2003 Thesis3

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Name of Author: Ginette Lemire Rodger
Title of Thesis: A "Z" Nurse-Client Interaction and its Effects on Stress Level of
Clients
Degree: Doctor of Philosophy
Year this Degree Granted: 1995
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whatever without the author's prior written permission.
_______________________________
9938 - 86th Avenue
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T6E 2L7
Date: _______________________ 1995

"The most creative theories are often imaginative visions imposed upon facts (...)
I believe that a factual reality exists and that science, though often in an obtuse
and erratic manner, can learn about it."
Stephen Jay Gould
The mismeasure of man
(1981, p.352)
A "Z" Nurse-Client Interaction
and
its Effects on Stress Level of Clients
by
Ginette Lemire Rodger
A thesis submitted to the Faculty of Graduate Studies and Research in partial fulfillment
of the requirements for the degree of Doctor of Philosophy.
Faculty of Nursing
Edmonton, Alberta
Fall 1995
Faculty of Graduate Studies and Research
The undersigned certify that they have read, and recommend to the Faculty of Graduate
Studies and Research for acceptance, a title entitled A "Z" Nurse-Client Interaction and
its Effects on Stress Level of Clients submitted by Ginette Lemire Rodger in partial
fulfillment of the requirements for the degree of Doctor of Philosophy.
____________________________________
Dr. Pamela J. Brink
Supervisor
____________________________________
Dr. Terry Davis
Committee Member
____________________________________
Dr. Thomas O. Maguire
Committee Member
____________________________________
Dr. Joseph S. Davison
Committee Member
____________________________________
Dr. Judith Christensen
External Examiner
____________________________________
Dr. Phyllis Giovannetti
Chair
Date: ____________________ 1995

ABSTRACT
This study tested the first proposition of a new theory. The hypothesis stated that
a certain type of nurse-client interaction (labelled "Z") would reduce the stress level of
clients. A single subject quasi-experimental design with withdrawal and repeated
measures, was used.
The hypothesis tested was that a client who participates in a "Z" interaction will
report a lower level of stress than a client who does not participate in a "Z" interaction.
Four cancer patients participated in these interactions. A reduction of stress was
measured by changes in one of four physiological and one of three psychological
measures. The physiological measures selected were muscle tension (EMG), electrical
skin conductance (EDG), skin temperature and cardiovascular activities. The
psychological measures selected were two self-reports, the State Anxiety Inventory
(STAI), the Subjective Units of Disturbance (SUD) and an observation schema of
nonverbal behaviour using a Nonverbal Behaviour Worksheet.
"Z" nurse-client interactions reduced the stress level for three of the four clients
as indicated by the changes between the initial and end baseline data from the EMG. The
"Z" nurse-client interactions also reduced the stress level of all clients as indicated by
changes in scores on at least one of the psychological measures. The duration of the "Z"
interaction was significantly longer than other interactions as measured by a t-test. A
binomial test confirmed that the STAI measures and the Nonverbal Behaviour scores
were significantly different for the "Z" interactions on all clients.
The results of this study indicate that theory "Z" does exist as described, has
value, and can be documented. Further testing of the theory is recommended.

ACKNOWLEDGEMENTS
It has been my privilege to have been surrounded by scholars who created a
challenging and wonderful environment for my doctoral studies. I am grateful to all of
them. I would also like to acknowledge a few people in particular.
My first thanks goes to my supervisor Dr. Pamela J. Brink for her guidance, her
genuine interest in my work and her keen sense of observation which contributed to the
development and the testing of the theory. I am also very grateful to all the members of
my committee, Dr. Terry Davis, Dr. Thomas O. Maguire, Dr. Joseph S. Davison for their
advise, support and substantive contributions to my work. Without their vision and their
willingness to take some risk with a new theory, this piece of work would not have been
completed. I also wish to thank Dr. Phyllis Giovannetti and Dr. Judith Christensen for
their interest in my work and their helpful suggestions.
The people in the clinical setting where the research took place contributed
significantly to facilitating the project. I acknowledge the nurses who volunteered to
participate in the project and the generosity of the patients who gave of themselves even
when they were very sick. I thank Marjorie Allen for believing in the project and taking
on the organization and the logistical support on a day to day basis. I am also grateful to
Donna Armann and Karin Olson for their enthusiasm and their support for nursing
research. The cooperation of nurses, staff and the family members of the patients was
also essential in moving the project along to completion.
This field research was a complex endeavour that could not have been done
without the support of many colleagues who contribute first hand to the project. I am
grateful to the four research assistants who worked with me during the experiment. I
thank them for their enthusiasm and making themselves available to meet the demands of
the project. They are Nicole Brost, Deborah Miki, Daniel Scott and Jude Spiers. Several
colleagues helped me with the manuscript. I am thankful to Marilyn Hodgins for her
patience and her skills in preparing many of the graphs and to Trish Kryzanowski, Luc
Therrien and Wendy Wong for their availability and their help in the presentation of
other illustrations.
I am indebted to the Ph.D. students and candidates over the years who have
shared so much of their knowledge, skills and themselves. The support they have
provided was invaluable and I consider their friendship priceless. I wish each one of
them well.
It is hard to find appropriate words to acknowledge the contribution of my
husband, William J. Rodger to this project. He was my "editor in chief," always available
to help and to provide support and encouragement. He believes any thing is possible and
his love was a source of inspiration. I am also grateful for the support of all my family.
This research was supported in part by a Dissertation Fellowship from the
University of Alberta and by grants from the Edna Minton Endowment Foundation and
the Faculty of Nursing of the University of Alberta.

TABLE OF CONTENTS
CHAPTER PAGE
1. THE THEORY............................................................................................................. 1
Theory "Z": A Nurse-Client Interaction................................................................ 2
Origin of the Theory.................................................................................. 2
The "X" Nurse............................................................................................ 3
The "Y" Client........................................................................................... 7
The Environment...................................................................................... 10
The Encounter........................................................................................... 13
The "Z" Interaction................................................................................... 13
The Outcomes........................................................................................... 17
Propositions.............................................................................................. 21
Descriptive propositions............................................................... 21
Relational propositions................................................................. 22
2. REVIEW OF LITERATURE...................................................................................... 24
Nurse-Client Interaction Theories........................................................................ 25
Nurse-Client Interaction Theory Testing.............................................................. 33
Stress: Nature and Measurement......................................................................... 40
Stressors: Illness, Hospitalization and Cancer.......................................... 42
Mediator: Nurse-Client Interaction........................................................... 44
Psychological and Physiological Reactions.............................................. 47
Outcomes.................................................................................................. 49
Summary of Framework........................................................................... 50
3. THE STUDY............................................................................................................... 52
Purpose of the Study............................................................................................. 52
Assumptions.......................................................................................................... 52
Operational Definition of Terms.......................................................................... 53
The Research Design............................................................................................ 53
The Setting............................................................................................................ 56
Population and Sample......................................................................................... 57
Identification of "X" Nurses and "Y" Clients........................................... 58
Protection of Human Subjects.................................................................. 60
Data Collection..................................................................................................... 61
Analysis of Data.................................................................................................... 62
Physiological Data.................................................................................... 62
Psychological Data.................................................................................... 64
Relationship of Physiological and Psychological Data............................ 65
Videorecordings........................................................................................ 66
MBTI Data................................................................................................ 66
Instruments............................................................................................................ 66
Physiological Instruments......................................................................... 67
Electromyography......................................................................... 67
Electrodermal measurement......................................................... 70
Skin temperature........................................................................... 74
Blood pressure and heart rate measurement................................. 76

