BEING THERE AND BEING WITH FAMILIES: FAMILY UNDERSTANDINGS OF
PUBLIC HEALTH NURSE-FAMILY RELATIONSHIPS
by
Deborah-Lee Catherine Collette
BScN University of Northern British Columbia, 2007

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF SCIENCE
IN
NURSING

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
August 2013
©Deborah-Lee Catherine Collette, 2013

UMI Number: 1525711

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Abstract
As a phenomenon in nursing, the experience of presence is thought to unfold through
relationships between nurses and their clients. Although literature on nurse-client
relationships emphasizes the importance of presence few studies explore the phenomenon
from the perspective of families. In this thesis I explore families’ experience of nursing
presence in their relationships with public health nurses. The intent is to understand how
families experience presence and how nursing presence contributes to the development of
relationships. Eight family interview transcripts were analyzed using a hermeneutic
phenomenological approach. Analysis and interpretation of the transcripts revealed that
families experience nursing presence when they work with nurses whose perceptual abilities
and relational skills enable them to intuit how to respond to and work with families in ways
that are meaningful to the family. The study demonstrates the need for nurses to be
responsive to families’ needs as they shift and change over time.

iii

TABLE OF CONTENTS
Abstract

ii

Table of Contents

iii

Acknowledgments

v

Chapter One

Contextualizing the Problem: “Do for, do with, and cheer on”
Statement of Purpose
Overview of the Study

1
4
4

Chapter Two

Review of the Literature
Public Health Nursing Practice and Context:
Why Relationships Matter
What is Nursing Presence Theoretically?
How is Nursing Presence Defined Conceptually?
What does the Research say about the Nature and
Character of Nursing Presence?
High Priority Families
The Importance of Responsiveness
Public Health Nurses Presence and Home Visiting
Summary

7

Chapter Three

Chapter Four

8
13
15
16
20
23
25
27

Methodology and Method
The Qualitative Paradigm
Hermeneutic Phenomenology
Description of Participants
Data Collection
Participant Selection, Recruitment and
Interview Process
Data Analysis
Methodological Rigor
Ethical Considerations

28
28
28
31
32

Findings
Meeting at the Beginning, the Middle and the End
Meeting for the First Time
The importance of the first few moments
Teaching and learning in the beginning
Summary
Meeting in the Middle

40
40
41
45
46
49
49

33
35
37
38

iv

Teaching and learning in the middle
Sharing stories of being a mom too
Summary
Meeting at the End
Transitioning
Summary

52
54
56
57
60
62

Chapter Five

Discussion
A Responsive Use of Self
The Responsive Delivery of Services
Summary

63
66
68
71

Chapter Six

Conclusions and Implications
Summary of the Study
Conclusions
Implications for PHN Practice and Education with Families
Implications for Future Research
Re-visiting Do for, do with, and cheer on

74
74
75
79
82
83

References

86

Acknowledgments
It is a pleasure and a privilege to extend by deepest and most sincere gratitude to the
many people who have made this thesis possible. I would like to thank Don, my husband
whose unrelenting support and patience has seen this project through to the end. I would
also like to thank my children Emma and Nicholas who have supported me in ways that I can
never re-pay. I am extremely grateful for the contributions and sage advice provided by my
supervisors Dr. Martha MacLeod and Dr. Lela Zimmer. Thank you both for your frank
conversations, insightful suggestions, and patience.

1

CHAPTER ONE
Contextualizing the Problem
“Do for, do with, and cheer on”
The words written above Do for, do with, and cheer on, in many ways form the
impetus for this study. When I graduated with my undergraduate nursing degree, I entered
the practice area of public health where I worked with a program entitled Families Count.
The Families Count Program (FCP) provided intensive support for high priority families in
the areas of family functioning and child growth and development for up to five years.
When I first came to work with the program, I was confronted with the words Do for, do
with, and cheer on cut out of construction paper and tacked to a large bulletin board outside
the main door. I can distinctly remember my initial thoughts regarding what I assumed to be
a slogan or general words of motivation and wondered about their relevance to practice.
When I entered my office, which was shared with another Public Health Nurse (PHN), I
asked her, “What’s the Do for, do with, and cheer on thing all about?” Her response was,
“Oh that! That’s what we do here”.
Initially, my partner’s response confused me. I remember thinking “what do you
mean it’s what we do here”? It was not until I began my practice with families and realized
how important relationships were to the success of the work that I understood the depth and
breadth of the words that initially I thought were really rather simplistic, and juvenile in their
presentation. Do for, do with, and cheer on were words that formed a philosophy of practice
that guided all of our work with families in the FCP. More importantly they acted to guide
how we were to be in relationship with families. Do fo r informed what we did pragmatically

2

in the way of educating and sharing information and typically served to initiate relationships
with families. Do with and cheer on represented practically and philosophically how we
were to work with families in the middle and end stages of the relationship respectively.
Once relationships were firmly established with families engaged in service provision, we
were to begin a process of stepping back, allowing families to lead and leam on their own
until the family felt confident to “go it on their own”. In essence Do for, do with, and cheer
on called for an approach to practice that valued relationships built on reciprocity and
mutuality. In order to establish relationships that worked, PHNs had to value the strength
and resilience of families, have faith in families, and in turn act to invoke these feelings
within the families themselves.
When I completed my orientation with the FCP and began practicing independently, I
began wondering how I could operationalize the meanings embedded in the words Do for, do
with, and cheer on. I looked to other nurses for guidance and became intrigued with how
some had fully embraced the philosophy underlying the FCP, integrating it seamlessly
through all of their practice with families. They appeared to easily and openly cultivate
relationships with families, in particular families whose experiences and every day realities
were far removed from their own.
The ability to connect with families, despite apparent differences, was significant
because the FCP was primarily aimed at families whose experiences with varying degrees of
vulnerability at times made developing relationships challenging. Some of these families
had experienced untold hardships that made it difficult for them to be open and trust the
nurses. As I watched the nurses work to forge relationships with families, it became clear

3

that something exceptional existed within the relational capacity of those who easily
connected with families. But what was it? Was it something inherent in them; in their way of
being? Or was it something in the process of relating, something unspoken yet pervasive that >
worked to engender a sense of trust and willingness on the part of the family such that they
welcomed the opportunity for relationship?
These observations began a process of inquiry into the nature and character of
nursing presence and its contribution to developing and maintaining working relationships
with families. Nursing presence is considered to be a key feature of good working
relationships with families, but it is a concept that is poorly studied and thus difficult to
ascertain within the context of PHN practice (Benner, Tanner, & Chesla, 2009; Parse, 1997;
Paterson & Zderad, 1988). Despite extensive theoretical exploration, there is little research
examining how nursing presence is operationalized in practice. Furthermore, the few studies
that do explore the concept within the context of PHN practice only do so from the
perspective of nurses. Very few studies explore nursing presence from the perspective of
families. When we consider that nursing presence exists at the core of good working
relationships, it seemed prudent to obtain the perspectives of clients engaged in relationships.
With the perspectives of clients, we are better poised to understand what comprises nursing
presence and how its experience contributes to the development of relationships. Current
research only provides a partial view of the role of nursing presence plays in developing
relationships between nurses and families.

4

Statement of Purpose
This study is aimed at developing a clearer understanding of the nature and character
of nursing presence, and how it contributes to the development of working relationships with
high priority families. This study is particularly concerned with how families experience
nursing presence; how nursing presence unfolds over the course of the relationship; how it
makes families feel, and what they recognize as comprising nursing presence. Invoking an
understanding of how families experience nursing presence will enhance our
conceptualization regarding the nature and character of good working relationships and
contribute to the seemingly scant body of literature exploring presence from the perspective
of families.
Overview of the Study
Data for this study were produced as part of a larger qualitative project entitled, The
Nature and Character o f Working Relationships Between High Priority Families and Public
Health Nurses [WRP] (MacLeod et al., 2005). In the study, which was conducted in northern
British Columbia, public health nurses (PHNs) identified one of the most important, yet
difficult areas of their practice to be working with high priority families (MacLeod et al.,
2005). PHNs stated that “often they do not understand the experience of high priority
families and that they are concerned with whether or not their services make a difference to
the families” (p. 12a). PHNs recognized the importance of developing good nurse-family
relationships but also described inherent difficulties in doing so when family experiences
appeared to be far removed from their own (MacLeod et al., 2005).

5

In response to PHNs, the WRP (2005) sought to articulate the nature and character of
working relationships between PHNs and families. To this end, the WRP researchers
interviewed both nurses and families with the aim of not only understanding and articulating
processes involved in developing working relationships but as well, providing insight into
how families and nurses inter-relate to develop responsive, supportive relationships. The
original study employed three avenues of inquiry. The first was to conduct in-depth, open
ended interviews with participants to elicit rich narrative data about families’ and nurses’
experience, and the contexts of that experience (MacLeod et al., 2005). The second involved
participant observation of PHNs and lastly, a documentary analysis of relevant nursing
policies and standards was conducted (MacLeod et al., 2005). The research study reported in
this thesis utilizes interview data, both in audio form and transcripts, from eight families
interviewed during the original WRP study. Four transcripts were chosen from families who
described their relationship as challenging and four from families who considered their
relationship to be easy. The decision to choose transcripts that described extreme variances
in experience facilitated a better understanding of the complexities inherent in developing
relationships and the role nursing presence plays in mitigating those complexities.
In this study, an interpretive approach is used to uncover the lived experience of
nursing presence as it unfolds over the course of relationships with PHNs. Interpretive
approaches allow researchers to explore phenomena to uncover a meaningful account that
resonates with the experience of those involved in the study as well as those who read the
study results (Moules, 2002). Interpretive approaches are not used to achieve a truth that is
equated with frequency, reoccurrence, and control. In the original WRP study, MacLeod et

6

al. (2005) noted that an interpretive or hermeneutic phenomenological approach would be
used in data analysis. This study follows the approach taken in the WRP study and draws on
the philosophical hermeneutics of Hans Georg Gadamer (1989) and the methodological
approach to interpretive research afforded by Max vanManen (1997).

7

CHAPTER TWO
Review of the Literature
The following literature review presents literature concerned with the development of
relationships between PHNs and families. The first section provides background information
concerning the nature of PHN work and the context is which it is carried out in order to
explicate the role of relationships. The second part of this review explores theoretical
literature specifically concerned with nursing presence. The third section looks at concept
analyses exploring nursing presence in order to locate nursing presence within PHN-family
relationships. The fourth section of this review explores qualitative research concerned with
the nature and character of developing relationships between families and nurses. The fifth
section focuses on literature concerned with the nature of PHN-family relationships with
high priority families and includes a sixth section on the importance of responsiveness.
Finally, the last section of the review highlights the practice of home visiting in PHN practice
with families. All of the literature reviewed is used to explore what is thought to contribute to
the development of good working relationships between nurses and individuals or families.
What are missing from all three are the perspectives of individuals and families. With the
exception of one qualitative research study, views into what comprises good working
relationships are only offered from the perspective of nurses and as such, leave some
speculation as to how nurses and families interrelate to develop good working relationships.

8

Public Health Nursing Practice and Context: Why Relationships Matter
Developing good working relationships with families is relevant to all nursing roles,
but it is particularly relevant to the work of PHNs (Heaman, Chalmers, Woodgate, & Brown,
2006). The nature of PHN work and the context in which it is carried out emphasize
relational skills that enable nurses to gain entre, develop rapport, and engage clients in the
provision of service (Heaman et al., 2006; 2007; Luker & Chalmers, 1990). Despite the
emphasis on relationships in PHN practice, PHN education does not emphasize the skills
necessary to engage in good working relationships with families. Although therapeutic
communication courses teach skills and techniques associated with good communication,
they do so prescriptively, failing to emphasize the importance of connection and
collaboration in PHN practice with families (Arnold & Boggs, 1999).
In other nursing roles, gaining entre, developing rapport, and engaging clients in
service can be less challenging because explicitly stated health problems determine clearly
the nurse’s course of action (Briggs, 2007). PHN work however, focuses on what are often
considered the invisible aspects of health: health promotion and disease prevention (Public
Health Agency of Canada, 2007). Health promotion is defined as a mediating strategy
between people and their environments, “a positive, dynamic, empowering and unifying
concept that is based on the socio-environmental approach to health” (Community Health
Nurses Association of Canada [CHNAC], 2003, p. 36). According to the Community Health
Nurses Association of Canada Standards of Practice (2003), disease prevention involves a
repertoire of activities designed to minimize the occurrence of diseases or injuries and their
consequences to individuals, families, and communities.

