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Keywords:

  • health promotion;
  • professional-client relations;
  • special populations;
  • stigma

Abstract

  1. Top of page
  2. Abstract
  3. Implications of Stigmatization for Relationship Building
  4. Interactional Strategies
  5. Engaging in a Positive Manner
  6. Offering Verbal Commendations
  7. Fulfilling the Practice Standard of Building Relationship
  8. Recommendations
  9. References

This Clinical Concepts article concerns the relational tools required by public health nurses to establish relationships with single mothers living on public assistance, mothers who are vulnerable and often stigmatized. The implications of stigmatization for relationship building are highlighted based on previous research investigating how public health nurses working in Canadian jurisdictions establish professional caring relationships with this cohort of mothers. Public health nurses employed interactional strategies including engaging in a positive manner and offering verbal commendations which served as effective relational tools to break through mothers' walls of defensiveness and to resume the dynamic process of relationship building. Building Relationship is a key practice standard for public health nurses and is instrumental to their work at both individual and community levels to improve social determinants of health. The author concludes with recommendations to facilitate building relationships during everyday public health nursing practice.

In Canada, the core functions of public health are health promotion, health protection, and disease prevention (Public Health Agency of Canada [PHAC], 2007). A public health nurse (PHN) is a professional who promotes the health and prevents illness and injury of individuals, families, aggregates, populations, and targeted vulnerable groups in the community (Canadian Nurses Association [CNA], 2007). Individuals who are new immigrants, substance users, pregnant and parenting teens, severely mentally ill, elderly, disabled, homeless, or living in poverty are examples of groups categorized as vulnerable (McEwen & Pullis, 2009).

In this article I focus on individuals who live in poverty, specifically the single mother living on public assistance (henceforth referred to as single mother or mother) who is considered vulnerable to health problems due to insufficient economic and social resources, and whose vulnerability is often compounded by stigmatizing labels such as “underserving”, “unfit”, “welfare mother” (Kissane, 2012). In particular, I discuss how PHNs working with single mothers fulfill the public health nursing practice standard Building Relationship (Community Health Nurses of Canada [CHNC], 2011). I highlight how PHNs accommodate heightened sensitivities of the stigmatized mother to build relationship to embark on the process of health promotion which is

Enabling people to increase control over, and to improve, their health … a commitment to dealing with the challenges of reducing inequities, extending the scope of prevention, and helping people to cope with their circumstances … creating environments conducive to health, in which people are better able to take care of themselves. (Epp, 1986, p. 422)

In keeping with the aims of health promotion, the PHN is mandated to build a professional caring relationship with the single mother to promote the mother's efforts to exercise existing abilities to cope with day-to-day concerns and issues. In addition, the practice standard entails PHNs building relationships with aggregates (e.g., a group of single mothers in the community and other stakeholders representing community organizations and other sectors) to take action to address underlying social, political, and economic issues impacting health and well-being (Marmot & Wilkinson, 2006) such as inadequate housing and food insecurity.

To build relationships PHNs must be equipped with relational tools. “Targeting Essence: Pragmatic Variation of the Therapeutic Relationship” is an explanatory theory of relationship building that I formulated to guide the relational practice efforts of PHNs. Grounded theory methodology enabled me to investigate the process by which PHNs establish relationships with single mothers living on public assistance. I interviewed 21 single mothers and 15 PHNs about their professional relationship experiences and perceptions, observed 14 nurse-mother dyadic interactions, and consulted with 15 health and social service practitioners and managers. Targeting Essence is a relationship building process of back-and-forth actions and reactions by the PHN and mother that constitute six interdependent stages:

  • Stage 1: Projecting Optimism,
  • Stage 2: Child as Mediating Presence,
  • Stage 3: Ascertaining Motives,
  • Stage 4: Exercising Social Facility,
  • Stage 5: Concerted Intentionality, and
  • Stage 6: Redrawing Professional Boundaries.

It is beyond the scope of this article to provide full explication of the theory and each interdependent stage (see Porr, Drummond, & Olson, 2012, for full details); rather, the threefold purpose of this article is: (1) to underscore the implications of stigmatization for relationship building, (2) to present key interactional strategies that I discovered PHNs use as relational tools during the first stage, and (3) to put forth recommendations to facilitate and to foster professional relationships during everyday public health nursing practice.