Psychological Instruments........................................................................ 80
Subjective anxiety scale................................................................ 80
Spielberger's State Anxiety Inventory.......................................... 81
Nonverbal Behaviour Worksheet.................................................. 83
Additional Psychological Instrument........................................................ 85
Myers-Briggs Type Indicator........................................................ 85
4. THE PILOT................................................................................................................ 88
Sample.................................................................................................................. 88
The Protocol.......................................................................................................... 90
Instruments............................................................................................................ 90
Analysis of Data.................................................................................................... 91
5. RESULTS...................................................................................................................100
Client Two...........................................................................................................100
Physiological reactions............................................................................100
Psychological Reactions..........................................................................105
Client Three.........................................................................................................106
Physiological Reaction.............................................................................106
Client Four...........................................................................................................111
Physiological Reactions...........................................................................112
Client Five............................................................................................................117
Physiological Reactions...........................................................................117
6. SUMMATIVE RESULTS...........................................................................................124
Effectiveness of the Tools....................................................................................129
Interobserver Reliability..........................................................................129
Myers-Briggs Type Indicator...................................................................131
7. DISCUSSION OF FINDINGS..................................................................................138
Selection of "Z" Interaction Components............................................................138
Research Method..................................................................................................140
Design Issues............................................................................................140
Bias 140
Passage of time in clinical setting................................................141
Measurements Issues................................................................................141
Physiological instruments............................................................141
Self-reports...................................................................................143
Videorecordings...........................................................................144
Myers-Briggs Type Indicator.......................................................145
Implications for the Z" Interaction Theory..........................................................146
"X" Nurses...............................................................................................146
"Y" Client.................................................................................................148
Implication for Nursing Practice and Research...................................................149
Nursing Practice.......................................................................................149
Nursing Research.....................................................................................150
Summary..............................................................................................................151
Conclusion...........................................................................................................153
REFERENCES................................................................................................................154
APPENDIX A. Physiology of Stress...............................................................................176
APPENDIX B. Characteristics of the Nurse Population.................................................195
APPENDIX C. Nurse Data Sheet....................................................................................196
APPENDIX D. Nurses' Consent Form............................................................................197
APPENDIX E. Clients' Consent Form............................................................................200
APPENDIX F. Visitor and Staff Consent Form..............................................................204
APPENDIX G. Client Data Sheet...................................................................................207
APPENDIX H. Dinamap Readings.................................................................................209
APPENDIX I. Nonverbal Behaviour Worksheet............................................................210
APPENDIX J. Summary: Physiology of Blood Pressure and Heart Rate......................214
APPENDIX K. "Z" Interaction Observation Grid...........................................................216
APPENDIX L. Client Two Results: Physiological and Psychological Measures...........217
APPENDIX M. Client Three Results: Physiological and Psychological
Measures..............................................................................................................225
APPENDIX N. Client Four Results: Physiological and Psychological Measures..........233
APPENDIX O. Client Five Results: Physiological and Psychological Measures...........241
APPENDIX P. Aggregate of Clients' Results by Interaction and Variable:
Reduction or Non-Reduction of Stress.......................................................249
APPENDIX Q. MBTI Preferences and Scores Results...................................................260

LIST OF TABLES
TABLE PAGE
1. Design Description for Day One................................................................................. 55
2. Characteristics of the Client Subjects.......................................................................... 59
3. Characteristics of the Nurse Subjects.......................................................................... 59
4. Design description using sequence A-B-C.................................................................. 89
5. EMG, EDG and Skin Temperature trial results in numbers........................................ 92
6. EMG, EDG and Skin Temperature period results in numbers.................................... 95
7. Comparison of sequential observations scored by two observers of live and

video recordings using the "Z" Interaction Observation Grid for the nurse-
client interaction 1B and 1C................................................................................. 98
8. Reliability coefficient of the nonverbal behaviour of the client tallied by two

observers as it happened (live) and on video recordings using the
Nonverbal Behaviour Worksheet for the nurse-client interaction 2B and
2C.......................................................................................................................... 99
9. Time of medications administered to client 2 during the study.................................101
10. Client 2 Results by Interaction: Reduction or Non-reduction of Stress....................102
11. Time of medications administered to client 3 during the study................................107
17. Duration of "Z" and "non-Z" interactions..................................................................126
18. Summary: Reduction of Client's Stress Associated with "Z" or any Nurse-
Client Interactions................................................................................................128
19. One-tailed Binomial Test Summary Table: Proportion of Cases with
Reduction of Stress During "Z" and "Non-Z" Interactions.................................130
20. Pearson correlation (r) and Spearman-Brown (2r/1 + r) estimates for client's
nonverbal behaviour............................................................................................132
21. Myers-Briggs Type Indicator (MBTI) Preference Scores of Seventeen "X"

and "Non-X" Nurses............................................................................................133
22. Myers-Briggs Type Indicator (MBTI): Classification of Seventeen "X" and

"Non-X" Nurses Based on MBTI Sixteen Types................................................135
23. Summary of preferences and scores on the Myers-Briggs Type Indicator

(MBTI) for each client and nurse who participated in the study.........................137
L1. Client 2 - Blood Pressure (systolic, diastolic), Mean Arterial Pressure (MAP)
and Pulse Readings Taken at the Beginning and the End of each
Interaction............................................................................................................221
L2. Client 2 - Subjective Units of Disturbance (SUD) and State Anxiety

Inventory (STAI) Measures Taken Before and After each Interaction...............222
L3. Frequencies of Nonverbal Behaviours Reported by Two Observers during "Z"

and "Non-Z" Interactions.....................................................................................223
M1. Client 3 - Blood pressure (systolic, diastolic), Mean Arterial Pressure (MAP)
Interaction............................................................................................................229
M2. Client 3 - Subjective Units of Disturbance (SUD) and State Anxiety

M3. Client 3 Frequencies of Nonverbal Behaviours Reported by Two Observers

during "Z" and "Non-Z" Interactions...................................................................231
N1. Client 4 - Blood pressure (systolic, diastolic), Mean Arterial Pressure (MAP)
Interaction............................................................................................................237
N2. Client 4 - Subjective Units of Disturbance (SUD) and State Anxiety

N3. Client 4 Frequencies of Nonverbal Behaviours Reported by Two Observers

during "Z" and "Non-Z" Interactions...................................................................239
O1. Client 5 - Blood pressure (systolic, diastolic), Mean Arterial Pressure (MAP)
Interaction............................................................................................................245
O2. Client 5 - Subjective Units of Disturbance (SUD) and State Anxiety

O3. Client 5 Frequencies of Nonverbal Behaviours by Two Observers during "Z"

and "Non-Z" Interactions.....................................................................................247
P1. Skin Temperature......................................................................................................250
P2. Electrodermal Measurements....................................................................................251
P3. Electromyography Activity.......................................................................................252
P4. Systolic Blood Pressure.............................................................................................253
P5. Diastolic Blood Pressure...........................................................................................254
P6. Mean Arterial Pressure..............................................................................................255
P7. Pulse...........................................................................................................................256
P8. Nonverbal Behaviours...............................................................................................257
P9. State-Trait Anxiety Inventory...................................................................................258
P10. Subjective Units of Disturbance..............................................................................259