9

The foci of health promotion and disease prevention on the prevention of illness are
often what characterize the work of public health nurses as invisible. In Canada, the approach
to health care delivery has largely been focused on curing illness instead of prevention. The
largest consumers of health care spending in Canada have historically been hospitals,
physician services, and pharmaceuticals (Canadian Institute for Health Information, [CIHI],
2011). Although trends in spending are beginning to shift with public health receiving more
funding, public uptake of health promotion and disease prevention strategies continues to
wane within some populations (CIHI, 2011). It is not uncommon for PHNs to feel as though
they have to sell health promotion and disease prevention work to the general public.
Adding to the complexity of the work is the role of PHNs in addressing issues related
to the non-medical or social determinants of health which focus on social and environmental
issues thought to impact health status (CHNAC, 2003). Some of these determinants include
issues related to income and social status, race, and gender that because of inequities related
to the distribution of money and power, profoundly impact the lives and health status of
families globally, nationally, and locally (Epp, 1986). Although the social determinants of
health are now widely accepted and considered essential to approaching health status
holistically, addressing these issues on an individual and a collective basis can prove
challenging (Hogan, 2008). Many of the systemic issues identified as impacting the health
status of a population require inordinate amounts of time, resources, and funding in order to
be adequately dealt with (Hogan, 2008). Furthermore, many individuals and families who
live with varying degrees of vulnerability already feel underserved and undermined which

10

can create barriers to overcoming issues related to the social determinants of health
(MacLeod et al., 2005; Moules, MacLeod, Thirsk, & Hanlon, 2010).
Given the magnitude of issues related to the social determinants of health, the
CHNAC (2003) directs PHN practice towards building individual and community capacity to
increase the skills, knowledge, and willingness so community members can take action on
their own in the future. One of the key aspects throughout this process is ensuring maximum
involvement and participation of community members (CHNAC, 2003). This involves an
element of outreach whereby PHNs seek out and meet with those who would likely benefit
from their services. It also involves the capacity to form long and lasting relationships to
ensure the success of programs and services (CHNAC, 2003). Mittlemark (2001) writes that
building relationships with individuals, families, and communities helps promote social
responsibility for health. Mittlemark (2001) argues that the best-intentioned national or
international healthy public policy initiatives may fail to have the intended impact at local
levels because of an ignorance of local contexts. PHNs working in communities are perfectly
poised to translate and contextualize national policy in ways meaningful to the families and
communities with whom they engage. PHNs do this through the development of
relationships. Their position as nurses and community members provides them with a unique
understanding of the community that can assist with the mobilization of resources and the
maximization of public participation (Mittlemark, 2001).
The focus on relationships is further emphasized by the context in which PHNs work
(Briggs, 2007; Doane, Browne, Reimer, MacLeod, & McLellan, 2009). According to the
CHNAC (2003), the nature of PHN work requires that PHNs meet clients in increasingly

11

diverse settings, such as community health centers, schools, the street, and in family homes.
In addition, PHN services are invited services (Hogan, 2008). They are not required nor are
they mandatory but occur at the volition of individuals, families, and communities (Hogan,
2008). The emphasis on meeting clients where they are coupled with the voluntary
acceptance of service places considerable emphasis on relational skills. PHNs are required to
pay particular attention to processes involved in developing, maintaining, and ending
relationships that are respectful and indicative of the nurses’ full attention to the needs of
individuals, families, and communities (Hogan, 2008).
Studies that have explored the relational processes involved in developing,
maintaining, and ending relationships have found that underlying most good working
relationships is a need for nurses to be highly attuned and in synchrony with families
(Appleton, 1996; Briggs, 2006; Chalmers, 1992; de la Cuesta, 1994; DeMay, 2003; Moules
et al. 2010; SmithBattle, 1997; 2009; SmithBattle, Lorenz, & Leander, 2012). MacLeod et
al. (2005) liken the process to a “tip toe dance”; “a precarious interaction full of tentative
advances and retreats” (p.32). During a tip toe dance there is an ever-present risk that toes
might get stepped on. In the context of developing relationships, the toes to worry about are
those of the clients with whom the PHN engages. By being attuned to the subtle cues and
nuances of the family, PHNs poise themselves to ensure that their next step is the right step
in serving the needs of the family.
The precariousness of relationships between PHNs and families is well documented
in the literature (Byrd, 1995; MacLeod et al., 2005; Moules et al., 2010; SmithBattle, 1997;
2009; SmithBattle et al., 2012). Relationships are tenuous, particularly in the beginning

12

where there is “a careful testing of boundaries, rules, and conditions of the relationship”
(Moules et al., 2009, p. 3). This is particularly significant for many high priority families
who may be extremely reticent about inviting PHNs into their homes. Past experiences with
authority and/or other service providers may have been experienced negatively, which in
some cases clouds expectations for all future interactions with people in positions of
authority (Byrd, 1995; Selwood, 2010).
Under the circumstances outlined above, developing relationships with families can
be extremely challenging. Literature exploring the nature of relationships between PHNs
and high priority families stresses the importance of highly developed perceptual and
relational skills. Very few studies, however offer a view into how these unfold in practice.
Many studies list, somewhat prescriptively, nurse characteristics thought to contribute to
good working relationships but few provide any insight into the inter-relational experience
that unfolds between families and PHNs. The following section of this review explores
literature specifically concerned with nursing presence. Although presence is a difficult
concept to define, literature focused on the phenomenon recognizes it as a key component of
developing relationships. The sections that follow explore theoretical literature and concept
analyses concerned with presence in order to gain a sense of what presence looks like, how it
unfolds in practice, and what it contributes to the development of relationships.

13

What is Nursing Presence Theoretically?
Presence exists as a somewhat ineffable concept which makes it difficult to describe
and define. Most dictionaries provide circuitous definitions owing to its numerous uses in
describing particular qualities or conditions or states of existence. For example, presence is
used to describe a way of being that denotes an individual’s bearing, stature or carriage
(Oxford English Dictionary, n.d.). It also describes a type of existence that is detectable
either physically or spiritually, and it is also used to imply proximity to something or
someone (Oxford English Dictionary, n.d.). Despite its multiple uses in the English
language, the experience of presence always invokes a particular feeling that develops in
relation to something or someone else. As a phenomenon in nursing, presence is thought to
unfold, and thought to be experienced, through relationships. The emphasis on the word,
thought, is deliberate. Without the perspectives of individuals and families, it is difficult to
know for certain the extent of the phenomenon as it is experienced in relationships with
nurses. The following body of literature however does contribute to the phenomenon as it is
understood by nurses.
Theoretical nursing literature exploring nursing presence focuses on qualities
associated with the concept that are thought to invoke a sense of unconditional regard for
individuals and families and that have great capacity to heal physically, spiritually, and
emotionally (Benner et al., 2009; Godkin, 2001; Parse, 1997; Paterson & Zderad, 1988).
Parse (1997) locates presence within relationships between nurses and individuals and
families by relating true presence with the intention and the will to be present with another.
Nurses who are present are with people without expectation or preconceived ideas of what

14

the other is going through or experiencing (Parse, 1997). True presence, as Parse (1997)
describes it, is a “subject-to-subject interrelationship that honours the ever-changing reality
of the other” (p. 173).
Paterson and Zderad (1988) similarly understand presence to be a phenomenon that
occurs in practice, with the giving of oneself in an inter-subjective reciprocal relationship.
Presence evolves through dialogical experiences that occur between the nurse and client.
Dialogue is understood in this context to include an ontological sphere: a form of lived
dialogue that involves a particular way of inter-subjective relating (Lived Dialogue section
para. 2). Paterson and Zderad (1988) described the dialogical experience as a way of
“seeing” the other person as a distinct unique individual and openly entering into relation
with them (Lived Dialogue section para. 6). In their openness to enter and engage fully in
relationship, the available nurse reveals themselves as present (Lived Dialogue section
para. 8).
Benner et al. (2009) also locate presence within relational practices that involve
nurses, who through years of practice experience have developed a moral and ethical
comportment that reflects “embodied, skilled know-how of relating to others in ways that are
respectful, responsive, and supportive of their concerns” (p. 280). The experience of
presence then occurs in relationship with nurses whose comportment reflects more than
words, beliefs, and values; “it encompasses stance, orientation, touch - thoughts and feelings
fused with physical presence and action” (p. 180).

15

How is Nursing Presence Defined Conceptually?
Concept analyses concerned with nursing presence follow the work of the theorists
explored above by also locating presence within praxis. Praxis refers to the application of
theory in practice. In contrast to the theoretical literature, concept analyses focus on defining
attributes and antecedents associated with the concept of presence in an attempt to define the
phenomenon. The concept analyses explore presence as it is practiced by nurses engaged in
the development of relationship. In order to articulate presence in practice, the concept
analyses focus on defining attributes and antecedents associated with the concept such that
the practice of presence becomes visible and can be more easily operationalized in practice.
Doona, Chase, and Haggerty (1999), Finfgeld-Connett (2006), and Hessel (2009), and
Tavemier (2006) list several attributes such as openness, availability, willingness, and
attentiveness that, in practice, invite individuals and families into therapeutic alliances or
relationships with nurses. Antecedents listed include the client’s need for presence, which is
evidence by physical and psychological distress. The individual in need must also be open to
presence (Doona et al., 1999; Finfgeld-Connett, 2006; 2008). In other words, the presence of
the nurse can be invited but enacting presence requires that the client accepts the nurse’s
invitation of presence (Finfgeld-Connett, 2006; 2008).
Osterman, Schwartz-Barcott, and Aselin (2010) explore nursing presence with a
focus on the acute care setting. In their qualitative study, they detail many of the same
attributes and antecedents associated with nursing presence that are outlined in the concept
analyses discussed above. One striking difference however is the distinction made between
four different types of presence observed in hospital based nursing. Osterman, et al., (1996;

16

2010) point to different ways of being there and being with clients. Firstly, “presence alone”
is defined as being there in the context of another. Second, “partial presence” is defined as
being there but focused on a particular task that is relevant to but not directly focused on the
client. Third, “full presence” is distinguished as a way of being there in the context of
another that involves physical presence and an “interactive presence which is evidenced by
attentive listening and responding, and focused on the client” (p. 198). Lastly, Osterman, et
al., (2010) describe “transcendent presence” which is broader in scope, more abstract and
elusive. Transcendent presence focuses on the existential and is reminiscent of descriptions
offered by Parse (1997). Here the focus is on the metaphysical, referring to an energy
exchange between the client and nurse that is transforming and more spiritual in quality
(Osterman & Schwartz-Barcott, 1996; Osterman, et al., 2010). Individuals involved in
transcendental presence are physically there and centered as in a meditative state, “they feel
spiritually connected, and energy emitted can be felt by others in the environment”
(Osterman, et al., p. 199).
What Does the Research say about the Nature and Character of Nursing Presence?
In contrast to the theoretical literature and the concept analyses reviewed, qualitative
research literature does not locate presence as a topic of inquiry within the context of
developing relationships. Rather, this body of literature focuses on particular nurse
characteristics thought to contribute to ways of being and working with families that invite
them into relationship and keep families engaged until the completion of services. Presence
is not overtly discussed but rather alluded to through various descriptions related to the nurse
and her way of working with the family.

17

Studies exploring the nature and character of relationships between PHNs and
families emphasize good working relationships with nurses whose particular ways of being
and working with families engender a sense of trust, confidence, and empowerment with
families. Relationships are defined as a meeting, whether deliberate or not, between a nurse
and an individual for an expressed purpose that is usually defined by some kind of health
concern (Peplau, 1997). Inherent in each relationship are relations that Peplau (1997) defines
as “the connections, linkages, bonds or patterns that develop and are identifiable within the
relationship” (p. 162). Relations, Peplau (1997) reasons, are developed, formed, and
dependent on reciprocity. Their reciprocal nature, howver is not equal nor is it balanced.
According to Peplau (1997) the formation of relation within the context of nurse-family
relationships rests squarely with the nurse. She writes:
Relations depend on participant observation; on the nurses unflinching self-scrutiny
and total honesty in assessment of their behaviour in interactions with patients. By
observing and analyzing their own behaviour, nurses become aware of the needs,
intentions and messages they communicate to patients (p. 163).
Developing relationships therefore involves a capacity for self-reflection that results in a
nurse’s heightened awareness of the words, voice tones, body language, and other gestural
messages that they use and that are noticed by clients. By paying attention to these, nurses
become aware of their own ways of communicating, and in turn learn to recognize what is
useful and what is not useful to the families with whom they engage.
Peplau (1997) calls this process participant observation, which on first reading seems
rather erroneous. Participant observation usually refers to processes carried out by the nurse

18

in their assessment of individuals and clients and rarely emphasizes self-assessment.
However, in her definition, Peplau not only stresses the importance of a nursing selfassessment, but also emphasizes the family’s assessment of the nurse. In other words,
participant observation occurs on both sides of the relationship. By emphasizing the
importance of self-assessment and including families in the process, Peplau accomplishes
two things. First, she offers a view of the relationship from the perspectives of families.
Although this view is not emphasized nor is it clearly articulated, its importance is certainly
implied. Second, she asks that nurses be cognizant of their approach with families and that
they consider how they might shift and change approaches to suit the needs of families. This
process, reasons Peplau, involves an adjunct form of observation called empathic linkages.
Empathic linkages involve the ability to feel in oneself the emotions experienced by
another in the same or similar situation (Peplau, 1997). When an individual or family is
experiencing anxiety, nurses who similarly feel their anxiety form an empathic link. The
nurse essentially connects with the family through the shared feelings associated with
anxiety. More important to developing empathic links is how the nurse responds to these
feelings (SmithBattle et al., 2012). If the nurse is attuned to their own ways of being and
acting in relationship, and has taken the time to observe how the family responds, then
theoretically her response should be congruent with the experience of the family. However,
if the nurse understands one way and one way only in her way of relating with families, then
quite possibly her response will fall short causing the relationship to falter.
Participant observation and observation that fosters empathic linkages are according
to Peplau (1997), critical to moving with individuals and families through relationships to

19

ensure the success of interventions. Moving with families requires a different approach than
what is normally applied in those situations that emphasize a do to approach with families.
Do to relationships, reasons Peplau, should only occur in emergent situations where a client’s
life hangs in the balance. Do with should always be the goal of any therapeutic alliance or
relationship with individuals and families because its focus is with the family and its goal is
it to empower the family (Peplau).
Relationships in general evolve over three phases: an orientation phase, a working
phase, and a termination phase (Peplau, 1997). Throughout the literature these phases are
described differently, however all explanations represent a definitive beginning, middle, and
end to relationships. In PHN-family relationships each phase of the relationship is
distinguished from one another by the nature of the work and by subtle differences in the
way PHNs respond to families from one phase to the next (Mulcahy & McCarthy, 2008;
SmithBattle, 1997). Movement through the phases is largely determined by the family’s
response to the nurse (Heaman et al., 2006). For example, the orientation phase with a family
who seems reticent to engage with PHN services may involve a nurse who approaches the
family with warmth and openness in hopes of establishing trust. If the nurse’s reading of the
family is indeed on mark and they respond to her by choosing to engage with services, they
effectively move to the next phase, the working phase. Movement into the working phase
may bring with it a need for a different kind of interaction than that which characterized the
first phase. The nurse who approached the family with cautious optimism in the orientation
phase may find that the family in the next phase requires confidence and a sense of
friendship. Peplau (1997) cautions against relationships that bear any resemblance to

20

friendship, however other authors offer different perspectives by insisting that the word
friend be an integral part of professional relationships between nurses and families
(SmithBattle, 2000; 2009; SmithBattle et al., 2012).
The most widely understood definition of friend is “a person with whom one has a
bond of mutual affection, typically one exclusive of sexual or family relations” (Oxford
English Dictionary, n.d.). Other definitions offer a different dimension to the meaning of the
word that when considered in the context of nurse-family relationships make friendship
important in the development of good working relationships. The most notable of these
definitions are friend, defined as “a person attached to another by feelings of affection or
personal regard” and friend as “a person who gives assistance; a patron or supporter”
(Oxford English Dictionary, n.d.). When conceptualized this way, the word friend implies an
inter-relatedness that evolves with PHNs whose relational skills support families based on
who they are, rather than who the nurse presumes they should be. Conveying a sense of
unconditional regard for families is particularly significant for many high priority families
whose experiences with vulnerability often leave them consigned to the outer margins of
society (SmithBattle, 2000).
High Priority Families
The term high priority family or vulnerable family evolves from the language of
PHNs interviewed during the WRP (2005) study. PHNs in northern communities use the
term to describe families identified as having actual or potential parenting concerns that may
impede optimal growth, development, or safety of their children (Moules et al. 2010). In the
WRP study, PHNs reported that standard practice was to identify high priority families

21

through the use of the Parkyn infant risk screening tool that assesses families over
physiological, developmental, and functional domains (Selwood, 2010). Families with a
score of 9 or more on initial infant/child screening are flagged by the PHN who then follows
up with the family in an effort to foster healthy infant and family development (Selwood,
2010 ).

