing/boundary setting mode
  1. Have a clear picture of themselves as carers (e.g. how they save nation money)
  2. Generally male
  3. Often adopt language of an occupation – treat role as a job
  4. May emotionally detach themselves from recipient
  • Symbiotic mode
  1. Positive gain by caring
  2. Does not want role taken away

            The therapeutic relationship with this group is essential in empowering patients to actively participate in decisions about their care. Peplau’s (1952) developmental model is often used as the framework for developing a therapeutic relationship (Collister 1986) with the assessment (or orientation) phase focusing on the development of mutual trust and regard between nurse and patient, as well as data gathering. Addressing anxiety is the overarching aim of the therapeutic relationship (Aggleton and Chalmers 2000), and the community nurse may take on a number of roles to facilitate this including that of counsellor, resource, teacher, leader or surrogate. All nurses working in the community develop knowledge of local resources and other agencies and facilitating the patient to access these may be the key component within this relationship.

            It should also be acknowledged that the therapeutic relationship in the community setting is not only formed between nurse and patient, but will often encompass an informal carer. In the United Kingdom there are approximately 6 million informal carers who are the primary carers for a range of patients ranging from young people with learning disabilities, to the frail elderly (Bond et al. 1999). The Carers Recognition and Services Act (DOH 1995) and the Carers and Disabled Childrens Act (DOH 2000) enshrined the principle that carers should be assessed and acknowledged as an individual rather than simply an adjunct to the patient. For the community nurse this reinforces that an individual therapeutic relationship must also be developed with the informal carer, but this poses a number of challenges.

            First, a significant number of informal carers are unknown to the community nurse, with Henwood (1998) estimating that only half of all carers receive any support from community nurses. Second, the more an informal carer does for the patient, the less intervention there will be from the community nurse (Pickard et al. 2000). Consequently, the informal carers most likely to benefit from a therapeutic relationship are less likely to be visited by the community nurse. Third, there are often misguided assumptions by many professionals that informal carers should undertake the caring role and that the role is taken on very willingly (Procter et al. 2001).

           Finally, studies have shown that many informal carers have significant health needs of their own which often are unrecognised (Henwood 1998) and undertake very complex and technical tasks (Pickard et al. 2000). All too frequently community nurses first meet an informal carer when there is a crisis and the nursing input is a short-term measure to help the patient and carer over this period. However, the therapeutic relationship with informal carers should ideally be long-term, with the nurse aiming to provide information and acting as a resource (Seddon and Robinson 2001) and responding to the role the carer is happy to undertake.
Twigg and Atkin (1994) describe three different responses by individuals to the informal caring role, given in Table 5.1. It is important for the community nurse to recognise the informal carer’s response to their situation.

          Another frequently met scenario is that of the husband caring for his wife. He has every detail organised and is business-like in his approach to the community nurse. Again, this may hide a number of physical and emotional needs, and the community nurse must develop a therapeutic relationship in order to enable him to express these. The needs of informal carers are only now being recognised and the community nurse must develop a relationship and provide intervention appropriate to both the patient and informal carer as individuals.


          In reality it is hard to learn about boundaries unless one is involved in setting them, and extending beyond the therapeutic boundary may only be apparent once it has been breached.

          It may be that it is in the interests of the patient and his carer to encourage the professional to develop a relationship of friendship since this has the potential to ‘normalise’ the patient, as it is ‘normal’ to have friends who visit. This is perhaps more likely to occur if nurses do not wear uniforms. Families may be keen that friendships do develop since a friend is likely to respond to requests for help, perhaps more swiftly than a detached professional. Therefore nurses must consider their actions carefully in case actions are misinterpreted, as perhaps was the case when Ann attended John’s party.

        Hylton Rushton et al. (1996) describes over- involvement as a lack of separation between the nurse’s own feelings and that of the patient. Typically the nurse may spend off-duty time with the patient (Barnsteiner and Gillis-Donovan 1990), appear territorial over the care (Morse 1991), or treat certain patients with favouritism (Wilson 2001a). Consequences for the patient are an over- dependence on that particular nurse and a lack of support in reaching therapeutic goals. For the community nurse the implications are often significant stress and deterioration in job satisfaction (Hylton Rushton et al. 1996) and an inevitable detrimental effect on team working.

         Of course, the balance in the therapeutic relationship may be tipped the other way. The detached, cold nurse who seems indifferent to her patient’s emotional needs may be familiar to the reader. The results of under-involvement are a lack of understanding by the nurse of the patient’s perspective, conflict, and standardised rather than contextually dependant care (Hylton Rushton et al. 1996). It has been suggested that the overwhelming feelings that a nurse may have for a patient’s situation can lead to dissociation by the nurse within the therapeutic relationship (Crowe 2000). Within the community setting the feelings of being the last resort in care has also been linked to under- involvement within the therapeutic relationship (Wilson 2001a). The consequences of under- involvement for the patient is that the nurse has a lack of insight into the patient’s perspective and is unable to facilitate the patient in meeting therapeutic goals.