LIST OF FIGURES
FIGURE PAGE
1. "Z" Nurse-client interaction progressive model.......................................................... 18
2. "Z" Nurse-client interaction model.............................................................................. 19
3. Layout of research set up............................................................................................. 57
4. Skin temperature, EDG, and EMG trials results......................................................... 94
5. Skin temperature, EDG, and EMG period results....................................................... 96
6. Client-nurse triads and resulting interaction sequence...............................................125
A1. Stress central pathway...............................................................................................181
A2. Endocrine system pathway.......................................................................................185
A3. Nervous system pathway..........................................................................................192
L1. Client 2 skin temperature period averages................................................................218
L2. Client 2 electrodermal (EDG) measurements period averages.................................219
L3. Client 2 electromyography (EMG) measurements period averages.........................220
M1. Client 3 skin temperature period averages...............................................................226
M2. Client 3 electrodermal (EDG) measurements period averages................................227
M3. Client 3 electromyography (EMG) measurements period averages........................228
N1. Client 4 skin temperature period averages................................................................234
N2. Client 4 electrodermal (EDG) measurements period averages.................................235
N3. Client 4 electromyography (EMG) measurements period averages.........................236
O1. Client 5 skin temperature period averages................................................................242
O2. Client 5 electrodermal (EDG) measurements period averages.................................243
O3. Client 5 electromyography (EMG) measurements period averages.........................244

1
1. THE THEORY
The nurse-client interaction is one of the essential components of the discipline of

nursing. Nursing care cannot be provided without the nurse interacting with the client. In
fact, interaction is one of the tools nurses use to provide care, to adapt care to each client
and to enhance the quality of care. The way nurses interact with their clients has an
important effect on the well-being of clients, the restoration and maintenance of health
and the reduction of stress experienced by clients when they interface with the health
care system. Illness, hospitalization and treatment are stress-producing experiences that
draw on the energy of the client. Energy is considered as a precious resource that is finite
in each individual and therefore, should be conserved to promote healing and well-being
(Selye, 1974). Nurse-client interactions are instrumental in helping the client conserve
their energy by reducing their level of stress.
The "Z" Nurse-Client Interaction Theory is a conceptualization of one type of
nurse-client interaction which claims, as an effect, the reduction of stress for the client.
"Z" interaction can be described as a distinctive and observable encounter between some
nurses and some clients. During the encounter, an instantaneous, privileged link is
created between the nurse and the client through a synchronized exchange which takes
place in a shared and exclusive phenomenal field. The purpose of this study is to test one
of the relational propositions of the theory: "Z" interaction reduces the level of stress for
clients.
The research project took place at a cancer research centre in a metropolitan area
in western Canada. One room on one in-patient unit was set aside for the 24 hour
videotaping of nurse-client interactions. Four seriously ill cancer patients, and seven
nurses participated in this study over a four month period. The design was a single
subject withdrawal quasi-experiment with repeated measures. Each client was subjected
to eight series of observations which were videotaped.
The theory stated that nurses with a quality designated as "X," in interaction with
a client whose characteristics were identified as "Y," would result in a reduction in stress
in the client. This theory was tested using physiological and psychological measures.
2
In the following pages, the background to the study and the detailed research protocol
will be presented.
Theory "Z": A Nurse-Client Interaction

Origin of the Theory
"Z" interaction has been developed from empirical knowledge grounded in the
practice of nursing and enriched by theoretical analysis. This conceptualization begins
with the view that nursing has four essential components: a client, a nurse, an interaction
and an environment. Direct nursing care is delivered through the interaction of a nurse
with a client1 within an environment. "Z" was the interaction identified following
observations of nurse-client interactions between 14 nurses and 17 patients over a period
of four months on three nursing units in a tertiary hospital.
While observing nurses interacting with clients, some interactions appeared to
have different qualities and different consequences for the client than other interactions,
regardless of the setting. Upon further analysis, even though all clients observed had the
potential to enter in a "Z" interaction, not all nurses observed had the ability to do so.
Through observations, analysis and conceptualization, Theory "Z" was formulated and
includes a description of the essential components of the theory and their elements; the
description of the "Z" interaction; the development of a model; the theoretical definition;
the description of the outcomes of the "Z" interaction for the client; and the development
of descriptive and relational propositions. This conceptualization has four essential
components that are the antecedents2 to the occurrence of a "Z" interaction. They are an
"X" nurse, a "Y" client, an environment and an encounter.
The "X" Nurse
1 A client could be an individual, a family or a group. The theory addresses only the
individual level at this time.
2 "Antecedents are those events or incidents that must occur prior to the occurrence of
the concept" (Walker & Avant, 1988, p. 43).
3
"X" nurses have a set of characteristics described below that are similar to and
also distinct from, other nurses. For the purpose of identification these nurses will be
labelled "X" nurses. Like many other nurses they are clinically competent and committed
to nursing.
Clinically competent means that the nurse has mastered basic nursing knowledge
and skills and is able to integrate knowledge and skills in order to provide safe, adequate
and human care regardless of the situation of the client. This level of integration of
knowledge and skills is evident even when the nurse is in an apprenticeship situation,
such as the second day orientation in a step-down unit with an instructor by her side.
Commitment to nursing and to the client under her care, means that nursing and
what it stands for (health, wholeness and well-being of the client), is valued and
important to the nurse. The nurse is proud to be a nurse and believes that the services she
provides to the client make a difference. She will give of herself and, as Rinaldi (1989)
identified in a phenomenological study of nurses' commitment, her first commitment is to
the patient. At times, the nurse will skip a coffee-break or delay the end of a shift of duty
to complete her work or pay a last visit to a client or to his/her family that she is worried
about. "Duty first" seems to be the motto. There is commitment to the client and to
nursing as a profession.
The "X" nurse also possesses a set of additional characteristics that seem to stand
out from other excellent nurses. They are: the ability to set aside the needs of one's own
ego; the ability to focus on another person; the ability to respect the uniqueness of
another person; the ability to unconditionally accept another person's behaviour; the
ability to enter the client's life space; the ability to intuit the client's reality; and the
ability to use "self" as the therapeutic agent. These characteristics refer to the way the
nurse is in the world, a manner of being, her "isness," a quality of presence which can be
described as existential abilities. It is too early in the development of the theory to know
whether these abilities are innate or acquired or gender related.
4
A person who has the ability to set aside one's own ego leaves herself, her daily
preoccupations, her joys or worries behind and makes a place for another person to be
welcomed as a guest in her consciousness. In the spirituality literature, this ability is
described by Lane (1987) as the virtue of hospitality.
This gracious warmth and generosity that opens the self and the
environment to the guest (...). The hospitable nurse is totally present to the
patient as if he or she were all that existed in the universe at this moment
(...) the nurse's ability to convey by presence that (her) own fears and ego
needs have been laid aside and (she is) yours. The aliveness of (her) own
spirit and (her) presence communicates to the patient that I am ready to
receive and comfort (you) should that be desired. The patient may let go,
let be, because by (her) presence and bearing, (she) recognizes and affirms
his or her freedom and provides assurance of (her) availability. (p. 336)
A person who has the ability to focus on another person is able to make the other
the point of attraction or attention to the exclusion of other elements in the environment.
The "X" nurse is able to converge her thoughts intensely toward that person. Travelbee
(1971) describes it as "being all there" (p. 106) psychologically, as well as physically.
This "ability to focus on another individual is a prerequisite to being able to use
communication techniques in any meaningful way" (p. 107). This ability is governed by
the theory of the Process of Focal Attention (Schachtel, 1959). Peplau (1989) describes
the acts of focal attention as "governed by curiosity and intense interest in an aspect of a
larger field." "Focal attention includes: 1. observing in a particular direction; 2. noticing
an external or internal object, such as a thing, idea or feeling; 3. making an active effort
to grasp the object intellectually; and 4. using not only a sustained approach but also
subsequent efforts to explore the object's various aspects and relations" (p. 339).
A person who has the ability to respect the uniqueness of another person first
and foremost, views each individual as being one of a kind, having no equal and
5
therefore being irreplaceable. Second, the person is mindful of the differences of each
person, holding them in esteem and acting accordingly. Even though there are
commonalities of human experience "each person is different in his own unique way.
This difference can be accounted for, not only on the basis of heredity and environment,
but seems to be especially due to the particular life experiences each person encounters,
his perception of these experiences and the manner in which he reacts to these
experiences" (Travelbee, 1971, p. 28). The "X" nurse follows Travelbee's suggestion and
seems to be guided by the supposition that human beings are more different than they are
alike in order to avoid the common error of assuming that others are like herself and then
judging others accordingly to her personal mores instead of being respectful of their
differences.
A person who has the ability to accept another's behaviour unconditionally