Implications of Stigmatization for Relationship Building

  1. Top of page
  2. Abstract
  3. Implications of Stigmatization for Relationship Building
  4. Interactional Strategies
  5. Engaging in a Positive Manner
  6. Offering Verbal Commendations
  7. Fulfilling the Practice Standard of Building Relationship
  8. Recommendations
  9. References

Twenty percent of Canadians live in poverty and are overburdened with the stress of trying to secure the basic necessities of food, shelter and clothing. Available statistics indicate that poverty rates are more than doubled for single mother families (Murphy, Zhang, & Dionne, 2012). The economic hardships experienced by single mothers are severe (Raphael, 2007). Several of the single mothers who participated in my study

  • lived alone with their children in subsidized housing, or in a costly nonsubsidized rental suite, or in a safe house;
  • visited the food bank and food cooperative regularly or restricted their own food consumption to feed their children;
  • depended on public transportation;
  • were estranged from partner, friends, and extended family members;
  • had experienced domestic violence;
  • kept to themselves to avoid conflict with neighbors and to shield their children from potential dangers in the community;
  • retreated occasionally to addictions to cope with stressors;
  • suffered at times from depression, anxiety, and psychological distress; and,
  • tended to be suspicious, distrusting, and insecure with health and social service professionals.

Single mothers, especially those who rely on public assistance, may not only be experiencing the stress of raising children in substandard living conditions, but their stress may be exacerbated by society's stigma and negative constructions of mothers as welfare recipients (Broussard, Joseph, & Thompson, 2012).

Stigmatization can threaten one's self-concept (van Laar & Levin, 2006) and self-esteem by creating doubt about one's worth and value as a person (Crocker & Garcia, 2006). The mother's self-concept that she is a contributing productive member of society is undermined by the stigma of unfit welfare mother and the welfare discourse of undeserving dependency (Wiegers, 2002). During my grounded theory study I learned that stigmatization was very much a disturbing daily reality for single mothers. Stigmatization carried implications for relationship building because single mothers were expecting to be judged by PHNs which caused mothers to be guarded and self-protective. Mothers were apt to put up what PHNs described as “walls” or “barriers” and to “shut themselves off” (Porr et al., 2012).

Interactional Strategies

  1. Top of page
  2. Abstract
  3. Implications of Stigmatization for Relationship Building
  4. Interactional Strategies
  5. Engaging in a Positive Manner
  6. Offering Verbal Commendations
  7. Fulfilling the Practice Standard of Building Relationship
  8. Recommendations
  9. References

PHNs, in turn, were required to employ certain interactional strategies to bring down walls of defensiveness including engaging in a positive manner and offering verbal commendations.

Engaging in a Positive Manner

  1. Top of page
  2. Abstract
  3. Implications of Stigmatization for Relationship Building
  4. Interactional Strategies
  5. Engaging in a Positive Manner
  6. Offering Verbal Commendations
  7. Fulfilling the Practice Standard of Building Relationship
  8. Recommendations
  9. References

For example, the PHN used interactional strategies during the first stage of relationship building (Projecting Optimism) that were deliberate yet genuinely nonthreatening, and served to penetrate the mother's initial defensiveness and to foster trust. The initial moments of any encounter are critical. Communication theorists claim it takes only 4 minutes for the average person who meets a stranger to decide whether he or she wants to continue any form of interaction (Zunin & Zunin, 1972). The potential for caring relationship was contingent on the mother's first impressions of the PHN. Just as the PHN was looking at the mother, at the same time the mother was looking at the PHN. From the outset it was imperative that the PHN engaged in a positive manner; more precisely, that the PHN projected an “upbeat”, “chipper” disposition. All mothers interviewed explained that the friendly approach was calming. The PHN's smile, eye contact, relaxed body posture, and gentle warm voice quality contributed to the mother's sense of comfort in the presence of the PHN. The PHN was also conscious of her attire. The PHN dressed informally which appealed to mothers. In fact, some of the mother participants commented that if they had their wish the PHN would remind them of an “old hippie women in a skirt” (Porr et al., 2012).