          Maintaining a therapeutic relationship is particularly challenging in the community nursing context because of the commonly intense nature of care, duration of contact and the non-clinical environment. Reflection with colleagues and clinical supervision become invaluable tools to facilitate the nurse in developing the appropriate relationship with patients.


          Long-term interventions within the community setting will continue to increase with an ageing population and rise in chronic illness (Kalache 1996; Wellard 1998; DOH 1999b), and this chapter has already explored the impact of duration of care on the therapeutic relationship. One response by policy makers to the rise in long- term conditions is the facilitation of individuals to self-manage their own conditions. The expert patient programme (DOH 2001b) recognises that individuals often have significant expertise about their chronic illness which has developed over years through experience and the aim of the programme is to further develop this expertise in order to promote symptom control, quality of life and effective use of health resources (Wilson 2001b). Within all spheres of community nursing, nurses are now dealing with far more knowledgeable patients not least because of the readily available access to information via the Internet (Timmons 2001). Therapeutic relationships in the current climate must be based on an acknowledgement that the patient may have considerable expertise in their own condition, exceeding that of the nurse. There has been some debate as to how comfortable community nurses are with this (Wilson 2002), but there can be little doubt that a therapeutic relationship that fails to take into account the knowledge that both nurse and patient bring will fail.

         The expert patient programme is one example of a policy that is based on partnership and responsibility (Wilson 2001b). Another example is the move towards concordance (Royal Pharmaceutical Society of Great Britain 1997), where the patient’s views are considered of equal importance in treatment plans.

             Community nurses are required to demonstrate evidence-based practice (Woodward 2001) and the challenge of today’s therapeutic relationship is to balance this with informed choice by the patient (Wilson 2002). There is a balance to be maintained between the rights of the child (dependant on their age and understanding) and rights of the parents in decision-making, against the risks of significant harm that might result from the treatment. The parents in the above scenario should be advised to ensure the advice regarding the complementary treatment comes from a registered practitioner. Community nurses need to assess their own knowledge base regarding complementary therapy and seek specialist advice if necessary. Within a therapeutic relationship the nurse will be aiming to facilitate an atmosphere where the parents feel able to be honest about the treatments the child is currently receiving, and should be able to direct patients and their families to sources of appropriate information.

            A final feature of the current context of care that may have an effect on the therapeutic relationship is the fragmentation of care. In particular the division of health and social care (DOH 1990) means that patients within the community often have to deal with a vast array of professionals, which can inhibit the development of a therapeutic relationship (Hyde and Cotter 2001).


           In this chapter features of a therapeutic relationship have been identified, leading to an exploration of some of the challenges community nurses face in establishing therapeutic relationships. In future community health care provision, challenges will be shaped by an increasingly multi-cultural, ageing and informed population. The growing provision of health care in the community only serves to reinforce the need to establish appropriate relationships with patients, their families and other carers. Current government policy emphasises partnership in care at all levels; the challenge for the community nurse is to develop this opportunity in everyday working practice.



204 RLE Procedures



A tool making use of  a public health bag through which the nurse, during his /her home visit can perform nursing procedure with ease and deftness, saving time and effort with the end in view of rendering effective nursing care.


To render effective nursing care due to clients and/or members of the family during home visits.


  • The use of the bag should minimize if not totally prevent the spread of infection from individuals to families, hence, to the community.
  • Bag techniques should save time and effort on the part of the nurse in the performance of nursing procedures.
  • Bag technique should not overshadow concern for the patient rather should show the effectiveness of total care given to an individual or family.
  • Bag techniques can be performed in variety of ways depending upon agency policies, actual home situation, etc. as along as principles of avoiding transfer of infection is carried out.


> Paper Lining

> Extra paper for making bag for waste materials (paper bag)

> Plastic / linen lining

> Apron                                                           > 1 pair of rubber gloves

> Hand towel in plastic bag                      > 2 test tubes

>  Soap in soap dish                                     > Test tube holder

> Thermometers in case (one oral and rectal)

> 2 pairs of scissors (1 surgical and 1 bandage)

> 2 pairs of forceps (curved and straight)

> Syringes (5ml and 2 ml)

> Hypodermic needles g 19, 22, 23, 25

> Sterile dressings                                       > Betadine

> Sterile cord tie                                          > 70 % alcohol

> Adhesive plaster                                     > Ophthalmic ointment

> Alcohol lamp                                            > Zephiran solution

> Tape measure                                           > Hydrogen peroxide

> Medicines                                                   > Spirit of ammonia

> Acetic acid                                                 > Benedict’s solution

1. Upon arriving of the client’s home, place the bag on the table or any flat surface lined with paper lining, clean side out (folded part touching the table). Put the bag’s handles or strap beneath the bag.