In the literature, high priority families are typically referred to as vulnerable, highrisk or at-risk (Appleton, 1996; Jack, DiCenso, & Lohfield, 2002; Mulcahy, 2004; Plews,
Bryar, & Closs, 2005). Identification of these families in public health or community health
settings typically involves use of an assessment tool but is not limited to the Parkyn
(Selwood, 2010). Moreover, many PHNs admit to using their own professional judgment
when determining risk (Appleton, 1996). When PHNs define risk, they recognize it as both
ambiguous and transient, noting that many families can move in and out of risk and its
varying degrees (Appleton, 1996; Jack et al., 2002). Identification of risk however, always
involves an expressed concern with the development of children (Appleton, 1996; Jack et al.,
2002; Mulcahy, 2004). In extreme cases, it involves concerns for the physical safety of
children and/or other family members (Appleton, 1996).
SmithBattle’s (1997; 2000; 2009; SmithBattle et al., 2012) work focuses on
developing nurse-family relationships with a segment of society that is often understood as
being extremely high priority or high risk. Teenage childbearing is often believed to
jeopardize the trajectory to adulthood by interrupting education and curbing access to the
labour market, which ultimately leads to the persistent poverty associated with welfare
assistance or low-skill jobs (SmithBattle, 2000). Perhaps more damning is the scrutiny faced

22

by many of these teens when dealing with people in positions of authority. Many nurses and
clinicians treat teen pregnancy as a personal decision, laying blame with the mother for her
inability to make good decisions (Knott, & Latter, 1999; SmithBattle, 2000). SmithBattle,
(2000) argues that an over simplified understanding of teenage pregnancy disregards the
distinct life-worlds of teens. Contrary to what is often presumed, many teen mothers relish
in the dreams and accomplishments associated with teens that do not have children.
SmithBattle (2000) argues further that in the face of this kind of scrutiny, a friend as it is
defined above, with its emphasis on providing support and engendering a sense of regard, is
what many teen moms need. More importantly PHNs engaging in relationships with teen
mothers that resemble friends hips invite trust and forge connections considered critical to the
work of relationships.
A recent qualitative study by Landry, Jack, Whoush, Sheehan, and MacMillan,
(2012) exploring mother’s experiences in the Nurse-Family Partnership Program (NFP)
bolsters SmithBattle’s (2012) findings. The NFP is an intensive home visiting program
recently introduced in British Columbia that targets first-time mothers during pregnancy and
follows their progress through the first two years o f the child’s life (Landry et al., 2012). The
NFP program replaces the original Families First and Families Count programs in British
Columbia that were also aimed at ensuring optimal growth and development of children and
family functioning (Hackler, 2011). The Landry et al. (2012) study is the first to explore the
perspectives of families, specifically mothers’, engaged in the NFP program. Findings from
interviews with mothers who had positive experiences with the NFP program indicated that
most associated the success of the program with the relationships they had developed with

23

their nurses. Six themes describing positive relationships were identified. The first theme
entitled, the NFP Nurse is an Expert, but also like a Friend Providing Support, echoes what
is described by SmithBattle (2000). The second theme related to the nurse’s personality, the
third related to her respectfulness and trustworthiness. The fourth theme related to
empowerment and advocacy. The fifth theme was titled, The NFP Nurse is an Honest Expert
and the sixth related to how easy it was to access the NFP nurse when help was needed.
While Landry et al. (2012) usefully describe what contributes to families positive
experiences with the NFP program, there remains room to examine what underpins the
nurses’ contributions to the experience. For example, questions remain as to how nurses
develop relationships that provide a sense of expertise while also creating a sense of
friendship.
The Importance of Responsiveness
Much of the literature exploring relationships between nurses and high priority
families emphasizes the importance of particular nurse characteristics that invite a sense of
friendship that when coupled with expertise and a capacity to respond to the needs of
families support the development of good working relationships (Plews et al., 2005;
SmithBattle, 1997; 2000; SmithBattle et al., 2012). However, underlying descriptions of the
characteristics and expertise required to develop relationships is a call for nurses to be above
all else responsive; to open themselves to families such that they can intuit their needs and
then act in such a way as to ensure needs are met (SmithBattle, 1997).
Responsive relationships are conceptualized in the nursing literature as founded on
three essential elements: respect, trust, and mutuality (Tarlier, 2004). Tarlier (2004) reasons

24

that these three elements are grounded in ethical nursing knowledge; “a knowledge that
integrates personal and public moral knowledge as the basis for nurse-family relationships”
(p. 232). Discussions in the literature concerned with responsive relationships often do not
include its moral underpinnings. Tarlier (2004) however, roots responsive relationships in
the nurses’ public and personal moral knowledge. To illustrate, Tarlier (2004) presents two
aspects of responsive relationships that reflect personal and public moral knowledge. These
are appropriate engagement with the nurse-family relationships and the politics of power in
nurse-patient relationships.
In the first aspect, Tarlier (2004) points to a need for nurses to approach families from
the perspective of their own standpoint, as a “person and a professional, while
simultaneously acknowledging and engaging from the standpoint of the family” (p. 239). In
this regard, nurses acknowledge their own personal morals but as well, try to reconcile and
understand those of the family through a stance that is largely empathetic. In the second
aspect Tarlier (1994) emphasizes the need for nurses to be constantly aware of and be willing
to negotiate issues related to “balancing patemalism/matemalism with advocacy, mediating
personal and professional mandates and managing issues of power” (p. 239). Responsive
nurse-family relationships imply collaboration, negotiation and sharing of knowledge and
power and as such are “incompatible with abuse or misuse of power and authority” (p. 240).
SmithBattle (1997) conceptualizes responsive relationships in much the same way as
Tarlier (2004) however SmithBattle (1997), does not discuss the moral underpinnings of
responsive relationships. Instead she focuses her discussion around the importance of
developing situated understandings that consider the lived realities of families as they are

25

influenced culturally, historically, traditionally, politically, and socially (SmithBattle, 1997).
When considered in light of Tarlier’s (1994) discussion, situated understandings imply a
personal and public moral knowledge that values the uniqueness of families. Indeed, situated
understandings evolve with nurses who, as Parse (1997) states, engage in relationships that
exist as “subject-to-subject interrelationship[s] that honour the ever-changing realities] of
the other” (p. 173).
Public Health Nurses Presence and Home Visiting
Literature concerned with the PHN practice of home visiting puts a particular
emphasis on the development of situated understandings (Benner, Tanner, & Chesla, 2009;
SmithBattle, 1997). Although this body of literature does not specifically use the term
situated understanding, it clearly points to the importance of embracing the lived realities of
families such that they feel understood, respected, and valued. Home visiting offers nurses
opportunities to engage with clients that are unparalleled in any other intervention. Meeting
in the home provides nurses with an opportunity to experience more fully the realities of
families as they are lived everyday. The practice of home visiting has been a part of the
public health nursing landscape since the time of Florence Nightingale, who saw home
nursing as an opportunity to access the sick and the poor in workhouses and workhouse
infirmaries (Monteiro, 1985). To date home visiting continues to exist as one of the most
effective ways to access and engage families, however it is also considered one of the most
challenging aspects of PHN practice, particularly with high priority families.
Literature concerned with home visiting stresses the importance of being open and
friendly, communicating effectively, and therapeutic use of self (DeMay, 2003; Heaman et

26

al., 2006; 2007; Jack et al., 2002). In addition, having a keen sense of timing, being
sensitive to the needs of the family, and being willing to suspend agendas to meet the family
where they’re at, work to develop trusting relationships between the home visitor and the
family (Briggs, 2007). However, these can be difficult to achieve, particularly for novice
PHNs whose practices are often indicative of inexperience. Novice PHNs can be tied to
policies, protocols and guidelines that make relating to the family a challenge (Benner, et al.,
2009; SmithBattle, 2004). Furthermore, the lack of practical experience associated with
novice PHNs can cause anxiety and nervousness as they grapple with the unfamiliar when
faced with a myriad of families and family concerns (SmithBattle, 2004).
SmithBattle (2004) recognizes the difficulty inherent in developing a situated
understanding and responsive relationships, particularly for novice PHNs but she concludes
by offering advice to new PHNs wanting to develop the skills necessary for both. I will end
this literature review with a view into some of what SmithBattle (1997) and Tarlier (2004)
suggest with respect to personal and professional development to create responsive
relationships. SmithBattle (1997; 2000) starts by asking that nurses reflect on their own
preconceived notions of what comprises high priority families and reflect on these notions
with an open mind. Tarlier (2004) offers a similar suggestion by highlighting the need to
“negotiate intersecting paradigms” as an important facet to appropriate engagement with
families. Negotiating intersecting paradigms involves the creation of a common space in
which to engage with the patient despite differing world views (Tarlier, 2004). This practice,
remarks Tarlier (2004) creates common ground and fosters a sense of willingness on the part
of the family to enter and engage in relationships.

27

Summary
In summary, this review explored several bodies of literature aimed at articulating
processes involved in developing good working relationships. The intent was to examine
closely the nature and character of good working relationships as they are presented in the
literature. A key component in this aim was to explore how nursing presence contributes to
the development of good working relationships. The theoretical literature focused on
presence provided a view into the phenomenon as it unfolds in relationships. The concept
analyses provided a similar view but focused more on antecedents and attributes associated
with nursing presence. The qualitative literature did not directly include nursing presence as
a topic of inquiry. It did however provide insight into how specific nurse characteristics
contribute to the development of relationships. Many of the characteristics outlined in the
qualitative research echoed those described in the concept analyses.

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CHAPTER THREE
Methodology and Method
The Qualitative Paradigm
Qualitative research supports a process of understanding that is in a continual
development. Coming to understand something requires shifts and changes as new
experiences emerge. Equally important is the idea that the researcher and participant are part
of a unique interaction that shapes and informs understanding, which involves the practice of
interpretation. In contrast to quantitative approaches that flow from a highly objective, decontextualized epistemological position, qualitative methods, particularly interpretive
approaches, emphasize the existence of multiple truths, realities and understandings of the
world and the inherent value of individual experience (Vis, 2008).
Research undertaken within the qualitative paradigm is well suited to questions that
are concerned with the nature of experience as it is lived daily by the participants under
study. Van Manen (1997) notes that “from a phenomenological point of view, to do research
is always to question the way we experience the world, to want to know the world in which
we live as human beings” (p. 5). In this regard, qualitative research assumes that reality is
socially constructed by every unique individual, from within their own unique contextual
understanding (Vis, 2008).
Hermeneutic Phenomenology
Hermeneutic phenomenology has been described as the practice and theory of
interpretation and understanding in human contexts (Moules, 2002). Its central premise is
that human beings are attuned to meaning and that meaning is derived through our being-in-

29

the-world (Fleming, Gaidys, & Robb, 2003; Thistleton, 2009). Through the practice of
interpretation, researchers seek to reveal meaning, meaning that is often taken for granted
with the goal to understand more fully (Moules, 2002). As an approach to inquiry, it is
considered a reflective inquiry that is concerned with “our entire understanding of the world
and thus...all the various forms in which this understanding manifests itself’ (Gadamer,
1989, p. 17).
Research undertaken with an interpretative or hermeneutic approach in many ways
defies method. Hermeneutics is a substantive philosophy rather than a strategic method
(Moules, 2002). There is no didactic play book that directs the researcher through a series of
steps to arrive at a foregone conclusion. Rather, there is philosophical guidance that asks the
researcher to stay true to certain underlying principles as they explore the topic under study
(Moules, 2002). The philosophical principles that served to guide this project were those laid
out by Hans Georg Gadamer (1989) and Max van Manen (1997). Gadamer (1989) asks that
we pay particular attention to language and its uses and that we keep our pre-conceptions or
pre-judgments constantly in view. Pre-judgments reasoned Gadamer (1989) are always with
us and shape who we are as beings-in-the-world and are shaped by our being-in-the-world
(Binding & Tapp, 2008; Fleming et al., 2003). They form as we experience the world and are
thus rooted in our histories, cultures, and traditions (Gadamer, 1989). Because our pre­
judgments exist as an inherent part of who we are, we cannot, as some would suggest,
bracket them out in our attempts to discover the true meaning of things. Instead, Gadamer
(1989) asks that we embrace our pre-judgments, keep them close so that we can understand