endeavours to understand why a person does what s/he does and forms a positive opinion
about each person. Acceptance has been defined by Carl Rogers in 1961 as a:
warm regard for him as a person of unconditional self-worth - of value no
matter what his condition, his behavior, or his feelings. It means a respect
and liking for him as a separate person, a willingness for him to possess
his own feelings in his own way (...). This acceptance of each fluctuating
aspect of this other person makes it for him a relationship of warmth and
safety, and the safety of being liked and prized as a person seems a highly
important element in a helping relationship. (p. 34)
Whatever the person does the "X" nurse seems to be comfortable with it and is able to
integrate it into the relationship.
A person who has the ability to enter the client's life space is able to mobilise
her/himself in the reality of someone else. For the "X" nurse it translates into the ability
to penetrate the client's world, and get absorbed by this new reality. The "X" nurse's own
reality is not part of her consciousness but it is replaced by the other person's reality.
Watson (1988) uses this concept when she describes transpersonal caring relationships in
6
these words: "human care can begin when the nurse enters into the life space or
phenomenal field of another person" (p. 63). Watson holds the position that these
abilities are a moral ideal but for the "X" nurse they are an empirical reality.
A person who has the ability to intuit the client's reality is able to apprehend the
total situation of the client, not as the sum of its parts but as a whole. This knowledge
does not seem to be the result of a linear reasoning process but of a "gestalt" or
knowledge of the whole pattern at once. The "X" nurse possesses this ability which is not
time-bound but immediate upon an encounter with a client. Kaplan (1964) describes
intuition as a kind of logic an individual uses and refers to it as "logic-in-use" which is
preconscious and outside the inference schema for which we have readily available
logical reconstruction (p. 14). Rew (1986) identified the following defining attributes for
intuition: "knowledge of a fact or truth, as a whole; immediate possession of knowledge;
and knowledge independent of the linear reasoning process." (p. 23).
A nurse who has the ability to use "self" as the therapeutic agent views the self
as one part of the therapeutic tools used to promote the well-being of a client. Travelbee
(1971) defines "therapeutic use of self" as "the ability to use one's personality
consciously and in full awareness in an attempt to establish relatedness and to structure
nursing intervention (...). To use oneself therapeutically also implies that the nurse
possesses a profound understanding of the human condition" (p. 19). In her view, such a
nurse will have explored and can discuss her beliefs about illness, suffering, and death,
and the meanings these beliefs have for her.
Even though all these characteristics of the "X" nurse can be inferred from
empirical referents3, other colleagues do not refer to them with such a specificity. Many
nurses recognize that some nurses have a set of specific characteristics that affect, in a
3 "Empirical referents are classes or categories of actual phenomena that their

existence or presence demonstrate the occurrence of the concept itself" (Walker & Avant,
1988, p. 43).
7
significant way, the nurse-client interaction while others do not have it. They give the
"X" nurse some general identifiers and they refer to them individually or in a group as "a
real caring nurse," "having an aura," "very special person," "nurses who pass on a special
kind of energy" and "nurses who seem to convey the message 'give your soul over to
me'."
The demographic characteristics of the client such as gender, age, education, type
of illness and personality traits, do not appear to affect the existential abilities of the "X"
nurse or her "isness." These distinct characteristics seem present all the time with every
client. Other variables such as age, education, experience of the nurse do not appear to be
relevant.
The "Y" Client

All clients observed seemed to be able to enter into these interactions regardless
of their individual demographic characteristics such as age, gender, level of education,
illness or personality traits and regardless of the demographic characteristics of the "X"
nurse, such as age, education or years of experience. But there are distinct characteristics
that can be inferred for all clients that enter into a "Z" interaction. For the purpose of
identification these clients will be labelled as "Y" clients.
The "Y" client is a fully-conscious adult person, "aware of one's own existence,
sensations, thoughts, surroundings" (Webster, 1989, p. 311) and able to communicate
with other individuals. In some instances when the client is unable to communicate
verbally with others, for example when intubated, s/he is always able to communicate
non-verbally with facial expressions and/or eye movements and/or gestures and/or in
writing. Since no empirical referents were evident for unconscious clients, they are not
considered at this time.
The client is also dependent on others for nursing care. The individual requires
assistance or support in relation to unmet needs which s/he would fulfil if s/he was well
8
and healthy. The needs may be related to any or all of the bio-psycho-social components
of the individual such as personal care, diagnostic or treatment of an illness, reassurance
and knowledge related to personal situation or an unknown environment, sense of
belonging and the like.
The "Y" client experiences a multi-faceted stressful situation due to illness and
hospitalization. Hadley (1969) identified two types of stress that clients experience: the
primary stress which exists when the homeostasis mechanisms are inadequate to face the
tensions in the internal or external environment of the subject; and the secondary stress
which exists when major changes occur in the structure and or functioning of the
subject's physical or psychosocial milieu due to causes such as illness or hospitalization.
So client "Y" experiences on an ongoing basis what Selye (1956) identified as a General
Adaptation Syndrome which results from the organism's efforts to maintain an internal
physio-chemical equilibrium whether the stressors are psychological, social or physical.
The "Y" clients, like the "X" nurse, appear to possess a set of additional
characteristics. These characteristics refer to the way the client is in the world, a manner
of being, an "isness," a quality of presence which can be described as existential abilities.
These abilities are: the ability to sense the purposefulness of the encounter; the ability to
sense the benevolence of the nurse; the ability to sense the competence of a provider; the
ability to accept or welcome the nurse to his/her world; the ability to relax; and the
ability to collaborate with and contribute to the interaction.
A person who has the ability to sense the purposefulness of the encounter is able
to use the external senses of touch, taste, smell, hearing and sight and the internal senses
of central sense, imagination, cogitative or estimative sense and memory (Wallace, 1983)
in order to feel and perceive that another person is pursuing a specific goal during a face
to face meeting.
A person who has the ability to sense the benevolence of the nurse is able to use
9
external and internal senses to feel and perceive that the nurse's intent is for the benefit of
the client and the nurse's desire is to act with kindness toward that person.
A person who has the ability to sense the competence of a provider is able to use
external and internal senses to feel and perceive whether the nurse possesses the required
skills, knowledge, manner of being and the capacity to cope with and manage any
situations she will encounter. The client is open to the evidence of the practitioner's
competence as it emerges, as the nurse's special knowledge is manifested in her
interaction with the client (Schon, 1983).
A person who has the ability to accept or welcome the nurse to his/her world is
responsive to the nurse's attempt to create a close connection or relationship and is
willing to let the nurse enter into his/her private space or intimacy and self-disclose.
Friedman and Huls (1991) define acceptance or intimacy as "sharing of self on a most
personal and private level and making oneself vulnerable to another" (p. 31).
A person who has the ability to relax is able to reduce the tension experienced
from bodily or mental efforts. The ability to reduce neuromuscular tensions and activities
pervades the whole person including the reduction of emotional tensions (Jacobson,
1952). Benson (1976) defines this ability as the relaxation response which is an innate,
intricate set of psychophysiological reactions in opposition to those produced by stress.
"The relaxation response is trophotropic, energy conserving, and nurturing" (Sundreen,
De Salva Rankin, & Cohen, 1989, p. 235).
A person who has the ability to collaborate with and contribute to the
interaction is capable of taking an active role and contributing to his/her own health and
well-being in spite of an environment which encourages a passive role. "In becoming a
patient one admits to a need for help. But does one necessarily also admit inability to
make any decisions or take any part in planning or execution of that help?" (Tryon &
Leonard, 1965, p. 121). Montgomery (1993) identifies that one of the abilities essential
10
in the client interaction is the ability to respond. "The impulse to care does not
necessarily depend on the participation of the patient, but the unfolding of the
relationship does" (p. 83).
The "X" and the "Y" characteristics are important elements of the theory. It is
essential that the participants possess a set of existential abilities for the "Z" interaction to
unfold. Even though the nurse initiates the interactions most of the times, the client's
participation is equally important to the interaction. The initiation of the interaction "does
not necessarily depend on the participation of the patients, but the unfolding of the
relationship does" (Montgomery, 1993, p. 83). The other two essential components
required for the occurrence of the "Z" interaction are the environment and the encounter.
The Environment
All human interaction takes place in and is part of an environment. The external
environment can be defined as an "aggregate of surrounding things, conditions or
influences, especially as affecting the existence or development of someone or
something" (Webster, 1989, p. 477). Levine's theory of nursing (1973) provides a
detailed description of the external environment that helps to clarify the complexity of
this concept. Using Bates' (1967) work, she identifies three dimensions to the external
environment: the perceptual environment (a response to individual sense organs); the
operational environment (that which physically affects an individual, such as objects,
possessions, weather or microorganisms); and the conceptual environment (elements
such as symbols, culture, values, language and roles).
The particular external environment in which a nurse-client interaction takes