Rationale To protect bag from contamination.

2. Ask for a basin of water and glass of water if faucet is not available. Place these outside the work area.

Rationale To be used for washing. To protect the work field from being wet.

3. Open the bag, take the linen/plastic lining and spread over the work field or area. The paper lining, clean side out (folded part out).

Rationale To make a non-contaminated work field or area.

4. Take out hand towel, soap dish and apron and place them at one corner of the work area (within the confines of the linen/plastic lining)

Rationale To prepare for hand washing.

5. Do hand washing. Wipe, dry with towel. Leave the plastic wrappers of the towel in soap dish in the bag.

Rationale Hand washing prevents possible infection from care provider to the client.

6. Put on apron right side out and wrong side with the crease touching the body, sliding the head into the neck strap, neatly tie into straps at the back.

Rationale To protect the nurse’s uniform. keeping the crease creates aesthetic appearance.

7. Put out things most needed for the specific case (example thermometer, kidney basin, cotton ball, waste proper bag) and place at one corner of the work area.

Rationale To make them readily accessible.

8. Place waste paper bag outside of work area.

Rationale To prevent contamination of clean area.

9. Close the bag.

Rationale To prevent contamination of bag and contents.

10. Proceed to the specific nursing care of treatment.

Rationale To give comfort and security, maintain personal hygiene and hasten recovery.

11. After completing nursing care treatment, clean and alcoholize the thing used.

Rationale To avoid microbes.

12. Do hand washing again.

Rationale To promote caregiver and prevent spread of infection to others.

13. Open the bag and put back all articles in their proper places.

Rationale To keep it organized.

After care: before keeping all articles in the bag, clean and alcoholize them.


Kozier, Barbara, Fundamental of Nursing. Philippines: Pearson Education South Asia PTE LTD 2004

Fundamentals Nursing

The Role of Religion in the Development of Nursing

Many of the world’s religions encourage benevolence, but it was the Christians value of “love thy neighbor as thyself” that had a significant impact on the development if Western nursing. The principle of caring was established with Christ’s parable of the Good Samaritan providing care for a tired and injured stranger. Converts to Christianity during the third and fourth centuries included several wealthy matrons of the Roman Empire, including Marcella, Fabiola, and Paula, who used their wealth to provide houses of care and healing (the forerunner of hospitals) for the poor, the sick, and the homeless.

Women were not the sole providers of nursing services in the third century in Rome there was an organization of men called the Parabolani Brotherhood. This group of men provided care to the sick and dying during the great plague in Alexandria. During the Crusades, several knighthood orders – such as the Knights of Saint John of Jerusalem (also known as the Knights of Lazarus  – formed, composed of brothers in arms who provided nursing care to their sick and injured comrades. These orders where responsible for building great hospitals, the organization and management of which set a standard for the administration of hospitals throughout Europe at that time. As the Christian church grew, more hospitals were built, as were specialized institutions providing care for orphans, widows, the elderly, the poor, and the sick. During the Middle Ages (AD 500-1500), male and female religious, military, and secular orders with the primary purpose of caring for the sick were formed. Conspicuous among them were the aforementioned Knights of Saint John (Knights Hospitalers); the Alexian Brotherhood (organized in 1431); and the Augustinian sisters, which was the first purely nursing order.

In the late 16th century, Camillus DeLellis, later sainted for his work of Christian charity, founded a nursing order to provide are for the poor, the sick, the dying, and those in prisons, In 1633, the Sisters of Charity were founded by Saint Vincent de Paul in France. It was the first of many such orders organized under various Roman Catholic church auspices and largely devoted to caring for the sick. The Order of the Sisters of Charity sent nursing sisters to provide care in the New World, establishing hospitals in Canada, the United States, and Australia.

The deaconess groups, composed of women who provided care, had their origins in the Roman Empire of the third and fourth centuries but were suppressed during the Middle Ages by the Western churches. However, these groups of nursing providers resurfaced occasionally throughout the centuries, most notably in 1836, when Theodor Fliedner reinstituted the Order of the Deaconesses and opened a small hospital and training school in Kaiserswerth, Germany. Florence Nightingale received her “training” in nursing at the Kaiserswerth School.

Kozier, Barbara Fundamentals of Nursing 5th edition (Addison –  Wesley Publishing Company, Inc. p.50)