The PHN's goal during this crucial first stage was to convey enthusiasm and interest. Especially when visiting the mother of a newborn baby, regardless of the home situation and circumstances, the mother was made to believe that the PHN truly celebrated the mother's transition to motherhood and that the PHN wanted to share the joy over the newborn. Mary (a pseudonym is used here and throughout the article) had continued to witness the euphoria over the birth of a new baby during her 10 years of experience as a PHN: “Absolutely it doesn't matter whether you are single or what your status everybody is excited about this baby. And whether it was you were unsure about wanting this baby, unsure you wanted the pregnancy. Whatever it was, you've got this baby now and it's part of you, and they're so excited” (Porr, 2009, p. 86).

Offering Verbal Commendations

  1. Top of page
  2. Abstract
  3. Implications of Stigmatization for Relationship Building
  4. Interactional Strategies
  5. Engaging in a Positive Manner
  6. Offering Verbal Commendations
  7. Fulfilling the Practice Standard of Building Relationship
  8. Recommendations
  9. References

The PHN communicated zeal and keen interest in the mother and child during this first stage of relationship building, and at the same time the PHN used verbal praise as another interactional strategy. The PHN attempted to acknowledge the mother's capabilities, skills, or competencies as early as possible, and then throughout the encounter. Offering such verbal commendations reflects a strengths-based orientation. Patty, based on her 30 years of public health nursing experience, explained how she called forth strengths to aid relationship building; she would tell mothers, “This is the most important job in the world raising this baby… this is huge. This is a big job. And it's really a special job. You are the only mom.” Then Patty would point out that “not just anybody can look after this baby.” Similarly, Julie, another 30-year veteran, stated that she constantly tried to identify “maternal successes,” big or small. “And when they do something that is positive, notice it” (Porr, 2009, p. 87).

Presaging any present-day feelings of low self-worth associated with the stigma of being a single mother living on public assistance, are possibly years of negative self-appraisals rooted in much earlier parental and social relationships. Mother after mother disclosed stories of deprivation, abuse, and rejection, leaving little reason to believe that they came away with high appraisals of themselves; more accurately, their formative years may have taught them that they were not loveable. One of the PHNs advised that the PHN has to “sort of pat them on the back” because “alot, especially young moms or single moms, they think the whole of society is looking down their nose at them like, ' How stupid are you why did you get yourself knocked up? Why are you having this baby? What do you have to offer?'” (Porr, 2009, p. 88).

Verbal commendations are the PHN's “language of gifts,” claimed Jasmine, who after only 3 years as a PHN can attest to the impact of compliments when bestowed on mothers who are seeking and needing self-affirmation that they have never or otherwise might never receive. “It feels good when you get compliments. I used to be just put down and you feel like you are nothing,” confirmed Lana, a single mother with two young children (Porr, 2009, p. 88).

By relating to the woman before her as a mother and, notably, a capable mother, the PHN influenced the mother's cognitions and feelings about her self in the role of mother and potentially, enhanced the mother's core self-concept and self-esteem. Social and personality psychologists posit that we all enter into face-to-face interaction with one or more interpersonal motives (Fiske, 2003). Of the five core motives (belonging, understanding, controlling, trusting others, and enhancing self) and on the basis of what I know about the mothers who participated in my study, I speculate that engaging in a positive manner and offering verbal commendations were effective relational tools because they addressed the mother's motive to enhance her self-concept or sense of self. Mother participants were exceptionally responsive to positive affirmation, most likely because the maternal role was firmly attached to how the mother identified herself and was closely associated with how she felt about her worth as a person, and hence produced stronger feelings (Turner, 2002) of pride, confidence, and happiness. Simultaneously, the PHN cultivated rich potential for trusting caring relationship because “walls eventually come down” and few mothers remain closed, even if “they are a little cold towards you,” Maude, a long-time PHN commented reassuringly. “As the visit goes on, they kind of relax and warm up to you, and know that we are there to help and provide the best resources, you know, for their family” (Porr, 2009, p. 91).