30

how they shape and influence our perceptions and understandings of what we believe to be
true.
Max van Manen (1989) offers six research principles or activities thought to guide
phenomenological research. He writes: “How can human science research be pursued?
Reduced to its elemental methodical structure, hermeneutic phenomenological research may
be seen as a dynamic interplay among six research activities” (p. 30). This chapter outlines
four of these activities as they are described by van Manen. The first of these activities;
turning to a phenomenon which seriously interests us and commits us to the world which
Gadamer (1989) aptly called “the experience of address” is described in Chapter One of this
thesis. The second principle or step in van Manen’s (1997) approach involves investigating
experience as it is lived rather than as we conceptualize it (p. 30). This activity is outlined
with a description of the participants involved in the research and data collection processes.
Step three, reflecting on the essential themes which characterize the phenomenon and step
four, describing the phenomenon through the art o f writing and rewriting are described in
the discussion and conclusion sections.
van Manen’s fifth research activity maintaining a strong and oriented relation to the
phenomenon relates to my overall research approach, van Manen insists that qualitative
phenomenological researchers must maintain a strong orientation to the phenomenon in
question in order to avoid getting “side-tracked or to wander aimlessly and indulge in wishywashy speculations, to settle for preconceived opinions and conceptions” (p.33). In this
study I attempted to maintain a strong orientation to the phenomenon by constantly reflecting
on my own understanding of nursing presence and on the experience as I sought to interpret,

31

explain, and deeply understand the nature and character of nursing presence from the
perspective of families. Lastly, van Manen’s sixth research activity refers to a continuous
process of balancing the research context by considering parts and whole. Carrying through
the sixth research activity involved consciously moving in and out of all five of the previous
outlined research activities. To engage in phenomenological research, one must be willing to
live in the tensions that phenomenological research presents (p. 131). Throughout this study,
I continuously had to balance my intense, personal involvement with the experience of
nursing presence while simultaneously providing a thoughtful inteipretation of what families
had described throughout their experience.
Description of Participants
Participants in this study included eight families from northern British Columbia
whose last recorded contact with PHN services was no less than three months prior, and no
longer than one year to being interviewed for the original WRP (2005) study (MacLeod et
al., 2005). All families lived in northern British Columbia communities whose populations
range from 10,000 to 76,000 (Statistics Canada, 2011). The closest metropolitan center of
100,000 residents or more is located over 500 km away from each respective community.
The main industries within these communities are forestry, mining, oil and gas, lumber and
pulp mills, and fishing (MacLeod et al., 2005).
All of the families selected for this study had children and reported having been
involved with PHN services through the practice of intensive home visiting. Although
family units were not explicitly described or defined by the families themselves, most
interviews occurred with the mother of the family. In one instance, both the mother and the

32

father participated in the interview. Until recently, home visits in northern British Columbia
were offered through the Family’s First Program (FFP), a program that offered universal
home visiting to all primiparous women following the birth of their child (Reiter, 2005). If
following the initial home visit, families were found to require more in the way of service,
PHNs would arrange for more intensive visiting with families (Reiter, 2005).
The FFP program was carried out differently in the various communities represented.
For the seven families living in some of the smaller communities, the FFP was incorporated
into the general practice of PHNs (MacLeod et al., 2005). The one family living in the
largest community was offered intensive home visiting services through the Families Count
Program (FCP). In this program, teams including PHNs and home visitors provide intensive
support to families for upwards of five years through an ascribed program delivered weekly
through home visits by lay visitors who would report to PHNs acting as case managers
(Reiter, 2005).
Data Collection
Data for this research project were collected as part of a larger qualitative research
project entitled, The Working Relationships o f Public Health Nurses and High Priority
Families in Northern Communities (WRP). Participants for this study included twenty-five
families, thirty-two PHNs and three lay visitors in the Northern Health Authority. The
original study employed three avenues of inquiry. The first was to conduct in-depth, open
ended interviews with participants to elicit rich narrative data about families’ and nurses’
experience and the contexts of that experience (MacLeod et al., 2005). The second involved
participant observation of PHNs and lastly, a documentary analysis of relevant nursing

33

policies and standards was conducted (MacLeod et al., 2005). This research study utilized
interview data, both in audio form and interview transcripts from eight families interviewed
for the narrative component of the original WRP (2005) project.
Participant Selection, Recruitment, and Interview Process
Participants for the WRP (2005) study were selected from fourteen communities in
northern British Columbia that represented eight different types of community contexts. The
community contexts were described by PHN collaborative partners in the study who reported
these contexts as profoundly impacting their work with high priority families (MacLeod et
al., 2005). The contexts were community size, the proximity of the community to First
Nations reserves, the numbers of public health nurses in the community, and the availability
of community resources (MacLeod et al., 2005).

Data were obtained through twenty-three

in-depth individual interviews and one focus group with families, eighteen individual
interviews and three focus groups with PHNs, one focus group with PHN interviewers and
one focus group with lay family visitors. Prior to interviews and focus groups, written
informed consent was obtained from participants. All interviews with families were
conducted in person by PHNs trained by one of the researchers in family interviewing
(Moules et al., 2005). Anonymity of participants was maintained by having PHNs interview
families outside their region of practice (Moules et al., 2005). Senior researchers conducted
all PHN interviews and focus groups, with one exception: one PHN focus group was
conducted by the research coordinator (MacLeod et al., 2005).
Of the eight interviews with families selected for this study, four described their
relationship as challenging and four considered their relationship to be easy. Interviews were

34

selected based on the depth and richness of family descriptions of their relationships with
PHNs. During my initial review of the family transcripts it became apparent that some
families described their experiences in more depth than others. They talked about the process
of developing relationships and in doing so revealed inherent complexities that seemed to
play a part in determining the outcome of the relationship. Choosing from a selection of
varied experiences facilitated a better understanding of how complexities were negotiated
over the course of the relationship.
The purposeful sample was also selected for logistical reasons related to data
management and analysis within interpretive approaches. The goal of hermeneutic inquiry is
to uncover a meaningful account that reflects and resonates with the experience of those in
the study (MacLeod et al., 2005). It is not an approach “validated by numbers but by the
completeness of examining the topic under study and the fullness and depth to which the
interpretation extends understanding” (Smith, 1991). An adequate sample size is one that
permits a deep analysis, which results in a new and richly textured understanding of
experience. As such, eight transcripts for a study of this nature were enough for the creation
of substantial themes.
This inquiry was guided by the following research questions:
•

What is nursing presence?

•

What is the experience of nursing presence for families engaged in relationships with
PHNs?

•

How does nursing presence influence PHN-family relationships?”

35

Data Analysis
Data analysis initially involved reading and re-reading all twenty-five transcripts
from interviews with families for the original WRP (2005) project. From these, I was able to
identify eight transcripts that provided rich and detailed descriptions of what comprised easy
relationships and challenging relationships for families engaged with PHN services. In order
to gamer a complete sense of the relevance of these family experiences to the research
questions, I also obtained audiotapes for the eight transcripts. The audiotapes proved
invaluable to gaining a holistic understanding of family experiences. Listening to the spoken
words of families invited a view into their experience as it unfolded in memory and as it was
re-lived with the PHN interviewer. The audiotapes provided an opportunity to hear subtle
inflections and changes in tone of voice over the course of the conversation. Listening to
family conversations with the PHN interviewer provided an opportunity to hear not only the
words but as well moments of thought and reflection that added to the detail and richness of
the written transcripts.
Both the audiotapes and transcripts proved essential in determining themes thought to
contribute to the meaning of the phenomenon. As I listened to the audiotapes and read the
transcripts, I wrote down bits of data that comprised words, sentences, phrases and anecdotes
into a journal and cross referenced these with the transcript number so that transcribed
material could be easily found. I also used the journal as a way to reflect on other literature I
had read that resonated with what I was seeing and hearing in the audiotapes and transcripts.
This included research literature, philosophical literature, and even novels that felt as though
they had some resemblance to the topic under study. The journal also allowed me to record

36

my personal reactions to the data. I was able to write down how I felt, or what I believed was
being suggested, in order to examine the impact that my pre-judgments had on my
interpretations. This encouraged me to further question what I was reading, hearing, and
what I was feeling to again ensure that what I was seeing was indeed reflective of what was
being stated by families.
Following this, I reviewed all transcribed material in my journal with a deliberate aim
to find similarities and differences among what families had described. Over the course of
several weeks, essential themes were revealed. Essential themes are defined by van Manen
(1997) as those that cannot be removed from the phenomenon lest the phenomenon loses its
fundamental meaning (p. 107). Once I was confident about what I understood to comprise
the essential themes, they were coupled with thoughtful selections of text and copied
verbatim from the transcripts to illuminate their meaning.
The analysis of these excerpts involved careful reflection, writing, and rewriting in
order to enliven the thematic aspects of the participants’ words. In hermeneutic traditions
this involves “bringing the topic to life in language” (Moules, 2002, p. 32). This does not
imply that hermeneutics reports on meaning but rather, “creates it, not by translating one’s
subjectivity out of the interpretation but by applying oneself to it with a sense of
responsibility to deepen understanding” (p. 32). This proved most difficult for me as a
neophyte hermeneutic phenomenological researcher. I was forever enmeshed in how to
articulate meaning without sounding overly didactic or prescriptive. At the same time, I
found it difficult to fully immerse myself in the circularity of language that often defines
many hermeneutic studies. I wanted to create an account that resonates but as well, that was

37

equally accessible to those less familiar with hermeneutic processes. A helpful process in
this regard was to engage with the data by constantly questioning what I was seeing and
hearing. Equally important was writing down my thoughts to provide an account of my
interpretations that remained true to the whole of what was being said but as well, remained
true to the voice of families who described their experiences in simple yet resonant terms.
Methodological Rigor
Rigor in qualitative research is equated with notions of credibility, transferability, and
dependability (Koch, 1994). Credibility and transferability in hermeneutic studies are
obtained when interpretations provide faithful, recognizable, and true descriptions of
experience, in that they ring true to those who read them (Moules, 2002; Laverty, 2003).
Gadamer (1989) suggested that there are many interpretations, and though none are finite
there are some which offer a better account and ring more true. This applies not only to study
participants but as well to others in similar situations. Findings can “fit into contexts outside
the study situations and [are] viewed by audiences as meaningful and applicable in terms of
their own experiences” (Moules, 2002, p. 33).
The method I used to determine if interpretations were indeed faithful, recognizable,
and true involved reviewing the findings of this study with colleagues and other nurses,
particularly those working in acute care settings. I was particularly interested in whether or
not the account offered would resonate with nurses working outside of public health.
Unfortunately, it was not possible to re-establish contact with the families interviewed in the
original WRP (2005) study, however connecting with nursing colleagues in both public
health, acute care, and those who currently teach was accomplished. These nurses indicated

38

that the findings of the study resonated with their own experience and they expressed general
agreement that indeed, relationships in general could be challenging; particularly those with
high priority families. Two of the nurses appreciated the insights afforded through the
discussion regarding responsive relationships, adding that the connection between responsive
relationships, self-reflection, and self-awareness was what resonated most.
Dependability lies in the exact documentation of the process of inquiry and
interpretations must be supported by the selection of transcripts (Moules, 2002). The
researcher must not be led astray by tendencies to interpret the speaker beyond what is being
said. At times this proved difficult as I found myself empathizing with the experiences of
families as a public health nurse as opposed to a researcher. In my practice as a public health
nurse, I had witnessed and personally experienced many nurse- family relationships that
were similar to those described by the families. It was difficult at times not to presume to
know what the right or proper approach with families should be. My hope is that, throughout
this project, I have indeed remained true to the words of participants and presented
interpretations that would ring true to them and other families engaging with PHNs in
relationships.
Ethical Considerations
Participants in the WRP (2005) study were informed of the voluntary nature of their
participation in this study and their right to withdraw at any time. Confidentiality of
interview participants was maintained by ensuring access to audiotapes and/or transcriptions
by research personnel only. Anonymity was maintained through coding of all names and
places. Ethics approval for the WRP (2005) study was obtained in 2004 from the University

39

of Northern British Columbia. Ethical approval was obtained for this study in May 2012
from the University of Northern British Columbia.
Confidentiality of participants for this study has been maintained as per the requirements of
the original WRP (2005) study. Transcripts and audiotapes made available to myself were
coded. Anonymity was insured through letter coding of all identifying names, people, and
places. In addition, this study makes no reference to participants or places throughout. Data
have been securely stored under lock and key and will remain stored for an indefinite amount
of time.

