UNIT 6 INTERPERSONAL

RELATIONSHIP IN NURSING
Structure
6.0 Objectives
6.1 Introduction
6.2 Definition
6.3 Process, Principles and Characteristics of Interpersonal Relationships
6.3.1 Process
6.3.2 Principles
6.3.3 Characteristics
6.4 Difference between Therapeutics and Social Relationships
6.5 Phases of Nurse-Patient Relationship
6.5.1 Phases of Nurse-Patient Relationship
6.6 Role of a Nurse in Development of Interpersonal Relationships
6.7 Factors Enhancing Interpersonal Relationships
6.8 Factors Leading to poor Interpersonal Relationships
6.9 Role of a Nurse in Improving Interpersonal Relationships
6.10 Let Us Sum Up
6.11 Key Words
6.12 Activities
6.13 Answers to Check Your Progress

6.0 OBJECTIVES
After going through this unit, you will be able to:

define interpersonal relationships;

explain the process and principles of interpersonal relationships;

discuss the phases of development of interpersonal relationship and the tasks
associated with the each phase;

explain the role of nurse in establishing therapeutic relationships;

list the factors enhancing interpersonal relationship; and

identify the factors, which lead to poor interpersonal relationships.

6.1 INTRODUCTION
A relationship is an interpersonal process where two or more people interact with each
other. We meet people in a variety of settings and share our experiences and develop a
kind of relatedness. The basis for good inter-personal relationships is respect for human
personality with an understanding of the problem of other person. Understanding leads to
co-operation and trust, which brings in harmony and happiness, which is very significant in
developing therapeutics relationship loina the patient.

6.2 DEFINITION
“A healthy interpersonal relationships is one in which the individuals involved, experiences
intimacy with each other while maintaining separate identities”. According to Sullivan,
‘intimacy’ is characterized by sensitivity to needs of the other person and mutual validation
110 of personal worth.
Interpersonal relationship is a series of interactions where one individual perceives the Interpersonal
other individual as a human being. Relationship in Nursing

Interpersonal relationships in nursing is a mutually significant experience, where both

nurse and patient view each other as a unique human beings.

Mrs. Bimla Kapoor (1994) has defined nurse – patient relationship, “as an Interaction
process in which the nurse fulfills her role by using her professional knowledge and skill in
such a way that s/he is able to help the patient physically, socially and emotionally.”

Characteristics of healthy relations:

Open communication of feelings.

Acceptances of other as a valued unique identity.

Deep empathetic understanding.

6.3 PROCESS, PRINCIPLES AND CHARACTERISTICS

OF INTERPERSONAL RELATIONSHIPS (IPR)
6.3.1 Process
Peplau (1951) defined nursing as an interpersonal process she also mentioned the
importance of basic human needs. She considered two interacting components of health as
physiological demands and interpersonal conditions. The crux of the therapeutic process is
the corrective interpersonal experience. If two individuals have healthy relationship with
each other both can learn to have more satisfying Interpersonal relationships. Closeness in
interpersonal relationship builds trust, facilitate empathy, enhances self-esteem and fosters
growth towards healthy behaviour. Peplau termed this process as “psychological
mothering” which includes following steps:

Unconditional acceptance as a participant in a relationship that satisfy needs.

There is recognition of and response to one’s readiness for growth.

Power in the relationship shifts to the one in need (helpee) and s/he in turn is able to
delay gratification and to invert energy in goal achievement.

6.3.2 Principles
Given below are the principles which one needs to apply in establishing and maintaining
interpersonal relationships:

Principles of recognition

Principles of mutual understanding

Principles of inculcation of common interests

Principle of respect for human dignity

Principle of personality development

Principle of stimulation, motivation and encouragement

Principle of incentives/rewards for good accomplishment

Principle of honesty, punctuality and trust worthiness.