Fulfilling the Practice Standard of Building Relationship

  1. Top of page
  2. Abstract
  3. Implications of Stigmatization for Relationship Building
  4. Interactional Strategies
  5. Engaging in a Positive Manner
  6. Offering Verbal Commendations
  7. Fulfilling the Practice Standard of Building Relationship
  8. Recommendations
  9. References

It was demonstrated during my study that PHNs possess the requisite relational tools to build relationships with vulnerable and potentially stigmatized clients such as single mothers living on public assistance. Their interactional strategies—engaging in a positive manner and offering verbal commendations—enabled PHNs to establish a caring relationship so that PHNs could target mothers' concerns and issues. However, professional praxis often hindered opportunities to delve into psychosocial problems.

Several PHNs participating in my study stated that they had not been able to practice within the full scope and depth of the Building Relationship standard expectations. Time-limited immunization appointments, especially, posed a major obstacle. Notwithstanding the critical public health mandate to implement protective and preventive health measures, I learned that there was an ever-increasing volume of content to be covered during the immunization visit. Little time was allotted for PHNs to build relationship and inquire about the mother's home life and possible stressors.

Depression, for example, is common among single mothers living on public assistance, especially during the first year of the baby's life (Keating-Lefler & Wilson, 2004; Samuels-Dennis, 2006). Mother participants shared that they wanted to visit a PHN to whom they could turn for emotional support. Some of the PHNs stated that they found themselves day in and day out seeing new and different mothers during immunization clinic which they likened to an assembly line. PHNs lamented their former generalist roles when their office drawers contained their caseload of families whom they knew intimately. However, some PHNs shared how they had become technically proficient as well as masterful at imparting the important information about risks, benefits, and contraindications and at conducting developmental assessments. Consequently, they were able to create the relational opportunities for building relationship with mothers and could plant the seeds for later meaningful connection.

Fulfilling the full breadth of Building Relationship also entails building networks of partnerships with groups and communities to create environments conducive to health (Community Health Nurses of Canada [CHNC], 2011). PHNs wished they could capitalize on their interactional abilities and partner with groups of mothers within a community to build community capacity to address inadequate housing or food security issues. Building Relationship is a key practice standard and, undoubtedly, is pivotal to fulfilling expectations of other practice standards outlined in the Canadian Community Health Nursing Standards of Practice document (Stanhope, Lancaster, Jessup-Falcioni, & Viverais-Dresler, 2011) aimed at improving socio-environmental conditions (e.g., Promoting Health, and Building Individual and Community Capacity). However, according to the PHNs I interviewed, building relationships at the community level with aims to promote community action was not within their purview of responsibility despite being recognized as core functions of public health nursing practice (Issel, Bekemeier, & Kneipp, 2012; Mikkonen & Raphael, 2010; Reutter, 2000; World Health Organization [WHO], 2008).

Recommendations

  1. Top of page
  2. Abstract
  3. Implications of Stigmatization for Relationship Building
  4. Interactional Strategies
  5. Engaging in a Positive Manner
  6. Offering Verbal Commendations
  7. Fulfilling the Practice Standard of Building Relationship
  8. Recommendations
  9. References

When PHNs must respond to health-related issues by building relationships at both individual and aggregate levels, the “messy” complexities and demanding expectations must be nothing short of challenging. On the basis of my study findings, however, I am confident that PHNs are equipped with the relational tools to foster and not sabotage opportunities to build relationship as the fundamental first step to improve determinants of health. To fulfill the performance expectations of the practice standard, Building Relationship, I have put forth some recommendations based on my study findings.