40

CHAPTER FOUR
Findings
Meeting at the Beginning, the Middle, and the End
Studies have shown that the success of PHN work with families depends on the
development of relationships. The nature of PHN work and the context in which it is carried
out require that PHNs negotiate, collaborate, and work toward goals with families that are
mutually derived. In addition, PHN service is an invited service. It is not required or
mandatory but occurs at the volition of the family. The voluntary acceptance of the service,
its emphasis on collaboration and the context in which the work is carried out all have a
resounding influence upon family understandings with respect to the nature of PHN work
and its relationship to the comportment of the nurse. Comportment in this context is defined
as the way or manner in which one conducts oneself (Oxford English Dictionary). As I read
through the transcripts chosen for this study, it became clear that families have definite
expectations with respect to how PHNs should be as home visitors, be as purveyors of
knowledge, and be as sources of support.
The research questions guiding this study focus on family experiences with nursing
presence. Presence in this context refers to the nurse’s way of being; a manner or air that
acts to engage families in the development of relationships. In this study, nursing presence is
understood as being inherently connected to the comportment of the nurse. Although
nursing presence exists as a sentiment that at times seems almost palpable, it remains a
difficult concept to define. By attending closely to family descriptions of the nurse’s

41

comportment we are better poised to understand how the nurse’s way of being; her air, and
her manner influences family experiences of nursing presence. When families talked about
their relationship with the nurse, they described behaviours, mannerisms, and actions that
either supported the development of the relationship, or caused it to falter.
One of the most interesting and perhaps significant insights offered through family
descriptions of the nurse’s comportment is the idea that in order for relationships to work, the
nurse had to consistently demonstrate her presence in terms of her responsiveness and
willingness to be there for the family. Families described subtle yet very important changes
in how the nurse supported the family, shared information, and visited in the home as the
relationship evolved. Families also stressed how important it was that these changes or shifts
in how the nurse presented herself occur at the right time and in response to the families’
needs. Analysis of the family transcripts has revealed that broadly speaking, these shifts and
changes in how the nurse responded to families occur over three phases of the relationship.
The discussion that follows explores family experiences of the nurse-family relationship
when both meet for the first time, meet in the middle of the relationship, and at the end of the
relationship.
Meeting for the First Time
Meeting for the first time is critical to the development of trust between nurses and
families. Trust is considered the cornerstone to developing relationships. Without it,
relationships can falter or never figuratively get off the ground. When families described
meeting for the first time, they talked at length about how important it was that the nurse
convey trusting behaviours. They were equally concerned however, with their own ways of

42

being and how those would be perceived by the nurse causing feelings of nervousness and
anxiety at the outset of the first visit:
And again that might just be my personality... like afraid of what she might tell you
or maybe you’re doing something wrong and she’s there to tell you you’re doing it
wrong, I don’t know! Or is my house clean enough or...do I...does everything look
good? You know...you want to make a good first impression
Making a good first impression speaks to an overall sentiment families expressed at the
prospect of having this complete stranger in their home for the first time. Although families
understand the role of PHNs to be largely supportive and appreciate the convenience of home
visiting, many felt the initial entry into the home to be an extremely personal thing that at the
outset left them feeling a little exposed, “you’re inviting them into your life, at home they get
to see more of you”.
Feeling exposed was often tied to the perceived authority of the nurse, which is
understood as having two dimensions. The first relates to the knowledge of the nurse.
Families expected PHNs to be authorities in their field and share information that was both
current and practical. However, they also admitted to being intimated by the knowledge of
the nurse. If PHNs entered the home asserting more of their authority as an expert than was
perceived necessary by the family, the family felt they were too professional, overly focused
on their role as an expert nurse with not enough emphasis on the personal nature of the visit:
Well, the reason why I didn’t like her very much is because she was too... and
then I thought it was in my head, right, I’m thinking okay, well maybe I’m just

43

imagining this cause you don’t know yourself any more, right when you’re going
through that. So I asked my husband. And he sat through a visit and...what I
thought...now I understand that she’s a public health nurse, I understand that’s
her job and that kind of thing, but... when you’re coming over to somebody’s
home and...let’s face it, it is very personal. Your baby is involved, you’re
going...and if you are going through postpartum that’s a biggie and it would be
nice...she was too...I would say she was too job-like. This is my job and this is
what I do and this is black and white and these are the rules and.. .she wasn’t
personal at all.
The second way authority was understood relates to the role PHNs play in surveillance of the
family (Selwood, 2010). In cases where PHNs witness behaviours or lifestyle choices that
might put children at risk, they are bound by law to report to the appropriate authorities
(Selwood, 2010). Although this is far from the central mandate of public health nursing, it
does determine a certain level of authority over the family that although rarely asserted,
shapes some of the work and as such, some of what families understand about the role:
1 didn’t want to talk about everything, because some days were really bad. And so
I...I know your rules! I know your rules!
The personal nature of home visiting coupled with the understated yet very real authority of
the PHN was particularly pronounced for families who had negative experiences with other
support agencies and/or PHNs. These families expressed hesitancy at the prospect of having
public health enter the home because past experiences with authority had overshadowed the

44

supportive function of the nurse. Indeed, one family refused home visits outright opting
instead to meet with the PHN at the health unit:
I didn’t want them in my home.. .1 didn’t want to go through that again so...so
I took him to the office to have his shots.. .that’s where I met her first.
For this mom, meeting at the health unit, instead of at the home acted as an initial safeguard
against what she understood to be a potential threat. In cases where families had children
removed from the home, or lived with the threat of removal, home visiting was indeed a
danger. As indicated here, some families choose the safety of the office for their initial visit
because it is understood as neutral territory, a place where the family can acquire needed
service without feeling scrutinized, judged, or misunderstood.

Meeting at the health unit

also gave families an opportunity to assess and evaluate the PHN before inviting them into
their home. For families who felt intimated by the meeting in the home, meeting at the
health unit gave them an opportunity to discern, without prejudice whether or not they could
trust the nurse. During a brief office visit, families described how they could tell, almost
immediately, whether or not things were going to work out:
Well, for a period of time I went to see different nurses for their shots. And I
Didn’t like any of them...well, it’s not I didn’t like them, I didn’t feel comfortable
with them. They seemed to be mean with giving needles and not really...caring
about how the mother feels...whereas with S...she was always gentle...she gave
helpful advice. She...you can see that she cares about the child...or she cares
about the mother

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The importance of the first few moments. Families determine in moments, whether
or not they are going to be able to work with the PHN through a process called “thin-slicing”.
In his book Blink (2005), Malcolm Gladwell underscores the importance of the first few
seconds of any encounter and uses research about rapid cognition to show that the human
brain has an amazing ability to “thin-slice” and form impressions of others in a glance.
Before families have had the first encounter, they ask questions of themselves and of the
nurse. Is the PHN trustworthy, competent, and effective? Will she like me? What will she
think of our home and our family? Answers to these questions are arrived at within seconds
by attending to subtleties and nuances observed in the PHN’s comportment. Our capacity to
thin slice implies that the first few moments of conversation may predict the success of the
entire nurse-family relationship. Although families did not say so directly, they allude to the
importance of being self-aware; of being conscious of what is said, and not said through
body language:
The other nurse was judgmental. She was like...she had attitude the minute she just
walked in and looked at me. And I seen that and I didn’t like that at all so I gave her
an attitude right back
In the beginning of relationships, families stressed how much they appreciated a
nurse who entered the home as a guest and who shared stories. Those who entered
conveying a sense of respect for the family and a willingness to accept the family on their
terms, were viewed as welcome guests. For some these gestures may seem trite, but for
families experiencing hardship or who have felt scrutinized by other support agencies,
entering the home as a welcome guest is vital.

46

For many Northern British Columbia families, having a PHN who entered the home
as a welcome guest was particularly significant. In Northern British Columbia, there are a
number of families living in poverty who are of Aboriginal descent (Macdonald, 2011).
Aboriginal people across Canada have faced systemic hardship as a result of government
policies that continue to assert their effect today. Past assimilationist policies that saw the
forced removal of many aboriginal children from their homes have created a persistent
mistrust of outside agencies (Macdonald, 2011). PHNs have reported difficulty with
accessing and engaging Aboriginal families. When PHNs are invited into the home,
engendering a sense of trust, acceptance, and respect is pivotal to developing and
maintaining a relationship.
Teaching and learning in the beginning. One of the most powerful ways PHNs
engender a sense of trust with families was to share particular details of their lives through
stories. Sharing stories is among one of the oldest methods of communication (Hunter,
2008). Stories serve to educate others, record historical facts, teach cultural values, and share
common experiences (Hunter, 2008). For nurses, telling and listening to stories related to
health and illness provide a vital means through which human experiences can be honored
(Hunter, 2008). Stories give families an opportunity to voice, in their own words, what their
experience is like and how it has impacted the family. When nurses shared their stories,
families realized that their situation, although unique to them, is in many ways similar to the
experiences of the nurse. In the process of sharing, the family’s sense of being alone in the
experience can dissipate, restoring a sense of calm and control:
That worked for me, yeah. Actually it was good. I mean I w as...I’m a new

47

mom so...and I don’t have any family around here so I don’t have...my mom
here or any sisters or anything. So it was nice to have another... another person.
And it turns out she’s a mom so that’s helpful...because...you know, she has
personal experience with it you know. It’s just like being a teacher, you know .:
When.. .you know, I’ve worked with kids for almost ten years now so.. .but even
now that I’m a mom, I’m starting to look at things differently. And I mean it’s
just.. .1 mean.. .you know, you see a different point of view. One that you maybe
wouldn’t have considered before. Not to say that... not to say, of course that I was
callous or.. .you know, didn’t think of it in that way. But I think it gives you a
little more insight.
Families also remarked that when the nurse shared stories, they listened and learned
more:
She told us about what worked for her...different positions for
feeding...breastfeeding her baby and that was really helpful.
Sharing stories as a way to communicate knowledge is important to consider for the first
home visit. When PHNs visit families with new babies in the home, they deliberately do so
around 4-5 days post partum because this is when issues with breastfeeding or post partum
depression typically become apparent (Reiter, 2005). It is also a time when post partum
women in general need extra support. They are often exhausted, feel overwhelmed, and need
encouragement. When mothers are in this state, it is difficult to make sense of a day let alone

48

reams of information. Sharing stories can be a valuable way to educate moms who in their
postpartum state may not feel terribly open to didactic teaching.
Sharing stories also had a disarming effect for families who initially felt intimated by
the nurse’s authority. Some families expressed feelings of intimidation with the nurse’s level
of education. They had experienced being talked down to in the past, and had felt that their
knowledge hadn’t been valued, and that they had been doing things the wrong way:
I’ve spoken to nurses before, you know, in the health unit who they’re like oh,
well, you need to do this and you need to do that with your baby ‘cause they’re
just full of information and they just tell you how to do it.
When families felt intimated by the knowledge of the nurse, stories helped to contextualize
new information in terms more familiar to the family. Stories had the effect of making new
information more practical and accessible. In addition, when PHNs shared stories, families
were able to see that although the PHN perhaps had more education and a different lifestyle,
both had been shaped by the shared experience of parenting. Families in effect felt more
connected to the nurse and less intimidated by her education and knowledge.
Families who experienced visits with nurses who were willing to share their stories
felt as though the nurse had given something of themselves. Stories had the shared effect of
personalizing the first home visit and of engendering a sense of trust for the family. Through
stories families and PHNs came to know one another and together, could co-create a sense of
safety and comfort.

49

Summary. Relationships at the beginning are tentative, even precarious because of a
power imbalance related to professional practice. This is in part because families understand
the initial meeting or invitation into the home as representing more than a mere opportunity
to share information. It is an invitation into their lives. Families are keenly aware of what
home visiting offers the nurse in the way of assessment and they are equally aware that
relationships with PHNs are neither equal nor balanced. If relationships were going to
figuratively “get off the ground”, families insisted that nurses be carefully attuned to how
they walk in the door and share information. It is clear from the transcripts that if nurses
asserted too much authority, were in any way insensitive to the needs of the family, or
implied judgment, the relationship would falter.
Meeting in the Middle
Although meeting for the first time plays a pivotal role in the outcome of
relationships, relationships also require maintenance over time. In order for relationships to
hold together and grow, families required above all else that nurses be attuned to their needs
and be willing to meet them where they are at. “Meeting me where I’m at” was a phrase
used by families to describe how important it was that nurses move with the family, that they
be attuned to the needs of the family, and more importantly, tailor their responses to meet
those needs.
A central component to being able to meet families where they are is the need for
caregiver continuity. Being responsive to the needs of families at specific points in time
requires a heightened sensitivity to the ways of the family and the context in which they live.

50

When we consider that the beginning of relationships are marked with tentativeness requiring
time and effort to come to a place of mutual comfort, we can see how important it is that the
same nurse visit with the family whenever possible. Families equally stressed the
importance of continuity. Indeed, when continuity was amiss, they were very forthcoming in
their frustration:
They sent the two women over to the house.. .and I thought it was kind of odd
because they came to the house to see how things were going and then I.. .actually
I quite like them, right, and when I phoned or they phoned.. .1 was talking to
somebody and they told me that they wouldn’t be coming back. So.. .what is the point
of trying to.. .you know, you’re going to be getting something going with this
particular person and then it’s like.. .so I thought that was kind of strange.
Equally important to caregiver continuity was fulfilling the expectation that PHNs be
flexible. Flexibility was referred to in terms of time and as a necessary component of service
delivery. For some families being flexible meant working around their schedules, allowing
families to choose times for appointments and home visits as opposed to strictly adhering to
the PHNs schedule:
She was very flexible. I got to make a time and talk to her about his growth, his
development, his risks, his...what was happening, the plans for and all that. So
that was really good.
Flexibility was also an important consideration in delivery of services. Families chosen for
this study, who required PHN services beyond the first maternity home visit were enrolled in

51

the Families First Program (FFP). FFP was a PHN initiative designed to foster healthy infant
and family development among vulnerable families. The program has since been replaced by
the Nurse Family Partnership program that has similar goals but a different delivery
structure.
Families enrolled in the FFP were provided with continued support in the areas of
growth and development of an infant or child, parenting and child safety, and nutrition
education (Healthy Child Manitoba, 2010). Support was provided within a general
framework that focused on helping families to identify their own needs and set goals
accordingly (Healthy Child Manitoba, 2010). The PHN acted to provide support and
education in obtaining those goals. For some families, the structure and flow of the FFP
proved challenging. Like many programs the FFP had a limited enrolment time and was
structured so that certain requirements were met at certain times (BC Ministry of Health,
2005). The focus on time proved difficult for families who simply were not in a place to
meet the requirements of a program:
This particular program, there was.. .definitive things that needed to be done that
was.. .making personal goals and.. .and achieving them and doing the journal and
stuff like that. Like there were certain things that I really had a hard time doing
just because of my... well, first off, I was working full time, even...at two months
and one month and stuff like that. So doing extras was really challenging. And
setting goals...well, I could hardly see five o’clock let alone what I’m supposed to
do in two months and three months.