Nursing is considered as an interpersonal process, which is often therapeutic, in that people

benefit from the interaction. Nursing is also a human relationship between the one who is
in need of health services and the nurse who is trained and prepared to respond to the need
in therapeutic manner. The characteristics of a therapeutic relationship may include the
following:

6.3.3 Characteristics
Geniuness: The individual involved in relationship is an open, honest and sincere to
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himself and to the others. It is opposite to self-alienation where individual’s real and
Concepts in Nursing spontaneous reactions to life are suppressed. Genuineness means the person says the same
thing what S/he feels and not saying something different than what is feeling.

Respect: ‘Caring’, ‘liking’ and ‘valuing’ are other terms for respect. It is non possessive
warmth or unconditional positive regard which does not depend upon other person’s
behaviour. The other person is regarded as a person of worth and is respected but this does
not mean that we condone or accept all aspects of the individual’s behaviour as desirable or
likable. The behaviour is viewed as normal, natural and expected in a growth
circumstances.

Empathetic Understanding: Empathy is an ability to enter into the life of another person
and to perceive his or her current feeling accurately Rogers (1975) described it as “to sense
the client’s private world as if it were your own, but without loosing the ‘as if’ quality. A
high degree of empathy is one of the potent factors in bringing about change and learning
one of the most delicate and powerful way we have of using ourselves”. One has to keep
aside one’s view and values to enter another’s world without prejudice. Accurate empathy
is important for creating an environment in which a person can grow towards wellness.
‘Active listening’ and ‘creative listening’ are other terms, used for empathetic
understanding.
Empathy is of two types:
1) Basic empathy
2) Trained empathy.

Basic empathy is a natural ability of an individual to feel for others; and trained empathy is
taught and learnt for helping others. The trained empathy can also be termed a professional
or clinical empathy. Genuine and unconditional regard and empathetic understanding
conveyed to the other individual gives him or her personhood or identity this leads to
changing self-concept resulting in changed behaviour.

Concreteness: Use of specific terminology, rather than using of abstruction in the

discussion of patient’s feeling, experiences and behaviour. Concreteness helps. It is
opposite to generalizing, categorizing, classifying and labeling thus avoids vagueness and
ambiguity. Concreteness keeps one person’s responses close to the feelings of the other
person; fosters accuracy of understanding and can contribute to empathetic understanding.
The level of concreteness vary during different phases of interpersonal relationships/nurse
patient relationship. In orientation phase concreteness should be high this will contribute to
empathetic understanding, while a low level concreteness may be required to facilitate
through self-exploration. High level of concreteness is essential at the termination phase
when patients are engaging in action. Genuineness, report, empathetic understanding and
concreteness – facilitate the formation of therapeutic nurse patient relationship/
interpersonal relationship.

6.4 DIFFERENCE BETWEEN THERAPEUTICS AND

SOCIAL RELATIONSHIPS
The difference between therapeutic and social relationship described by Bimla Kapoor
(1994) is given below:

The therapeutic relationship is
The social relationship happens
planned because of mutual interaction

The objective is helping the patient
The objective is having fun together
and socialization

The length of relationship will
The length of relationship varies. It
depend on the goals. Time is limited. may last for year/lifetime

The nurse focuses on goals during the
Both are responsible in the relation-
relationship ship

The nurse accepts the patient as
Acceptance of relationship is based
“here and now” without attaching on shared value and beliefs
112 judgement.

It is important to terminate the
The term relationship may exist life Interpersonal
Relationship in Nursing
relationship. The termination is long, may terminate gradually.
planned and discussed with the
patient.

6.5 PHASES OF NURSE-PATIENT RELATIONSHIP

Kapoor, Bimla (1994) has identified four phases of Nurse-Patient Relationship:

i) Pre-interaction Phase;
ii) Introductory or Orientation Phase;
iii) Working Phase;
iv) Termination Phase.

The Pre-interaction Phase begins when the nurse is assigned a patient to develop
therapeutic relationship with him/her till she goes to the patient for interaction:

The tasks are that nurse explores her/his own fears and anxiety;

Sets objectives for interaction phase;

Takes help of the clinical supervisor or co-workers to overcome the fears.