place possess several specific characteristics. These characteristics refer to the way the
world is, its nature or its "isness." Since nurse-client interaction takes place in a multitude
of settings, this set of characteristics even though constant, vary in intensity depending on
the circumstances and the setting. For example, an intensive care unit (ICU) provides a
very different setting than a community health centre, or the individual's home or a
11
school. The characteristics deduced following observations of nurse-client interactions in
three settings (a cardiac catheterization laboratory, a medical surgical "step-down" unit
and a medical unit) are: the capacity to produce stress reactions; the capacity to delay the
healing process; the capacity to provide the required services for caring and curing; and
the capacity to inspire a sense of security or safety.
The nurse/client interaction takes place in an environment which has the capacity
to produce stress reactions. The milieu in which nursing care is provided has its own set
of values and beliefs, customs and organizational culture which are foreign to the client.
The clients often feel isolated, surrounded by strangers, depersonalized, concerned about
the diagnosis and treatment of an illness, concerned about their health and its impact on
their lives and the lives of others. The nurse is often surrounded by technology,
machines, the high-intensity pace of situation management, administrative tasks and the
manipulation of many people in order to meet the needs of the various systems required
to provide care (Watson, 1988). Any or all of these examples can create stress reactions
for the client and the nurse and increase the client's vulnerability.
Such a stressful environment has the capacity to delay the healing process for the
client or to be counter-productive for restoration of health or for a peaceful death. Selye
(1983) found that the same stressor can affect different people in different ways and to
different degrees but whether the stressors are psychological, social or physical, the
effects on the organism are the same. He also recognized that the adaptation capacity or
adaptation energy of the body is finite and that one should conserve this precious
resource. So, the more stressful the environment is for the client, the fewer resources are
left to facilitate the healing or restorative processes. These stressors leave some
irreversible "chemical scars" which accumulate to constitute wear and tear and ageing (p.
6). In this way, a stressful environment mitigates against healing and restoration.
The nurse-client environment is usually organized with all the means necessary to
provide the required services for caring and for curing a client. Those tools may be
12
extensive and technologically complex, such as in an ICU with the equipment, material,
computers, communication networks and a team of experts on site, or the tools may be
portable and low-tech as in a school where the nurse may have in a small bag all the
equipment and materiel necessary for the assessment of the students or where she may
use only interpersonal skills. In both examples, the nurse-client environment has the
appropriate support for the provision of health care services.
Because the external environment is organized for the provision of nursing care it
is capable of inspiring a sense of security or safety in the client. It conveys to the client
the message that his or her situation is being attended to, that help is available and that all
the equipment and material necessary are close by. These messages inspire confidence
because the environment is organized in a way to focus and protect the client and
everything is ready and available in case of need.
Even though the external environment is very important, the internal environment
of the client is equally important for this conceptualization. The internal environment of
the client is characterized, as described in the client section, as a General Adaptation
Syndrome (Selye, 1956) which results from the organism's efforts to maintain an internal
physio-chemical equilibrium. When the homeostasis mechanisms are inadequate to face
multiple tensions in the individual's internal and/or external environments, the client may
need help to re-establish homeostasis.
The nurse-client interaction takes place and is part of an environment which is an

open system where all dimensions of the environment affect each other. "Separate
consideration of either the internal or external environments can provide only a partial
view of the complex interaction that is taking place between them" (Levine, 1973, p. 12).
The Encounter
An encounter is a face to face meeting between two strangers, in this case a nurse
and a client, for the purpose of providing/ receiving direct nursing care. Goffman (1961)
13
describes an encounter or a focused gathering as "a natural unit of social organization in
which focused interaction occurs" (p. 8) and defines it as "one type of social arrangement
that occurs when persons are in one another's immediate physical presence" (p. 17).
What is particular to the encounter in this conceptualization is the type of

individuals that enter into it and the results it produces. The meeting takes place between
an "X" nurse and a "Y" client that have never met before, for the purpose of providing/
receiving direct nursing care. Every time this encounter happens a "Z" interaction results.
The "Z" Interaction

The four essential components of this conceptualization have been identified as
antecedents to "Z" but they can also be construed as the structural elements of the theory,
the "X" nurse, the "Y" client, the environment and the encounter. The interaction that
follows, can be described and analyzed as a process, meaning a "series of progressive and
interdependent steps by which an end is attained" (Webster, 1989, p. 1147). Even though
the process described here is in a detailed sequential fashion, it takes place within a few
minutes. Furthermore, only a few of the changes observed have empirical referents or are
actual behaviours that can be observed. The other changes are instigated or shaped by
elements whose nature can be inferred or by what Kaplan (1964) calls the "indirect
observables4." Therefore, the process described above is based upon assumptions
grounded in observations (Rodger, 1990) and interaction and caring theories
(Christensen, 1990; Gendron, 1988; Montgomery, 1993; Paterson & Zderad, 1988;
Peplau, 1989; Rew, 1986; Rogers, 1951; Travelbee, 1971; Watson, 1988).
The dynamic process starts with the encounter of two strangers for the purpose of
providing/receiving nursing care, an "X" nurse and a "Y" client. From the time the nurse
enters the visual field of the client, one can observe that she looks and moves toward
him/her. When in physical proximity, she touches the client physically and/or
4 "Indirect observables are...relatively more subtle, complex, or indirect observations,