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In these situations, families felt supported by PHNs who negotiated the program for them
and tailored its delivery to suit their needs:
She helped me try to find goals. Because I had a really hard time with it. So.. .but
then taking what I wanted to do and.. .and what my idea about goals is, cause I
have a different idea of goals than everyone else, for some reason.
When PHNs were flexible with time and provision of service, they made families feel
valued. Families felt valued as individuals and appreciated when the PHN recognized that
they have lives beyond their work with PHNs. When PHNs were flexible, families also felt
that their ideas and opinions were valued. Flexibility with the provision of service provided
families with an opportunity to discern for themselves what was most useful given their
situation and context. It allowed their own insights to take shape and inform goals that they
felt they could achieve.
Teaching and learning in the middle. Creating a space for families to learn and try
things for themselves assisted PHNs in maintaining relationships. In the beginning, families
new to programs and service needed PHNs to present them with information regarding the
best ways possible to care for their children. Information was offered by PHNs and taken up
by families in a way reminiscent of how teachers offer knowledge to pupils. As the
relationship progressed, families expected the PHN to shift from a role as teacher to one of
guide. Rather than expect the nurses to assume the role of leader in their approach to
knowledge sharing, families insisted that the PHN allow the family to lead and be there only
to support and guide when necessary:

53

I think it started off more...at first it was like...her showing us a little...showing
us things to do and we were looking more as like a .. .a guide or a teacher, to what
we were doing. But the more we.. .the more we started to learn about taking care
of H, the more we realized how unique his situation was [...] I mean, at the
beginning we really paid heed to everything she told us, and then after a while it
sort of like... we sort of put it through our little strainers and decided what to pay
attention to and what to just ...ignore
When the family felt as though the PHN was not letting them lead, families effectively
dismissed what the PHN had to say. Instead o f actively taking up what the PHN was trying
to teach, families ignored what they were being told:
We felt more like kids with a teacher coming to teach us, you know, like a piano
teacher or something. Like it didn’t ever seem like an equal sharing of...like it
didn’t feel like that to me. It felt like she was there to show and teach and we were
just to listen and follow.
Families were quick to state that although they appreciated the knowledge of the PHN, when
the PHN demonstrated a persistent need to assert her authority as an expert her actions
effectively countered their learning.
In situations where families felt the nurse was overly authoritative, families went as
far as to qualify the knowledge provided as “book knowledge” clearly distinguishing it from
practical knowledge. Book knowledge was described as being impersonal, overly didactic,
and in many ways cold in its presentation. By contrast, practical knowledge was often

54

presented through stories, was personal in nature, and forged a sense of connection for
families. Practical knowledge resonated with families in its capacity to relate to their own
personal experience and its usefulness. This is not to suggest that book knowledge was not
valued. On the contrary, it was not the content of the teaching but rather how it was
presented that influenced family understandings. When formal knowledge was translated
and communicated in a way that complimented the context of the family’s life, it became
practical. Families were able to connect what was being said to their personal experience and
use it to inform their own processes.
Sharing stories of being a mom too. Families described their connection to
practical, useful information by indicating a strong connection to information when it was
being communicated by nurses who were moms too. “Being a mom” too is a phrase that in
many ways describes the essence of what families considered practical, useful information
that they could relate to. When nurses shared their experience of being a mom, families
perceived their knowledge as being grounded in real experience. Families were able to hear
and see that book knowledge really works. Sharing information through experience helped to
ground book knowledge in reality:
And that’s what...when you’re a new mom you.. .want to know what really
works. You know, ‘cause a book can say you can put the baby in the bed and
give him a bottle and he’ll go to sleep by himself, but...is that really going to
happen?

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It is important to note that although sharing in the experience of parenting had the
effect of instilling faith in what was being taught, the experience of parenting should not be
considered a pre-requisite to developing good relationships. The effectiveness of the PHN
resides with the process of sharing. When information was shared contextually, by paying
attention to the family’s everyday reality, knowledge was perceived as useful and practical.
Sharing the experience of being a mother resonated with the realities of many families in this
study however, there were situations where families required PHNs to find different ways of
relating their knowledge. This is evidenced in two of the transcripts chosen for this study. In
one, the family describes a challenging relationship with a nurse who, despite sharing her
experience as a parent who had suffered post partum depression, failed to connect with the
everyday reality of the mom by not visiting when the mom needed it most:
When you get it. But don’t not come out and see me because I live in the toolies. If
anything, definitely come out and see me ‘cause I’ve got postpartum for God’s
sake, right? I need connection. And it...it...in a way it bothered me because she
told me that she went through postpartum and it’s like okay...you tell me that
you’ve gone through postpartum, you know how bad it is in the beginning, you
know how much you need to talk to people and where the hell are you?
In contrast to the above, another family described how diligently a brand new PHN worked
to gather and relay information with which she had no practical experience:
She just...I don’t know if it was anything that she said, but she was like...she
was very...like doing research and helping and...would bring me a plethora of

56

information on.. .It was helpful, you know, because.. .she is quite young and.. .it
was.. .1 was one of her first clients, like at home clients. She was new to the area.
She’s now having her first baby!
At the outset, it seems as though this nurse’s youth and inexperience might have served as a
barrier to the relationship, however, her willingness to share the only information she had to
support family rendered her lack of experience insignificant.
Summary. In summary, meeting in the middle marked a point in the relationship that
focused on maintaining the trust developed in the beginning but as well, empowering
families to “go it on their own”. Families characterized this process by describing subtle
changes in how the nurse shared information and supported the family. Nurses who were
willing to shift their stance from a position of teacher, as one who does for; to act more as a
guide, or one who does with, signaled confidence in the family. Families in turn felt assured;
took up what they had learned and made it their own.
Families indicated that information shared is more easily ‘taken up’ when it was
communicated through the shared experiences of being a parent. Sharing parenting
experiences had the effect of personalizing information. It made the work of parenting more
practical and easily understandable. More importantly, sharing parenting experiences created
a place where the nurse and family could connect. Differences in life experiences were set
aside in order to shift the focus toward what was shared and valued by both.

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Meeting at the End
Meeting at the end is described in many nursing theories as the termination phase of
the nurse-family relationship (Peplau, 1997). It marks the point where the relationship in its
entirety is evaluated in terms of the success of interventions and the attainment of goals
(Peplau, 1997). This section’s findings focus on the experience of three families who
described an overall easy relationship with nurses. The decision to focus on these families
relates to the provision of care by one nurse and the completion of her services. The
experience of care continuity places these families in a better position to recount and evaluate
the relationship at its end stage. In contrast, families who described challenging relationships
may have experienced an end but the end was not conducive to providing a comprehensive
evaluation of the relationship. Indeed, families who had experienced challenging
relationships focused more on how and why the relationship had faltered. This section is
aimed at exploring how it felt for families who had experienced good working relationships
to end the relationship. The discussion focuses on two nursing actions aimed at moving
families along during this time of transition, keeping doors open and transitioning. Families
who had experienced nurses that in response to their needs, moved them along in the
relationship and at the end indicated that doors would always be open, expressed a sense of
ease and empowerment when the relationship ended.
One of the most interesting findings with respect to the end of the relationship were
expressions of anxiousness and even fear on the part of the three families chosen for this
section. Initially, it was presumed that relationships which fostered a sense of trust and
empowerment insulated families from any sense of loss or anxiety associated with

58

terminating the relationship. Indeed, the assumption was that the three families, all of whom
experienced good working relationships, would indicate that they were ready, even willing to
end services with the PHN however, some expressed deep concerns with ending the
relationship:
I think 1 would probably.. .It would have been nice to have more frequent visits
and maybe have it go on a little longer, rather than even just a short six months
kind of thing.” Although I knew at the end it was okay and I was okay. Saying six
months really scared me. It was like oh my gosh, that’s it, that’s all you can
give me? And then you’re done and you throw me away? It was like really scary
because I felt there was a huge amount of help that I needed.
Although the sense of anxiousness expressed by this mother is indicative of what some
experienced, when at the beginning of the relationship they were told how much time they
were allotted for service, it also served as an expression of what some families felt when the
end was near.
When families are just beginning in programs, having a PHN establish time
boundaries is an important component in developing relationships (Reiter, 2005). However,
responding to the health-related goals and needs of the family at times requires flexibility
with timelines. Nurses reconciled the need to abide by timelines whilst honouring the needs
and goals of the family by indicating that despite programs ending at a pre-determined time,
doors would always remain open:

59

And she just said well, you know, if you really need me we could keep on...or,
you could keep coming to me for the immunizations. Even knowing that I could
still someday see her again was really helpful.
The effect of keeping doors open for families was twofold. In one sense, it demonstrated the
nurse’s willingness to be flexible and work with the family until health-related goals were
achieved. In another sense, keeping doors open gave families confidence and a sense of
comfort in knowing that they could remain connected with PHN services after programs had
ended. For families feeling anxious at the prospect of ending relationships, knowing doors
would remain open left them feeling re-assured that indeed, PHNs were always available
when needed.
In addition to keeping doors open, families also experienced nurses who made a point
of ensuring that, in the event families required more than the allotted time that they would be
the nurse who would continue providing service where possible. In situations where this was
not possible, the PHN made a point of personally informing the family that they may have to
see someone else:
She phoned, maybe not all public health nurses do that, but when there was this
switch and she couldn’t come out any more, she phoned me...you know, and
made the...that step in saying sorry I can’t be there any more, somebody is going to
be taking care of this aspect.. .She even expressed.. .she said oh, I won’t be able
see A anymore and I hope everything goes well. So I don’t know, I don’t
think... that’s not part of the job...it’s something extra that she just wanted to do.

to

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In this particular case, contacting the family personally to inform them that they would be
seeing someone else is immediately recognized as going beyond the call of duty. In
situations where the nurse was perceived as doing “something extra” for the family, the
effect on their sense of significance was profound. Doing something extra suggests that
families are cared about differently; as people and active members of a community rather
than clients on a caseload:
It’s the nurses...so it’s...you know, it’s who you deal with. And I’ve dealt with
many and remember them. And even today I can go downtown, you know and see
them, you know the ones that were always there for you and you remember
that.
Transitioning. Transitioning in the context of the nurse client relationship refers to a
way of starting to slowly move families from the beginning of the relationship toward its
inevitable end. Although transitioning looks different from family to family and from nurse
to nurse, it consistently involved making families aware of boundaries and timelines and
steadily increasing awareness as the relationship progressed. Initially, transitioning seemed
counterintuitive to the purpose of good working relationships. When we consider the
importance of relationships to the work of PHNs, telling clients that the relationship will
eventually end before it has even begun seemed wholly at odds with its intended purpose.
However, as I read through the transcripts it became clear that transitioning is indeed a key
component to ensuring good working relationships. In addition to moving families along in

61

the relationship, transitioning acted to help families evaluate their successes over the course
of the relationship and helped to maintain professional boundaries.
Families who experienced nurses that gently reminded them of the purpose, intention,
and time limitations of the relationship appreciated knowing up front what was expected of
them, what was involved, and how much time they had. Contrary to what was originally
assumed, families found that knowing that the relationships would end helped them develop
and focus on personal goals:
I think ‘cause I was getting weaned off, or that I didn’t have a choice! {laughs}
It just seemed like okay, I... I can feel that my feet are on the ground, I can feel
that there’s walls around me and I can feel that I can actually pay bills...you
know?
This family speaks directly to how knowing that the relationship was going to end pushed
them to realize their successes. Although we sense the family’s struggles in the beginning, it
is clear that knowing that the work of the relationship was purposeful and deliberate helped
the family overcome their difficulties. As the end neared, the family felt almost compelled to
recognize what they’ve accomplished.
Moving families along in the program through transitioning also serves to maintain
professional boundaries. When families understand that relationships are purposeful and
intentional with definitive time lines, it helps distinguish the nurse-family relationship from a
friendship. Although it is important that the nurse maintain a stance of warmth, openness
and friendliness in order to engage with families, their role is to support the family as a

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professional. This places considerable emphasis on the nature of transitioning as a relational
process dependent on sensitivity and responsiveness to the needs of the family. Although it
is critical to define the relationship in terms of its intended purpose and to indicate that it is
timely, to do so effectively requires nurses to be attuned to the family and carefully assess
their readiness. Families who experienced good working relationships alluded to having
worked with nurses who had transitioned them, almost seamlessly through the relationship.
Despite knowing expectations and timelines, they did not feel rushed. They felt supported
and confident in their capacity to set and meet desired goals. As one family stated, "she
didn’t rush us, we didn’t feel rushed...you know we felt easy with her”.
Summary. All of the families chosen for this section talked in varying degrees about
the end of the relationship but, as was previously mentioned, none felt like it was really the
end. This is due in part to the PHNs timing and sensitivity with respect to transitioning.
Families, who worked with nurses that were responsive to their needs, found transitioning
helpful. When conversations about time were coupled with sensitivity and a sense of
confidence in the abilities of the family, families found it easier to develop and focus on
goals. In a similar way, transitioning was met favourably when families felt that despite
programs ending, doors were always open. When they were told that they could “drop by
any time”, ending relationships seemed less daunting.