  1. All PHNs, regardless of assignment, should be made fully aware of potential stressors and the psychosocial impact experienced by single mothers living on public assistance through interdisciplinary and interagency in-services and workshops. Financial hardship takes its toll on mothers especially single mothers living on public assistance. Formal sessions exposing health care professionals to the effects of poverty have proven effectual for enhancing understanding (Stewart, Reutter, Veenstra, Love, & Raphael, 2007). Outreach workers and mothers should share their stories to expose PHNs to the everyday realities.
  2. Problematic for building trusting caring relationships, is the heavy emphasis on epidemiological indicators, immunization rates, harm reduction, screening, and surveillance. Health assessment tools should incorporate extensive assessment of psychosocial needs of mothers living in poverty, especially the vulnerable and potentially stigmatized single mother living on public assistance.
  3. Face-to-face contact is a much more effective medium for targeting real concerns than telephone conversations. PHNs told me that they are able to “read much more of what is really going on.” They can assess, for example, the mother's level of stress and anxiety by watching how she handles her baby. Mothers admitted that they had often told the PHN on the other end of the telephone that they were “fine” when many of them really wanted and needed to talk to someone. I uncovered story after story of missed opportunities to connect with mothers because they were contacted solely by telephone (Porr, 2009). “Talk is not an entirely adequate substitute for human contact, despite what telephone company slogans would have us believe. When people have something emotionally important to say, they need the full range of nonverbal channels” (Trenholm, 2008, p. 112). This communication theorist could be describing the sentiments of the mother participants. Human-to-human contact is strongly recommended to maximize opportunities for disclosure of intense emotions and feelings.
  4. PHNs should take the time to listen to the mother's personal concerns. PHNs are not unlike most health and social service professionals who are quickly socialized within their community of practice (Brown & Duguid, 1991) as to how to think about and do their work. Eventually, everyday habitual routines enable PHNs to perform their responsibilities in a timely efficient fashion. Although routinization is rewarded for its cost-effectiveness, the disadvantages outweigh the advantages for PHNs hoping to build relationships with potentially stigmatized mothers. A perfunctory manner sends messages to these mothers that the PHN is more interested in completing tasks and less interested in the mother's personal concerns. I became aware during my study that the mother might think herself unworthy of the PHN's time and attention.
  5. PHNs should assume primary responsibility for a caseload of families and continuity of care should be sustained from the antenatal period through to the child's fourth birthday. Repeatedly, mother participants voiced their frustrations about having to explain their situation over and over again to different PHNs. When there is no continuity mothers do not have sufficient opportunity to reach a point of trust with the PHN.
  6. “Critical companionship” should be incorporated into the PHN's orientation, mentorship, and continuing education. Critical companionship (Titchen & McGinley, 2003) is the pairing of PHNs with colleagues of equal or greater nursing experience. Colleagues would observe each other's relational approach with vulnerable and stigmatized mothers. Following interactions, colleagues would exchange reflections about each other's performance for the purposes of training and development of interactional strategies.
  7. PHNs should be afforded debriefing sessions for venting emotions and feelings arising from relationship experiences.
  8. PHNs should meet during trouble-shooting sessions to resolve complex relationship issues.
  9. PHNs should seek opportunities to establish connective and collaborative relationships with health professionals, community agency services (housing, drop-in programs, emergency food services, outreach, counseling), and other sectors to address adverse socio-environmental conditions of mothers living in poverty.

Discussed in this article were the interactional strategies PHNs employed during the first stage of building relationship with vulnerable and potentially stigmatized single mothers living on public assistance. The PHN interacted strategically from the outset by ensuring that critical first impressions projected the PHN's genuine delight in visiting with the mother and her child. Mothers could then relax their stiff postures in response to the PHN's warm, welcoming approach, and then tensions were further reduced by the PHN's language of gifts in the form of praise, and compliments directed at the mother's parenting abilities. The verbal commendations were pivotal to reframing the mother's perspective of self, including her beliefs that she is worthy, valuable and has the capacity to overcome. From this first stage (Projecting Optimism), the PHN-mother relationship would evolve through five more stages with additional interactional strategies employed to deepen the trusting, caring connection. By the sixth and final stage, the mother will have already begun reframing her sense of self and actualizing internal resources to address personal goals with a mind-set of hope and possibility.

PHNs demonstrated in my study that they were equipped with the relational tools to optimize capacity potential of individual clients so that the single mother living on public assistance, for example, could embark on the health promotion process of enacting change to pursue the life she desires. I am confident that PHNs are able to apply their relational tools to secure strong connections at group and community levels to empower and support action for change to promote healthier socio-environmental conditions.

References

  1. Top of page
  2. Abstract
  3. Implications of Stigmatization for Relationship Building
  4. Interactional Strategies
  5. Engaging in a Positive Manner
  6. Offering Verbal Commendations
  7. Fulfilling the Practice Standard of Building Relationship
  8. Recommendations
  9. References
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