in which inferences play an acknowledged part. Such inferences concern presumed
connections, usually causal..." (Kaplan, 1964, p. 55).
14
psychologically through skin to skin or eye contact. This is described in Peplau's theory
(1989) as focal attention: the nurse is "governed by an intense interest in an aspect of a
larger field (...) (and) includes observing in a particular direction (...) noticing an external
or internal object (...)." (p. 339). Focusing is also documented in the literature as part of
the initial phases of a human to human interaction ( Peplau, 1989; Rogers, 1951;
Travelbee, 1971). For the purpose of theory "Z", the expression coined is: the nurse
converges her thoughts intensely toward the client and deliberately focuses on him/her.
One of the hypothesis of the conceptualization is that before a client can relax,
which is the next empirically based step of the interaction, there has to be an intervening
step. The client must experience an internal process which brings her/him to the
conclusion that this nurse represents a positive and benevolent presence. The client's
response is inferred because relaxation cannot take place in the presence of a threat. Carl
Rogers's (1951) states that "in (an) atmosphere of safety, protection, and acceptance, the
firm boundaries of self-organization relax" (p. 193). This immediate positive response by
the client towards the nurse is further documented in Montgomery's (1993) dissertation
where she describes caring incidents where "trust seems to be an immediate survival
instinct rather than something that develops over time" (p. 77). This intervening step is
described as the client senses the positive presence of the nurse and her desire to act
with kindness toward him/her.
The reaction of the client that follows is described by one nurse as: "It is as if the
client seems to give himself up body and soul to that nurse." The relaxation is apparent in
a change of tension in the client's muscles (legs, arms or face), in facial expressions
(open facial expression or a smile) and in body posture. For these reasons, this reaction
of the client is labelled as: the client then relaxes in response to this positive,
benevolent presence and is able to let go or surrender.
The next step of the process is conditional to the relaxation of the client. From
Watson's (1988) caring theory, echoed by Montgomery's work (1993), the relaxed client
makes it possible for the nurse to get close and enter into the client's world. These
authors have inferred that caring starts when the nurse enters into the life space or
phenomenal field of the client. This inference is accepted and described as: the nurse
15
enters into the client's phenomenal field.
In response to the penetration by the nurse of the client's world, one can
hypothesize that the client welcomes her. This hypothesis is based on the observations of
cooperative actions on the part of the client with the nurse's initiatives and the absence of
verbal or non-verbal communications which would signal a withdrawal from the
relationship. It is labelled as: being welcomed.
The next empirical step is based on the fact that the nurse seems to know and
understand the client and the client's complexity right away and seems to be able to act
appropriately to the client's reality. Because the client's reality is multi-faceted and
complex, the process witnessed is unlikely to be a linear reasoning process since linear
reasoning is uni-dimensional and time consuming. Rew (1986) described this
phenomenon in her concept analysis as using intuitive knowledge and skills. Intuition is
characterized by immediate possession of knowledge as a whole (Gestalt) independent of
linear reasoning. The theoretical statement then, is: the nurse apprehends the whole
pattern of the client at once, by intuition.
As a result of this development, a relationship between the nurse and client is
created. The relationship is described in Paterson's and Zderad's (1988) nursing
interaction theory as a connection between the nurse and the client or an understanding
between them not shared with others and not transferable. 5 This relationship is called: a
privileged link between the nurse and the client.
From that step on, the observations demonstrated a harmonious give and take
evident between the nurse and the client where the verbal or non-verbal communications
and the actions seem to be appropriate to the moment and flow without any barriers in
the pursuit of their goal. This phenomenon was also documented by Montgomery (1993)
under the label aesthetics (p. 93) and Gendron (1988) under the metaphor of orchestral
music (p. 9). In the observations, these exchanges were ongoing in the provision and
5 During the observations, if a client was assigned a different nurse to care for him/her
who was "non-X" then, the client would ask to see the "X" nurse or would go to find her
and establish contact again.
16
receipt of direct nursing care and in the pursuit of the purpose of their interaction. The
expression coined to describe this step of the process is: the behaviours of one person,
serves as a cue for the behaviours of the other and a synchronized exchange begins
between them.
From there the process unfolds. The number of encounters that follow between
the nurse and the client may alter the intensity or timing of some of the steps of the
process described above, but essentially the process is always the same.
Even though the purpose of providing/receiving nursing care could imply a
certain dependency, in this particular nurse-client interaction: each person seems
independent of the other and each remain his/her own person. The client's awareness
seems to reside in the self rather than the nurse. Montgomery (1993) found in her work
that clients "who participate in a significant caring encounter seem to experience a
heightened sense of integrity and sense of self" (p. 103). Christensen (1990) also found
in her study that even when accepting expert advice, the client demonstrated their
retention of personal autonomy and freedom. The nurse is also free-standing and
independent. Even though she participates fully in the client's world she is not consumed
by it. She seems "motivated (... ) by an inner sense of integrity about what (she) has to
offer in each situation" (Montgomery, 1993, p. 89). The "Z" interaction has also another
important characteristic that can be described as: exclusivity of their environment. When
the "X" nurse and "Y" client share a phenomenal field they create not only a privileged
link between themselves but also a protected environment in which their privileged
relationship takes place. Only they belong to this environment. What goes on around
them seems to belong to another world and they may or may not choose to include it in
their exclusive environment.
Walker and Avant (1988) believe that "it is quite useful to represent beginning
theories in both graphic (model) and linguistic (theory) form. Theorists often move back
and forth between theories in written sentences and visual devices" (p. 167-168). For this
purpose, two models6 are presented, a progressive model (Figure 1) which depicts
6 "A model is a graphic and symbolic representation of a phenomenon that serves to
17
graphically in four sequences the "Z" interaction process described above and a general
model (Figure 2) which depicts the interaction as a whole.
18
Therefore, the theoretical definition of the "Z" interaction can be described 7 as an
encounter between an "X" nurse and a "Y" client for the purpose of providing/ receiving
nursing care. An instantaneous privileged link is created between the nurse and the client
through which a synchronized exchange takes place in a shared and exclusive
phenomenal field.
The Outcomes
19
The changes that occur in the client8 as a result of the "Z" interaction are evident
under any circumstances and could be identified under the general rubric of increased
Figure 1. "Z" Nurse-client interaction progressive model.
objectify and present a certain perspective or point of view about its nature and/or
function" (Powers & Knapp, 1990, p. 88).
7 "Z" interaction is an indirect observable term, Kaplan suggests that one way to
define such theoretical terms, is by description (Kaplan, 1964, p. 55).
8 The theory does not address the outcomes for the nurse at this time.
Figure 2. "Z" Nurse-client interaction model.
22
sense of well-being. The more stressful the environment in which the interaction takes
place, the larger is the effect and the consequences are more visible. Some of the
consequences are: stress reduction; feeling of security and safety; willingness to share
personal concerns; and increased participation in self-care.
One of the effects of the "Z' interaction on the client has already been alluded
to in the description of the antecedent under the rubric "ability of the client to relax."
The client experiences to varying degrees, a stressful internal and external environment
and these experiences produce bodily and mental tensions or stress. When exposed to
stress, a number of changes are observed; they are psychological, physiological and overt
behavioural in nature (Burchfield, 1985). But when a "Z" nurse-client interaction takes
place the client experiences a: reduction of stress. Since stress is multidimensional it can
be observed in several ways such as observing muscle relaxation, verbal or facial
expressions or a smile.
Another change that occurs in the client is manifest as a: feeling of security and
safety. The client feels protected, secure and willing to trust. "Trust is that secure feeling
one has when relating to another person. This sense of security evolves because the
person feels that he is not being judged or ridiculed. The person feels safe - he can be
himself and does not have to put on a facade" (Hames & Hunt, 1980, p. 3). Even though
one of the critical attributes of the concept analysis of trust is "being bound in time"
(Meize-Grochowski, 1984; Ruditis, 1979) it is not the case in this conceptualization. The
feeling of security and safety is instantaneous. Montgomery (1993) documented in her
dissertation that trust seems to be an immediate result when the client's vulnerability is
heightened "rather than something that develops over time during the course of a
therapeutic relationship" (p. 77).
Clients who are involved in a "Z" interaction demonstrate: a willingness to share
personal concerns. Because the client is able to let go, the client is able to volunteer
information about him or herself which is very personal. Nurses learn communications
techniques to solicit information about the clients that is relevant to their care. In most
cases, the client will respond positively to the use of these communications techniques.
Through the "Z" interaction, the client responds to the nurse's cues but goes further by
23
also initiating self-disclosure.9 In the "Z" interaction the client is able to initiate
disclosure at the second or third level of disclosure.
The "Z" nurse-client interaction increases participation of the client in her/his
care. Montgomery (1993) identified in her work that "the most striking effect described
by caregivers is that when patients experience the caring of the clinician, they are
inspired to want to care about themselves" (p. 102). The client not only responds to the
nurse's suggestions or initiations of care but engages in self-care. 10
Propositions11
The next step in theory formalization is the specification of propositions. In order to
summarize the major elements of the "Z" interaction and their relationship, non-relational
or descriptive propositions will be stated followed by relational propositions.
Descriptive propositions12
1. Conscious adult clients in need of nursing care who have all the identified existential
characteristics13 can enter into a "Z" interaction.
9 Burnard and Morrison (1992) in their discussion of self-disclosure use Cox's (1978)
conceptualization of three levels of self-disclosure by the client: the first level is
disclosure of safe and relatively unimportant items; the second level is disclosure of
feelings; and the third level is disclosure of deep, existential concerns of the client (p. 64-
65).
10 Self-care "is the practice of activities that individuals personally initiate and
perform on their own behalf in maintaining life, health and well-being" (Orem, 1980, p.
35).
11 "Propositions are tentative statements about reality and its nature" (Meleis 1991, p.
205).
12 The descriptive or non-relational propositions are statements that acknowledge the