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CHAPTER FIVE
Discussion
This study began as an exploration into the nature of nursing presence. The questions
that guided this inquiry were concerned with how nursing presence is experienced by
families engaged in relationships with PHNs and how presence contributes to the
development of those relationships. Although families do not discuss nursing presence
overtly, they do offer a glimpse into its nature when they describe the comportment of the
nurse; her behaviours, actions and mannerisms and how these contribute to developing
relationships. By attending closely to what families described, we learn how important it is
that nurses act and be in ways that convey a sense of openness and willingness such that
families feel safe, confident, and secure about entering into relationships as well as
comfortable with how services are provided. We are also enlightened to the importance of
timing and of being sensitive to situation and context. Findings show that the actions,
behaviours, and mannerisms of the nurse were understood as meaningful only when they
were carried out at the right time, in the right place, and with particular attention to context.
In essence, families experienced nursing presence when they worked with nurses whose
perceptual abilities and relational skills enabled them to intuit how to be over the course of
the relationship and deliver services in response to the family’s needs.
Overall, families equated good working relationships with relationships that were
responsive in nature. In this study, developing responsive relationships was crucial to
developing partnerships between PHNs and families. This is, in part, because all of the
families highlighted in this study were high priority families whose experiences with

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vulnerability often have left them consigned to the outer status of society, judged inferior and
sometimes blamed for the social issues that insinuate their lives. Some had experienced
issues related to poverty, substance misuse, and poor family functioning that left them
feeling scrutinized, judged, and misunderstood. Families who lived with constant scrutiny
found it difficult to trust PHNs. They were often reticent to enter into relationships with
nurses because of previous experiences that had left them feeling undervalued.
PHNs who worked to develop responsive relationships were able to engage some of
the most reticent of families by being open, willing, and available. When PHNs were open
and genuine, families felt understood and accepted. They were more likely to engage in
open and frank conversation with the PHN and enter programs and services with fortitude
and determination. SmithBattle, (2009) and SmithBattle et al. (2012) recognized nurses who
openly engaged with families as nurses who were able to develop situated understandings of
families. Situated understandings are contextual understandings that consider the lived
experiences of families as they are influenced culturally, historically, politically, and
socially. Rather than approach families from an oversimplified understanding based on
purely objective norms, PHNs who formed situated understanding of families were able to
comprehend the complexities inherent in the lives of family’s. In addition developing
situated understandings provided the PHN with an opportunity to see and understand the
family more fully, accept their differences, and work with the family in meaningful ways.
In this study, nurse-family relationships that were responsive in nature evolved with
nurses whose ability to fully understand and appreciate the family enabled them to practice in
a truly family centered way. Family centered care is a care philosophy that builds on the

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strengths of families and fosters partnerships to collaboratively identify and address the
family’s needs and concerns (Blaycock, 2002). Family centered care is cited in the literature
as the crux of PHN practice with families. As this study demonstrates, there are PHNs who
instead of following the tenets of family centered care, practice from their own narrow
vantage point and focus on ‘fixing’ what they perceive as parenting deficits (Blaycock, 2002;
SmithBattle, 2009; SmithBattle et al., 2012). Rather than let families lead and guide their
practice, some PHNs tend to apply health promotion theory and patient education in naive
ways with the intent of correcting risky practices and unhealthy lifestyles.
For most families in this study, relationships did not work well with PHNs whose
approach to practice was overly didactic, formal, and focused on fixing problems. Rather
than experience the strength and empowerment that is supposed to permeate relationships
with PHNs, these families became disengaged with the services provided, and in extreme
cases, disenfranchised from exercising their own expertise. When PHNs approached
families bearing too much authority, as though they had all the answers, they inadvertently
de-valued the knowledge of the family. Conversely, nurses who invited the family’s
participation and recognized their personal experiences as valuable sources of information,
empowered families and supported their personal growth.
Families described many behaviours of the nurse that encouraged the development of
relationships that were responsive in nature; that exemplified a family centered approach to
care and that focused on empowerment. Two themes that represent a summary gestalt of all
that families said with respect to the nurse’s way of being are a responsive use of self and the
responsive delivery of services. In the following sections, these two themes are discussed

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separately however in practice both are inextricably bound as they reveal themselves within
the context of developing relationships with families. As this discussion will highlight,
families who experienced nurses who engaged in a responsive use of self also experienced
nurses who were responsive to their needs by being flexible with the provision of service.
A Responsive Use of Self
A responsive use of self is described in the literature as the action of a nurse who
above all else is present with the family; is there and with the family openly, willingly, and
attentively and who listens deeply and intentionally to what the family says and does not say
in order to disclose the relevant details of their life (SmithBattle, 1997; 2009). Once the
family’s frame of is grasped and better understood then the nurse can respond to the specifics
of the family’s situation and context. SmithBattle (2009), drawing on the work of
Heidegger, equates a responsive use of self as an act of liberating solicitude that “leaps
ahead...not to take away ‘care’ but rather to give it back” (Heidegger as cited in SmithBattle,
2009, p. 194). Leaping ahead occurs when the nurse in her stance of openness and
willingness grasps the family’s frame of reference. In her understanding, she positions
herself to develop rapport and a trusting relationship so that the family feels safe to disclose
their concerns, priorities, setbacks, and struggles.
In this study, families described acts of liberating solicitude with nurses who shared
particular aspects of their life and experience to develop common ground and teach in
meaningful ways. Findings show that relationships between PHNs and families can over
emphasize disparities in knowledge, authority, and power. Rather than foster relationships
that focused on respect and mutuality, some PHNs asserted power and authority over the

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family leaving them feeling de-valued and mistrustful. Families spoke quite candidly about
their concerns with the power of the PHN in surveillance of the family and with the PHNs
authority that comes with a specialized body of knowledge.
When families were apprehensive about entering relationships it was extremely
important that PHNs create a sense of common ground between themselves and the family.
One of the most effective ways to create common ground was to share personal experiences
with parenting or some other aspect of the PHNs life relevant to the family’s situation and
context. The effect of sharing on the development of the relationship was profound. When
families experienced PHNs who were willing to share a part of themselves, the family’s
reticence to enter into relationship seemed to melt away. Families willingly engaged with
PHNs, and perhaps more importantly, felt safe sharing parts of their personal life.
For families who felt particularly intimidated by the knowledge of the nurse, sharing
was also a valued way to render information less daunting. Indeed, nurses whose approach
to teaching overemphasized their expertise were frequently “tuned out”. Rather than take up
the knowledge they had to share, families disregarded what the nurse had to say and
dismissed her expertise as self-importance. Conversely, families expressed a deeper more
heartfelt understanding with what they had learned when PHNs shared information by
teaching through example and with reference to real life situations.
When the PHN responded to the reticence of the family and their concerns with
authority through the act of sharing they brought to light similarities in the everyday realities
of both that are all too often enshrouded beneath ascribed roles that emphasize difference.
This is particularly significant for high priority families whose experiences with vulnerability

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emphasize difference daily. In a society that places high regard on individual success and
achievement, vulnerable families are consigned to outsider status and often experience
judgment and prejudice based on prevailing assumptions that understand vulnerability as a
life choice. Given the vulnerability and social distance of these families from the PHN and
her services, sharing to create common ground is crucial to inviting families in, developing
rapport, and trust so that relationships flourish.
The Responsive Delivery of Services
As stated earlier, a responsive delivery of services was found to unfold with nurses
who, over the course of the relationship related to families through a responsive use of self.
Findings show that families who experienced relationships that evolved through sharing to
develop common ground, similarly experienced nurses who responded to their needs by
being flexible with time and the provision of service. Nurses who approached relationships
failing to grasp the complexities inherent in the lives of families and who failed to embrace
their uniqueness, offered services in a pre-determined, nurse-directed way that emphasized
programmatic policies and protocols. Conversely, it would seem that nurses who invited
families into relationships by offering up part of themselves in a more personal and
connected way worked to ensure that services were delivered and taken up by families
meaningfully.
In order to illustrate the differences inherent in both ways of being and working with
families, I will draw on the work of Aristotle. Aristotle referred to a practice that relies on
fully spelled out rules and guidelines to achieve outcomes as episteme (Parry, 2008, Aristotle
section, para 2.). Episteme in the context of this study refers to those nurses who rather than

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share information meaningfully, through personal experience and real life examples,
approached the family overemphasizing the theoretical embedded in their knowledge.
Instead of working with the family to develop the best way to convey information, some
PHNs rigidly adhered to guidelines, policies, and book knowledge in their teaching. In
some cases an overly didactic approach to teaching effectively diminished the experiential
knowledge of the family. Rather than feel as though the PHN was there to work with the
family, some families felt as though the PHN was simply there because it was her job. By
contrast, nurses who communicated information in useful and meaningful ways were able to
grasp and understand the family’s frame of reference, embrace the family’s lived experiences
and value the family’s knowledge. Nurses who worked with families engaged in what
Aristotle calls phronesis; a term for the mode of reasoning associated with praxis (Cohen,
2012, Categories section, para 22). Phronesis involves “the character development, skill and
judgment to act in accord with the demands of a situation and the larger goods of the
[nursing] discipline” (SmithBattle, 2009, p. 115). It is concerned with practical judgment and
ethical know-how that is suited “to the right person, [with] the right amount, at the right time,
for the right purpose, and in the right manner” (Cohen, 2012, Categories section, para. 10).
Phronesis as it is described here is indicated throughout the findings with specific
reference to nurses who were responsive; whose highly developed perception allowed them
to “leap ahead” to ensure families felt comfortable and safe throughout the process of
relating. In addition to teaching approaches that valued the knowledge of the family, these
nurses were also flexible with time and the provision of services. High priority families can
experience great difficulty with everyday tasks that others take for granted and even consider

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mundane (MacLeod et al. 2005; Moules et al. 2009). It is not uncommon for families to
experience challenges related to socioeconomic status that make availability and access to
services difficult. I am reminded of one family who candidly described the difficulty she had
packing up four children in the middle of winter to attend an immunization appointment for
her two month old. She did not have a car and lived on social assistance. The nurse, in
acknowledging her challenges, arranged to administer the next set of immunizations at the
mother’s convenience, outside of regularly scheduled immunization clinic hours.
This kind of practice, a practice that reflects an incisive ability to tailor interventions
to the client’s world is recognized in the literature as exemplary but is thought to arise only
with nurses who have had extensive experience in practice.
Benner et al. (2009), SmithBattle (2009) and SmithBattle et al. (2012) suggest that the
perceptual abilities and relational skills required to respond appropriately to clients’ needs
only develop with increased practice experience that exposes nurses to different clinical
situations. As nurses work through different clinical experiences, they learn to discern what
stands out as most important for families. Novice or new nurses, according to Benner
(1984), SmithBattle (1997; 2009), and SmithBatlle et al. (2012), are unable to hone in on the
subtleties and nuances that shape the experiences of families because they are overly reliant
on theory, process, and procedure to guide their practice.
Findings from this study suggest that although practice experience may help to
develop the skills necessary to foster responsive relationships, it is not a pre-requisite nor
does experience pre-determine a capacity to engage fully with families. It is clear from the
findings that families continue to encounter nurses who, regardless of years in practice,

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approach families from a highly objective, de-contextualized place that understands only one
way in their work with families. In contrast, findings also highlight one instance where a
novice nurse in her first year of practice, was able to openly and easily respond to the needs
of a family despite her lack of experience. Indeed, her status as a novice nurse paled in
comparison to her experience as a mature student whose experiences in life led her to care
for the family in a way conducive to their needs. This raises questions about the nature of
experience. What kind of experience and how much experience is required to practice
responsively? These questions are clearly beyond the scope of this project however, based on
the findings of this study I would surmise that the kind of experiences that shape our capacity
to develop responsive relationships are those that emphasize the importance of humanity,
experiences that invite kindness and compassion and ask that we be open to difference.
Equally important is how we embrace these experiences, that we are fully engaged and allow
their newness and difference to shape who we are and how we understand the world.
Summary
Overall in this study, families stress the importance of being understood; an
understanding that was made clear through the development of responsive relationships.
Many PHNs focus on the differences that seem to permeate the lives of high priority
families. Developing and understanding that embraces these differences can be challenging
when faced with lived realities that counter our own. So how do we foster understanding in
the face of what appears alien? What is required of us and how can we encourage
understanding in others? Gadamer (1989) offers us a way into understanding that unfolds
through the process of relating. Gadamer (1989) reasoned that all understanding is

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historically, traditionally, and culturally rooted. When we come to new and different
experiences, we arrive with preconceptions that, like understanding, are also historically,
traditionally, and culturally rooted. These preconceptions form what Gadamer (1989) calls
our horizon. Our view of the world as it is informed through our experiences within the
world. New understandings emerge when our openness allows us to discover to the horizon
of another. When we move beyond our own preconceptions to confirm, amend, or abandon
our earlier assumptions based on what we have learned from the other we experience what
Gadamer (1989) called a fusion of horizons. Our initial assumptions no longer appear as
natural or true but instead reflect the possibility and limits of the life-world we inhabit
(Gadamer, 1989, p. 277). When considered in the context of developing relationships with
families, Gadamer (1989) insists that we must first be open and interested with the horizon of
another and perhaps more importantly, be willing to legitimize their lifeworlds by listening,
attending, and responding in kind. More importantly, Gadamer (1989) would insist that we
allow what we come to understand through our interactions to transform us; to expand our
own horizons so that we can understand and affirm the family’s strengths, resilience and
support them in a way meaningful to their lives as they are lived our daily.
In summary, findings from this study enlighten us to what families feel is most
important as they engage with PHN services. Contrary to what some believe, it is neither
knowledge nor is it programs and services but rather how both are presented and offered to
families. As findings show, knowledge is only useful when it is shared and communicated in
a way that is meaningful. Similarly, services are only fully realized when families are
afforded some control; some power over their content and how it is delivered. In this study

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this was exemplified by PHNs whose capacity to be present with families, be there and be
with families allowed them to truly center their practice around the needs of the family.
PHNs who were present and willing to be with families characteristically demonstrated
highly developed perceptual abilities, experience, and compassion that fostered a deep and
resonant understanding of the family, their situation and their context.

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CHAPTER SIX
Conclusions and Implications
Summary of the Study
Relationships between PHNs and families is an area of study that has received much
attention in the literature however very few studies have explored how nursing presence
contributes to the development of these relationships. Moreover, there is little exploring the
perspectives of families and their experience with nursing presence as it unfolds over
relationships with PHNs. The purpose of this study was to elicit an understanding of how
families experience nursing presence and understand its role in the development of
relationships. The research questions that guided this study were: “what is nursing
presence?” “What is the experience of nursing presence for families engaged in relationships
with PHNs?” and “how does nursing presence influence PHN-family relationships?” This
study utilized interview data from eight families interviewed for the narrative component of
the WRP (2005) project. In order to draw out family experiences with nursing presence, this
study utilized an interpretive approach to data analysis that was informed by the
philosophical hermeneutics of Hans Georg Gadamer (1989) and the methodological
approach offered by Max vanManen (1997). Findings from this study show that families
experienced presence with nurses whose ways of being and working fostered responsive
relationships; relationships that reflected the uniqueness of families; their situation and
context, and that centered around their needs.