Introductory/Orientation Phase: It begins when the nurse goes to the patient and
introduces herself/himself to the patient:

The tasks are that the nurse introduces herself/himself to the patient;

Talks with the patients.

Working Phase: Working phase of the nurse-patient relationship starts when the nurse and
patient start interacting with each other and nurse collect the data from primary and
secondary sources.

Assists the patient to identify his/her problem

Plan the nursing intervention.

Termination Phase is also called as resolution phase. It begins with orientation phase
itself when nurse explains to the patient the purpose of care to the patient.

The tasks of nurse would be to help the client:

To make best use of the services available;

Get prepared for discharge;

Get informed about rehabilitation and follow up.
6.5.1 Phases of Nurse-Patient Relationship
All the therapeutic relationship go through some phases. These phases may not be clearly
demarcated, but they do happen. The details of these phases you will be studying in unit 6
of this block.

i) Orientation Phase

This is the phase when patient and the nurse get to know each other. They start off as
strangers. Though the nurse has the advantage of having some information about the
patient through his records and from other nurses before she meets him.

The nurse takes the initiative in the relationship by introducing herself to the patient and
setting goals for working phase. In this phase security is been establish through continued
development of trust. Patient is being assisted to verbalize thoughts and feelings while the
strengths and weaknesses are being assessed.

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Concepts in Nursing Some time certain barriers appear such as the spoken language, manner in which nurse and
patient perceive each other or anxiety of the both the participants in the interaction.

ii) Working Phase

The working phase begins when nurse has collected all the information and begins to draw
up a plan of care for the patient. In this the nurse and the patient develop mutually
agreeable goals, and contract is formed, for example ‘I shall demonstrate deep breathing
exercises that you need to do before surgery. You need to practice them four times a day
on your own so that you can perform them post operatively on your own.

During this phase nurse can take several therapeutic maneouvers. For Example: Offering
support, remaining with the patient during stressful situation, helping the patient to arrive at
his own decision and helping the patient to see his strengths, progress and successes. If the
goals are met contract is terminated if not a new contract is negotiated.

Sometimes certain barrier can arise to accomplish the task–such as when patient starts
testing the nurse or nurse’s unwillingness to engage in the tedious task of improving her
ability to collect and interpret data.

iii) Termination Phase

Termination is one of the most difficult but most critically important phases of nurse
patient relationship. There are several reasons for termination of relationship such as when
patient gets discharged or nurse’s duty is transferred or when patient can manage his own
health needs and care within reasonably safe limits or patient may be transferred to another
ward or institution. Relationship can be for short duration or long duration, depends on the
situation but feeling of loss is inevitable. This feeling one can overcome if the goals have
been met and the patient no longer needs the nurse’s care. We can review with the patient
the accomplishments that have been made. Sometimes it is necessary that another person
of your patient do this. In this case introduce the patient to the person who will be
carrying for him. In case of transfer, prepare the patient for transfer. In larger hospitals,. A
nurse is employed as discharge Co-coordinator and can assist in facilitating the discharge.

Check Your Progress 1

1) List four characteristics of nurse-patient relationship.

a) ..................................................................................................................................
b) ..................................................................................................................................
c) ..................................................................................................................................
d) ..................................................................................................................................
2) List three phases of nurse-patient relationship.
a) ..................................................................................................................................
b) ..................................................................................................................................
c) ..................................................................................................................................
3) Discuss the functions of a nurse in the first phase.
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
4) List some of the barriers that may arise in the second phase.
a) ..................................................................................................................................
b) ..................................................................................................................................

All the phases have action-oriented conditions which facilitate growth:

Based on the interpersonal theory of Peplau has also describe four phases of Nurse-Patient
relationships. These are orientation, identification, exploitation and termination. One can
114 visualize an overlapping in all the phases.
Orientation Phase: Interpersonal
Relationship in Nursing

Nurse identifies patient’s problems,

Mutually formulate a contract

Identification Phase:

Exchange social amenities;

Nurse identifies patient’s problems;

Clarify each other’s roles-nurse clarifies or correct the misconceptions on previous
experience;

Exploitation Phase:

Nurse and client start experiencing each other as unique individuals;

Client experiences acceptance;

Client develops high degree of trust in nurse;

Client starts taking full advantage of the nurse Patient relationships;

Client develops ability to test;
Termination Phase:

Mutually explore feelings of rejection, loss, sadness and anger related behaviours;

Client leans that termination that is important.