existence or describe the properties of the concepts (Fawcett & Downs, 1992; Meleis,
1991).
13 They are: the ability to sense purposefulness of the encounter, the ability to sense
the benevolence of the nurse, the ability to sense the competence of a provider, the ability
to accept or welcome the nurse to his/her world, the ability to relax, and the ability to
24
2. Nurses who have all the identified existential characteristics14 can enter into a "Z"
interaction.
3. The environment in which the "Z" interaction takes place is stressful and organized to
provide the required services for caring and curing.
4. The "Z" interaction begins in the first few minutes of the initial encounter between two
strangers, it is instantaneous.
5. During the "Z" interaction, each person is independent from the other and they remain
their own person.
6. The "Z" interaction is initiated by the nurse.
7. The "Z" interaction is client-centered and includes several processes such as focusing,
sensing, relaxing, entering, welcoming, intuiting and synchronized exchange.
8. The "Z" interaction takes place in a protected environment that is created and belongs
exclusively to that nurse and that client.
9. The outcomes of "Z" interaction are beneficial to the client's well-being.
Relational propositions15
1. If an "X" nurse encounters a "Y" client for the purpose of providing/receiving nursing
care then, a "Z" interaction will result.
2. The number of encounters may alter the intensity or timing of components of the
interaction but not the process or the effect.
3. When the nurse focuses on the client, the client feels the warm and generous presence
of the nurse causing the client to relax and feel safe.
collaborate with and contribute to the interaction.
14 They are: the ability to set aside one's own ego needs, the ability to focus on
another person, the ability to respect the uniqueness of another person, the ability to
accept another's behaviour unconditionally, the ability to enter the client's life space, the
ability to intuit the client's reality, the ability to use "self" as the therapeutic agent.
15 The relational propositions are "declarative statements that express an association

between concepts" (Fawcett & Downs, 1992, p. 27-28). Most of the relational
propositions in this conceptualization are causal statements concerning the interaction
itself and the consequences of the interaction.
25
4. The relaxed client allows the nurse to penetrate the client's world and apprehend
her/his whole reality by intuition.
5. When a privileged link is created between the "X" nurse and the "Y" client, a
synchronized exchange starts where the cues of one person serve as cues for the
behaviour of the other person.
6. A stressful environment will delay the healing process within the client.
7. An environment organized to provide required caring or curing of the client will
inspire a sense of security and safety in the client.
8. The effect of the "Z" interaction on the client will be proportionally related to the
stressfulness of the environment.
9. The "Z" interaction reduces the stress level of the client.
10. The "Z" interaction increases the client's feeling of security and safety.
11. The "Z" interaction encourages the client to share personal concerns.
12. The "Z" interaction increases the client's participation in self-care.
Each concept in this conceptualization needs to be developed further and each of

the relational propositions needs to be tested to further develop this emerging theory.
This study will test the relational proposition number 9: that "Z" interaction reduces the
stress level of the client.
2. REVIEW OF LITERATURE
Even though the nurse-client interaction is one of the essential components of the
discipline of nursing, it has not been regarded to date, as a major source of knowledge
development (Moch, 1990). As background to this study, a review of scholarly works on
the topic of nurse-client interaction, in the area of theory development and testing, is
presented.
Nurse-client interaction is defined for this study as a face-to-face encounter
between a nurse and a client for the purpose of providing/receiving nursing care, where
the cues of one individual serve as cues for the other in guiding their actions. The term
nurse-client interaction is not used interchangeably with nursing actions (Kim, 1983),
nursing therapeutics (Meleis, 1991) or nursing interventions (Bulechek & McCloskey,
1987) which all refer to what nurses do for or with clients.
In order to circumscribe the scholarly work in this domain, a review of literature
was conducted for articles and books published in the health, nursing and psychological
literature between 1966 and March 1995. Historical sources prior to 1966, were used as
required, through the ancestry approach tracking citations from one source to the other
(Cooper, 1982). Several key words were used to access the broadest possible concepts
that related to nurse-client interaction. They included nurse, client or patient, interaction
or relations or interpersonal relations. Retrieval of information included on-line computer
searches of the automated University of Alberta Library Catalogue (130,000 health
sciences titles), the Medline program which reviewed over 7,000 publications in the
nursing, medical, dental and health care field (National Library of Medicine, 1990), the
CINAHL program which reviewed 300 publications in the nursing field and allied health
literature (Fishel, 1990), the PsychLIT program which reviewed 1,300 publications in
psychology, education and psychiatry (American Psychologist Association, 1992) and
the DISS data base which reviewed doctoral dissertations and master's thesis from North
American and British universities (BRS, 1993). A hand search of the Annual Review of
Nursing Research and Communicating Nursing Research was also carried our. The topic
was limited to texts in English or French, related to theory and research in the area of
nurse-adult client interaction. Pieces of information with a focus on psychiatric or
unconscious clients, teaching interpersonal skills, single concepts related to interaction
such as empathy, self-disclosure, touch and studies of social and organizational context
were excluded.
Nurse-Client Interaction Theories16