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Conclusions
Working with families is a vastly complex skill that requires much more than what is
afforded in books, policies and protocols. As this study demonstrates, it requires highly
developed relational skills that enable nurses to be with families and be there for families so
that the work of relationships truly centers around their experiences and everyday realities.
The literature offers some insight into what is involved in fostering these kinds of
relationships by focusing on nurse characteristics that are thought to engender trust,
openness, and willingness such that families feel safe and comfortable with entering
relationships. However few provide any insight into how nurses convey openness,
willingness, and trustworthiness. Nor do they provide any evidence as to whether or not
these characteristics indeed help to foster good working relationships that are responsive in
nature.
SmithBattle (1997; 2009) and SmithBattle et al. (2012) provides considerable insight
into what is involved in centering families at the heart of practice. In her work she highlights
the practice of expert nurses whose perceptual and relational skills guide their practice with
some of the most vulnerable families. However, like many others concerned with the nature
of practice with families, she only offers a view from the nurse’s side of the relationship.
Although her work echoes much of what families say in this study about the importance of
developing common ground and tailoring services to meet the needs of families, without the
perspective of families we can only presume that her findings indeed support the
development of responsive relationships.

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By exploring the voice of families, this study invites a view into the relationship that
informs us of our approach with families. For nurses whose work with families exemplifies
willingness and an openness to understand and embrace the family based on who they are,
these findings reinforce their practice. For those whose practices are ruled by programmatic
policy and guidelines and focused on fixing deficits as opposed to promoting strengths, this
study’s findings provide insight into the importance of coming to know the family; of
understanding and accepting the complexity that is inherent in their lives so that the work of
programs can be achieved with success.
Interpretations offered also provide insight into how PHNs can begin to understand
family’s in truly situated ways. For example, findings stress the importance of being willing,
willing to engage with families openly and genuinely with a sense of curiosity about who
they are as people, rather than who they are as clients on a caseload. Findings also suggest
that nurses find ways to honour families, honour their knowledge and expertise that have
developed over years of practical experience. Lastly, findings stress a need for PHNs to
walk with families and allow them to lead in practice. One of the key insights offered by
families in this study was the need for PHNs to work with them in different ways over the
course of the relationships. Families who experienced PHNs who delivered services in
response to their needs and who allowed families to lead the PHN in her practice felt
empowered and confident to move ahead in life on their own.
In addition to offering insights into how PHNs can foster responsive relationships,
interpretations also add to the body of knowledge about family perspectives of the nurse
family relationship and the role that nursing presence plays in the development of those

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relationships. To date most of the literature concerned with nursing presence has looked to
define the concept by identifying its attributes and antecedents. Several concept analyses
outline presence as a phenomenon that occurs in relationship but few point to how it is
experienced in relationship. Exploring the perspectives of families from the hermeneutic
phenomenological approach outlined by Max van Manen (1997) enabled a view into the
nature and character of nursing presence, what comprises nursing presence and how nursing
presence contributes to the development of relationships.
Although families in this study do not use the word presence, they described
behaviours and approaches of the nurse; her way of being that were understood to represent
the essence of nursing presence. Some of these were described as particular attributes or
characteristics of the nurse whereas others were indicative of a particular feeling or sense that
the family experienced while working with the nurse. Although families described nurse
qualities differently, all families emphasized a need for the nurse to convey a sense of
unconditional regard and respect for the family’s everyday reality. The effect of nursing
presence on the development of relationships in this study was to ensure their success. In
situations where families experienced nursing presence as a phenomenon that engendered
feelings of understanding, value and respect relationships flourished. Conversely when
families felt undermined, or undervalued, the relationship faltered. This finding is consistent
with much of the literature exploring nursing presence in the context of nurse-family
relationships. Respecting and valuing the uniqueness of families and their lives as they are
lived daily is stressed throughout this body of literature. What this study adds are family
understandings regarding the nature and character of nursing presence and its contribution to

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the development of relationships. To date there are very few research studies exploring
nurse-family relationships from the perspective of families.
The two themes highlighted in this study that exemplified the presence of the nurse
were a responsive use of self and the responsive delivery of services. Families experienced a
responsive use of self when they worked with nurses who personalized their practice by
sharing aspects of their lives. Families experienced a responsive delivery of services with
PHNs who were flexible with their time and how they delivered service. What resonates
most from the study findings is the profound impact responsiveness had on developing
relationships with families. When PHNs responded to families through the acts of sharing
and being flexible, they were able to gain entre, develop rapport, and complete the required
work of home visiting. Moreover, families felt valued and respected based on who they
were. When nurses personalized their relationships with families, any concerns the family
had with how the nurse may perceive them were quickly put to rest.
On the surface, nursing acts such as sharing and being flexible seem simple however
there is considerable background work involved in being open, willing, and understanding so
that indeed, sharing and being flexible occur in response to the needs of families. Being
open, willing, and understanding can require considerable effort, but it is an effort that can be
embedded in nurses everyday practice. Nursing, above all else, is a caring profession that by
nature insists on character development that fosters the relational skills necessary to be and
work with families in ways that are responsive to their needs. Ultimately when we resist
cultivating the skills necessary to respond to all types of people, regardless of their situation

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or their lifestyles, we neglect a fundamental part of nursing practice, developing
relationships.
Implications for PHN Practice and Education with Families
Interpretations offered in this study hold significant implications for PHN practice
with families. One asks that PHNs carefully consider what families feel is important in
developing relationships to ensure that the work of relationships is carried out meaningfully
and intentionally with the needs of families at the fore. The second concerns the practices
and actions of nurses. In keeping with much of the literature, families describe the presence
of the nurse by focusing on specific nurse characteristics however they also describe specific
actions and behaviours that contribute to developing relationships. In doing so families offer
practicing nurses and student nurses a glimpse into how nurses can be and act in ways that
contribute to the development of good working relationships. Interpretations offered in this
study add a new and different dimension to what it means to be present with families by
providing a how for PHNs in practice.
In addition to providing insight into how nurses can be in practice to develop good
working relationships, the study illuminates tangible and effective ways to educate families.
Families throughout this study benefitted from personal stories and real life situations to
grasp the meaning embedded in theory. When nurses provided examples or shared stories to
support what they were teaching, families were more apt to take up the information in
meaningful ways. Moreover, families felt a strong connection with nurses who were willing
and able to share stories that rendered information more meaningful. This finding calls into
question what we currently teach students about developing and maintaining therapeutic

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relationships. Currently, the practice of many educators is to teach the professional and
practice standards laid out by the College of Registered Nurses of British Columbia
(CRNBC). In the area of therapeutic communication, it is common to stress the importance
of the CRNBC standard entitled Boundaries in the nurse client relationships. Although the
importance of this practice standard cannot be overstated, findings from this study suggest
that perhaps some of the practice principles underlying the standard be taught with more
flexibility and openness. Currently the standard cautions against sharing personal
experiences and precludes ideas of friendship in developing therapeutic relationships with
families. If sharing and friendship were considered, as they are described by families in this
study, perhaps they could be included in the CRNBC practice standard as valuable
components to developing therapeutic relationships. In addition, educators would feel free to
teach the value of sharing and friendship when both are genuinely and professionally
included in developing therapeutic relationships with families.
Further to the development of therapeutic relationships with families, sharing stories
may also have implications for educating nursing students. The practice of nursing is
steeped in theory that can be difficult for students to grasp and therefore, extremely difficult
to integrate into practice (Dieklemann, 2000). Pedagogical approaches that utilize stories or
real life experiences may be utilized to render information more meaningful and thereby
easier to recognize and incorporate into practice. In addition, understanding the value of
stories as a student may help educate newly graduated nurses in how best to foster
connection and collaboration with families. If students are exposed to educators who are

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willing to share personal experiences this may encourage willingness on the part of students
to share stories with their clients.
Lastly, developing responsive relationships emphasizes the importance of personal
development both as an individual and a nurse. Nursing practice and education stresses
reflection on practice and suggests that nurses spend time reflecting on the self (Arnold &
Boggs, 2011; Benner, 1984). Many pedagogical approaches in nursing however do not offer
deep and thoughtful explanations regarding the nature of reflection and its intended purpose.
Although reflective practice is introduced at an undergraduate level, the introduction merely
skims the surface o f what it means to engage in reflective practice. In addition,
undergraduate education does not offer students thoughtful ways in which to engage in
reflection. Journaling does exists as part of clinical practice education, but void of a complete
and thorough understanding regarding the nature of reflection, journal submissions often fall
short of their intended purpose. Educators might think of ways to invite deeper reflection
that could include feedback from individuals and families with whom nursing students
interact. Although feedback can at times be difficult to receive, its usefulness as a vehicle for
reflection cannot be understated provided the intent and process of reflection is fully
understood.
Another educational vehicle to invite reflective practice is simulation technology.
Many nursing programs have integrated simulation technology as a way to enhance student
skills in clinical practice. Perhaps simulation could additionally be used to encourage
reflective practice, and enhance personal and communication skills required to practice
expertly.

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Implications for Future Research
Other areas of inquiry reside within the two prevailing themes; a responsive use of
self and a responsive delivery of services. Of particular interest is the question of experience
and how it relates to the relational skills required to practice responsively. As stated
previously, findings from other studies place considerable emphasis on the need for
extensive practice experience whereas this study demonstrates that indeed, novice nurses can
practice in a way that responds to the needs of families. This calls into question the nature of
experience and what kind of experience is required in PHN work with families.
Another area that requires considerable exploration rests with the relational skills
necessary to develop responsive relationships. The literature cites the importance of being
understanding. Gadamer (1989) offers us a view into how understanding unfolds through the
process of relating, but what it means to truly understand remains a mystery. Moreover, how
do we open ourselves to understanding when much of who we are and how we experience
the world is pre-determined? How do we merge that which we hold to be true and right with
what might appear as fundamentally wrong to arrive at new and different understandings? In
other words, how do we temper our tendency to polarize when faced with difference? All of
the questions here are based within the development of relationships and how PHNs can
work to ensure that relationships are developed and sustained with the needs of families at
the fore. PHN work with families depends on relationship however, not all PHNs develop
relationships that are conducive to the needs of families.

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Re-visiting Do for, do with, and cheer on
I would like to end this thesis by returning to the beginning; by re-visiting the
Families Count practice philosophy, Do for, do with, and cheer on. At the outset of this
project I described how utterly confused I was with the words above and their meaning as it
related to practice with families. Over the course of this project I have given considerable
thought and reflection with respect to my own experience as a PHN and as a Masters student
of nursing. By reflecting on both experiences I have come to realize that the words, Do for,
do with and cheer on can be interpreted many different ways but underlying all
interpretations is the importance of supporting families in ways meaningful to the families
we serve. In this regard my practice will be forever changed. I have always been drawn to the
power of relationships in nursing, in particular how simple genuine gestures and interactions
can make a world of difference. Having conducted this study, I now realize that indeed, it is
the simple things we do that make the most profound difference. In this regard, my practice
will be forever changed. In order to illustrate my deep and profound feelings with respect to
what I have learned and what I have experienced as a PHN, I will draw on a personal
practice experience in order to illustrate my understanding with respect to the meaning
embedded in the Families Count Practice philosophy.
Early in my practice I met a family who initially appeared to require a great deal in
the way of help. I distinctly remember being focused on issues with substance misuse and
child growth and development that I neglected to recognize the incredible support system
this family had developed for themselves. When the mother was unwell, the grandmother
and aunt willingly stepped in to support the children and provide for them in the best way

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they could. Initially I remember thinking that their actions simply enabled the mothers
drinking and crack cocaine binges. I remember discussing my feelings with a colleague
describing the disdain I initially felt for the mother of this family. My colleague listened
intently. When I had finished my rant, she asked me one question, “Have you thought about
why the mother has addictions issues”? At the time I thought to myself “No”, “What does it
matter”?
As I continued my work with the family, I reflected on my colleagues question until I
finally thought to explore why the mother felt she had issues with addictions. The story the
mother told about her life as a child and as a parent was astounding. She revealed a reality so
far removed from my own, I was shocked and then almost instantly honoured that she felt
she could trust me with her story. By opening myself up to the possibility that perhaps my
initial assumptions regarding addictions were wrong, I discovered, that addiction issues are
often far more complex than what I initially presumed to be a lifestyle choice. With this
realization, I came to see the mother in an entirely different light. I was able to understand
the source of her pain and the reason for her addiction. I was also able to see that beyond the
initial dysfunction was an incredible love for all three of her children and a strong desire to
parent the children in the best way possible. In essence I came to realize that the family was
not the problem, it was the misuse of substance that was the problem. Focusing my
frustration and anger on the mother no longer made any sense. Instead, I found solace with
the family and with the love they shared for the children and each other. I was then able to
advocate for the family based on that love. When my work with the family came to an end,

85

the children were living full time with their aunt and grandmother, a decision that the family
came to with my support. The mother was seeking treatment for her addiction issues.
When I reflect on the anecdote above, I am grateful for the question posed by my
colleague when I disdainfully described the situation to her. More importantly, I was grateful
for how my colleague posed the question. My colleague’s stance at the time was open and
receptive. She listened attentively, did not judge my opinion, nor did she overtly judge me. In
retrospect she appeared thoughtful, and considerate. Moreover, she responded in a way that
forced me, unknowingly, to reflect upon my initial thoughts and eventually on my overall
opinion of the family. In essence, my colleague’s openness, willingness, and respect; coupled
with her poignant question compelled me to learn more. She subtly pushed me to develop a
different, more situated understanding of the family. To this day I approach families openly,
inquisitively, and with the utmost respect, regardless of the family’s situation and context. I
have learned to ask questions and be open to the answers as opposed to making judgments
based on my own erroneous assumptions.
Finally, when I consider the anecdote above in light of everything I have learned over
the course of this study, I realize similarities between what my colleague offered me and
what families ask of PHNs. Throughout this study families asked that PHNs be open and
receptive to their ways of being. They asked that PHNs listen attentively to what they have to
say and accept what they have to offer. Ultimately, families ask PHNs to be present with
them, to be there and with them as they learn new and meaningful ways o f being as a family.

86

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