Client learns that termination completes therapeutic relationships.

6.6 ROLE OF A NURSE IN DEVELOPMENT OF

INTERPERSONAL RELATIONSHIP
Role Definition
Stranger The roles assumed by both the nurse
meeting;
Resource person Provides knowledge and answers spec
health Promotion;
Surrogate Acts as substitute figure that the client im
Teacher Identifies learning needs of the client an
roles to develop clients interest in medic
Leader Provides direction during present proble
Socializing agent Participates in social activities with her
Manager Establishes and maintains therapeutic
conditions for patient’s recovery;
Counselor Facilitates self directed actions to help p
to changed life style.

Throughout the four phases of nurse patient relationship the nurse performs several roles.
These are presented above in box no. 1 Peplau’s theory is mainly concerned with the need
for growth and development and with Psycho-social needs. Peplau’s states that “the
nursing process is educative and therapeutic when nurse and patient comes to know each
other, as persons who are alike and yet, different, as persons who provided care and help in
the solutions of problems”. She states that Nursing is an interpersonal process that is often
therapeutic and a force that promotes development of personality in becoming more
creative and productive.

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Concepts in Nursing
6.7 FACTORS ENHANCING INTERPERSONAL
RELATIONSHIPS
Interpersonal factors refers to three factors involving relationships with others. The
helpfulness of the support offered by others and satisfaction gained from it are critical to
enhance good interpersonal-relationships, cooperation and mutual understanding between
nurse and patient; nurse and nurse, nurse and doctor and nurse and patient’s relative, are
imperative to good interpersonal relationships. Co-operation and mutual understanding
between all members of health team including patients are the basis of efficiency and is
greatly influenced by the nurse in-charge of the unit. If interpersonal relations are good
patients are well cared for and personal problems are reduced, concreteness in
communication, immediacy in communication and sensitive confrontation is an important
factor in establishing and maintaining good interpersonal relationships. The individual is
helped when s/he is encouraged to express her/his concerns and willingness to clarify
explicity. The most effective helper (nurse) does not avoid discussion about the dynamics
(interaction) occurring within their relationship. Nurse needs to develop some of the
following characteristics which can help her establish good interpersonal relationships:

Listen patiently

Talk meaningfully

Avoid hasty judgement

Judge unemotionally

Interpret properly

Never gossip

Never criticize

Acquire adequate knowledge regarding the policy and administrative setup

Know the other health agencies

Acquire communication skills

Respect others

Accept constructive criticism

Behave as human being towards patient (genuineness)

Sensitive to point out discrepancies in patient’s behaviour.

6.8 FACTORS LEADING TO POOR INTERPERSONAL

RELATIONSHIPS
The following factors can lead to poor IPR:

Lack of interest in work in some personnel may burden the other person which may
spoil the friendly environment of the department.

Lack of self-understanding and understanding of others is another factor leading to
poor interpersonal relationship.

Lack of understanding “how” you respond to others and what you expect from them.

Deliberately ignoring some one without any cause is another factor leading to poor
interpersonal relationships.

Embarrassment for oneself and others from non-acceptance also contributes to poor
interpersonal relationship.

Unwilling to accept help and advice from others may also lead to unhealthy
interpersonal relationships.

There may be personality clash among people working in a unit. The clashes are
usually caused by difference in styles of working.

Conflicting ideas might arise from different backgrounds and lead to poor
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interpersonal relationships.
 Interpersonal
6.9 ROLE OF A NURSE IN IMPROVING Relationship in Nursing
INTERPERSONAL RELATIONSHIPS
In interpersonal relationship the nurse may use various methods to achieve good
interpersonal relationships and these are definitely very important. Some of the methods
are detailed below:

i) Willingness to Give and Take: You had an unhappy experience with a friend of
yours in school time and started disliking her. In the hospital you meet a fellow nurse who
resembles your old friend so you decide that you don’t like her “type” and it seems you
won’t like her either. You work with her but she doesn’t enjoy working with you. So she
decides that she dislikes you. Your relationships are bound to be strained this made
working environment tense and unhappy. All that needed here was willingness to accept
your colleague as an individual, not as a “type”. One nurse commented publically that she
doesn’t like Community Health Nurses (CHN) and she wouldn’t work with the community
people. Unfortunately she had to work in the community health field where nurses had
very good IPR, which lead her to change her attitude towards CHNs. She was also able to
establish good I.P.R. While working in the hospital you have many opportunities to please
others by being willing to let them do you a favour, a favour which is perfectly acceptable
from a professional point of view. Sometimes we can do a better job but we let others do it
to please them.

A patient starts telling you some news from the newspaper, which you already know. If
you want him to feel happy you will let him tell you the news. Healthy, enjoyable and
good interpersonal relationships are possible among those individuals who understand the
importance of unselfish acceptance and they believe in the principle of willingness to give
and take. Be co-operative and appreciative with all your colleagues.

ii) Acceptance of Others: Nurses come in contact with a variety of people some
attractive some are unattractive, aged, young, rich or poor. Keeping in mind the ethics and
professional commitment nurse accept the fact that s/he need to give excellent care
regardless of her/his own feelings. Nurse needs to overcome the feeling of distaste for
anyone whose standard of personal appearance is different from her/his own.

To have satisfactory relationships with others in every situation we must accept that others
have right to their habits as we have to ours. Exerting undue influence on anyone to
change may not bring a long lasting improvement rather it may end up in a dislike for you
and nothing else. While caring for a patient it is important to “accept him as he is”. The
nursing activities nurse undertake will become more rewarding and successful if the nurse
hads developed rapport with the patient and ‘accepting him as he is’, is first step towards it.

Through personal acquaintance one can get to know people better than just hearing about
them or seeing them thus improves interpersonal relationships.

Respectful and healthy interpersonal relationships in the medical and nursing care of
patients demand understanding and appreciation of special responsibilities each member of
the health team has. Acceptance and co-operation leads to healthy and conducive
atmosphere for congenial and productive working relationships.

iii) Self Acceptance: If we know or understand why we behave as we do in certain

situations, will help us to understand the behaviour of others and adjust accordingly.
Sometimes we feel glad to meet some one where as other time we will be inclined to wait
for other person to take initiative. This happens with every one and it is normal. We must
know what we do and why we do it, depends upon our familiarity to the environment, our
status with our partner at that moment, duration and type of acquaintance with him/her. A
professional nurse requires development in the socio-cultural aspects of life as well as in
scientific and technological aspects. This is possible if the nurse sets some realistic and
achievable goals for progress in all phases of nursing education.

iv) Know-How: ‘It is very easy to preach but difficult to practice’, well said by a wise
man. “I want to adjust with others”. “I want to get along well with others,” “I want to
give love to others and be loved by others,” “I want to accept every one at any time in
every situation”. These are commonly expressed concerns of people, but how to go about 117
Concepts in Nursing it? No definite steps to be followed which can be listed, however some suggestions can be
of some use to the nurse:

Courteous and respectful gesture to every one will be fruitful.

Willingness to accept help and advice from others

Communicate skillfully, avoid being argumentative and thrusting your opinions on
others

Keep the tone of voice and laughter under control.

Get acquainted with all types of people

Take advantage of time factor.

Try to overcome your annoying and nervous habits, such as sniffing, finger tapping,
whistling, continuous humming etc.

Be careful of other people’s possessions.

Share appreciations with colleagues and other members of health team.

Take your share of the blame in any situation.

Should be generous and sincere in compliments.

Try to clear up misunderstandings at the earliest.

Be a modest looser and good winner.

Avoid embarrassment for oneself and others.

Indulging inspiteful gossip need to be evaded.

Deliberately ignoring some one without good cause should be avoided.

v) Emotional Maturity: A mentally healthy person is enriched with emotions as s/he

attains maturity and uses them intelligently. A nurse is considered to be mature person
endowed with emotions. She can assess her present status in this respect and guide her
progress ahead. Given below are some statements which can help you score you maturity
level.

An emotionally mature person is able to:

Control her/his emotions in most situations.

Use repression – a defense mechanism (what to forget and what to remember)

Refuse to let easily hurt people, make him feel guilty and remorseful over trifles.

Feel secure in the relationships with others.

Expect to be liked, valued and accepts the facts which doesn’t let it lead to lower the
self-esteem.

Carry on his work inspite of upsetting personal circumstances.

Recognize his own need as well as others needs.

Adjust to wide range of personalities without being emotionally involved.

Keep his religious life in proper perspective.

Refrain from being judgemental on emotional basis.

vi) The Nurse and Her Patients: The first responsibility of the nurse is to establishes
rapport with her patient as she plans comprehensive care for him. The patient also carries
some responsibility unless s/he is mentally sick or acutely ill physically. A sense of
humour, infinite patience and dignity will help the nurse to earn respect and liking from her
patient and keep her relationship as a professional one.

Therapeutic relationships with patients who are fearful, shy, unsure of themselves can help
them express their needs.

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Warm professional atmosphere conducive for patients’ recovery can be achieved through Interpersonal
good interpersonal relationships at the unit. Relationship in Nursing

Check Your Progress 2

1) For each of the activities described below, select the correct phase of the therapeutic
relationship.

Orientation phase, working phase, identification phase, termination phase:

a) ................................................. Analyse on feelings and fears.

b) ................................................. Define goals with the patient.
c) ................................................. Determine why the patient sought help.
d) ................................................. Explore feeling of loss and separation.
e) ................................................. Evaluate patient’s stressors.
f) ................................................. Formulate a contract.
g) ................................................. Gather data about patient.
h) ................................................. Overcome resistance.
i) ................................................. Promote insight and behavioural change.
j) ................................................. Review goal attainment.

2) Enlist four phases of nurse patient relationship by Hildegerd Peplau:

...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................

6.10 LET US SUM UP

In this section you have learnt about establishing and maintaining interpersonal
relationships it’s phases and roles the nurse enacts in these phases. The factors enhancing
the good interpersonal relationships and factors leading to poor interpersonal relationships
are also discussed. All the information given in this section can be applied in your work
setting.

6.11 KEY WORDS

Empathy : Ability to view the patient’s world from his/her frame
reference.
Genuineness : A quality of the nurse characterized by openness,
honesty and sincerity.
Interpersonal relationships : Interpersonal relation is a series of interactions where
one individual perceives the other individual as a
human being.
Repression : Involving exclusion of painful or conflicting thought,
impulse or memory from awareness.

6.12 ACTIVITIES
1) Some nurses accept without question the fact that persons holding superior positions
merit their respect and loyality; other do not. Do you agree with this or not? Give
your views.
2) Add eight to ten suggestions for maintaining good interpersonal relationships in your
work setting.
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Concepts in Nursing 3) You have a patient whom you have labeled as “unco-operative”. Interact with this
patient. Follow the four phases of interpersonal relationships and report accordingly.

6.13 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) a) Empathy
b) Mutual respect
c) Trust
d) Genuineness
2) a) Orientation phase
b) Working phase
c) Termination phase
3) Nurse takes the initiative in the relationship, introduces herself and setting goals for
working phase.
4) a) Testing the nurse by clients
b) Nurses unwillingness to engage in tasks to collect and interpret data.
Check Your Progress 2

1) a) Working phase
b) Working Phase
c) Orientation phase
d) Identification phase
e) Identification phase
f) Orientation phase
g) Working phase
h) Identification phase
i) Identification phase
j) Termination phase
2)
Orientation phase

Identification phase

Phase of explorations

Terminal phase

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