The first nursing article in Nursing Research that identified the need for a
theoretical framework for nursing research, was by Gunter in 1962 (Nicoll, 1986). She
stated that a theoretical framework for nursing research should include a theory of
interpersonal relations which, when used inter-dependently, interrelatedly and integrally
with a theory of organism and a theory of medicine, create a unique nursing theory. She
defined interpersonal relations "as the manner in which the nurse interacts with the
patient" (p. 219). The major interaction theories were "conceived in the late 1950s and
early 1960s and viewed nursing as an interaction process with a focus on the
development of a relationship between patient and nurse" (Meleis, 1991, p. 255). The
early attempts in theory development in nursing came primarily from leaders in
psychiatric nursing. They made an important contribution to theory development in
particular, in the area of the relationship between client and nurse. Ten nursing theorists
can be identified as having developed a nurse-client interaction theory or explicitly
discussed the phenomenon as part of their theory. They are Peplau (1952), Orlando
(1961), Wiedenbach (1964), Travelbee (1971), King (1981), Paterson and Zderad (1976),
Watson (1988), Parse (1987), Christensen (1990) and Montgomery (1993).
Peplau (1952) was the pioneer of the interactionist school of thought in nursing.
In her conceptual framework entitled, "Interpersonal Relations in Nursing" there are four
central components, interpersonal process, nurse, patient and anxiety. She defines
nursing as a "significant, therapeutic, interpersonal process (which) functions co-
operatively with other human processes that make health possible for individuals" (p.
16). The nurse-patient relationships have four overlapping phases in the move toward
health, they are orientation, identification, exploitation and resolution. In the orientation
16 The term theory is used interchangeably with theoretical framework and theoretical
model.
phase, the patient has a "felt need" and professional assistance is sought. When the
patient responds selectively to persons who seem to offer the help s/he 17 needs, this is the
identification phase. The phase of exploration is when the patient proceeds to make full
use of the services offered and finally, the phase of resolution is when old ties and
dependencies are fully relinquished as the patient prepares to go home. In each of the
four phases, several tasks and roles are required of the nurse as she 18 uses the
corresponding steps of the nursing process, assessment, planning, intervention and
evaluation.
Orlando (1961, 1972) also formulated a theory with the major concept being the
nurse-patient interaction entitled, "The Dynamic Nurse-Patient Relationship." In her
theory, she explicated the desirable structure of an interaction for the purpose of
assessing needs and providing the care deemed necessary for the patients. The process of
nursing is the ongoing interaction of the three elements with each other: the verbal and
non-verbal patient behaviours; the reaction of the nurse; and the automatic or deliberative
nursing actions which are undertaken for the patient's benefit.
"Clinical Nursing: A Helping Art" (Wiedenbach, 1964) is a theory that focuses on
three major concepts, needs, interaction and perception. It expands on one of Orlando's
concepts, the deliberative nursing action and in particular, the importance of validation of
perceptions, thoughts and feelings before deliberative action takes place. Part of the
deliberative action are the nurse's thoughts and feelings which evolve from the patient's
behaviour. "Validating-clarifying action which attempts to gain understanding of what
the individual's behavior means to him, constitutes a point of departure of deliberative
action from other forms of action taken by the nurse" (p. 109). This interaction is part of
the art of nursing which "is a helping process with action directed toward providing
something the patient requires or desires and which will restore or extend the patient's
ability to cope with demands implicit in his situation" (p. 36).
Travelbee (1971) has defined nursing as "an interpersonal process whereby the
17 When possible, the masculine and feminine forms will be used to refer to a client.
If the masculine form is used, it includes both genders.
18 Even though the feminine form is used when referring to a nurse, it includes both
genders.
professional nurse practitioner assists an individual, family, or community to prevent or
cope with the experience of illness and suffering and, if necessary, to find meaning in
these experiences" (p. 7). Nursing's purpose is fulfilled through a human-to-human
relationship characterized by having "both nurse and ill person perceive and relate to
each other as unique human beings, rather than as 'nurse' to 'patient'" (p. 119). In this
conceptualization, the human-to-human relationship is established after the nurse and the
recipient of her care have progressed through four preceding and interlocking phases.
These phases are: 1) the original encounter, 2) emerging identities, 3) empathy and 4)
sympathy. All of these phases culminate in rapport (or relatedness) and the establishment
of the human-to-human relationship. The other important concept that Travelbee
introduced in her theory, is in relation to the characteristics of a professional nurse in a
human-to-human relationship which is the therapeutic use of self. "By therapeutic use of
self is meant the ability to use one's personality, consciously and in full awareness in an
attempt to establish relatedness and to structure nursing intervention" (p. 19).
The "Theory of Goal Attainment" (King, 1981) is another theory with a major
focus on interaction. The main concepts are process, interaction and goal attainment. The
theory is based on the assumption that nurses as human beings, interact with patients as
human beings, and that both are open systems who also interact with the environment.
The theory therefore, includes the personal system (nurse and patient) interacting with
each other in an interpersonal system and with the environment that she called the social
system (society). Nursing is defined as "a process of human interaction between nurse
and client whereby each perceives the other in the situation and, through communication,
they set goals, explore means, and agree on means to achieve goals" (King, 1981, p.
144). And in turn, the nurse/patient relations are defined as "a process of perception and
communication between person and environment and between person and person,
represented by verbal and nonverbal behaviors that are goals-oriented" (p. 145).
"Humanistic Nursing Theory" (Paterson & Zderad, 1976) like previous theories,
defines nursing as an interaction but from a different perspective. The interaction is an
existential experience where both the nurse and the patient are the nursing clients19 who
19 The nurse is also considered a nursing client because she is an incarnate being that
reflects, values, experiences to become more than she is while giving help.
are unique when "they meet in a goal-directed (nurturing, well-being, more well-being)
intersubjective transaction (being with, doing with) occurring in time and space" (p. 23).
For them, the human dialogue is the essence of nursing and nursing is interaction.
Nurse/patient experience is an intersubjective transaction with empathy. This interhuman
intersubjective transaction takes place when one human being is helping another human
being and struggles with the other person through peak experiences related to health and
suffering.
The caring theories and conceptualizations are also from an existential
perspective. Some caring conceptualization could be described in terms of interaction
because caring is considered as "a highly complex communication phenomenon that
occurs at the level of biology, behavior, and metaphysics" (Montgomery, 1993, p. 36).
For example, Watson (1988) describes caring as a mutual transpersonal, intersubjective
exchange between a client and a nurse in which they relate on the level of their shared
humanness and both learn from each other. Watson considers that the terminology nurse-
patient interaction or intervention are not appropriate for her theory. The term "caring
process" should be utilized and the process "requires an intention, a will, a relationship,
and actions (that take place) with the full participation of the nurse/person with the
patient/person" (p. 74). The combination of possible interactions are referred to as
carative factors20 which become actualized in the moment-to-moment human care
process. Morse, Solberg, Neander, Bottorff, and Johnson (1990) examined 25 authors
who conceptualized the phenomenon of caring. They identified five epistemological
perspectives. One of these perspectives is caring as an interpersonal relationship.
Proponents of that perspective such as Knowlden (1988) and Weiss (1988) have a
different view than Watson regarding interpersonal relationships. Watson's theory
describes the nurse-client interaction as an "approximation of caring" (p. 34) or a vehicle,
20 Carative factors: humanistic-altruistic system of values; faith-hope; sensitivity to

self and others; helping-trusting, human care relationship; expressing positive and
negative feelings; creative problem-solving caring process; transpersonal teaching-
learning; supportive, protective, and/or corrective mental, physical, societal, and spiritual
environment; human needs assistance; and existential-phenomenological-spiritual forces
(Watson, 1988, p. 75).
while Knowlden and Weiss believe that the nurse-patient relationship is the essence of
caring which expresses and also defines caring. But they have not developed a
corresponding theory.
Parse (1987) also presents her theory which is based on interrelationships from a
specific world view. She claims that "Man-Living-Health Theory" is a theory within the
simultaneity paradigm21 where a human being is seen as mutually living and evolving
with the environment therefore, non-causal, nonpredictable interactions of a human being
with the environment exist. But Parse still conceptualized the practice of nursing as a
"subject-to-subject interrelationship, a loving, true presence with the other to promote
health and quality of life" (p. 169). In this practice methodology Parse identified three
dimensions: illuminating meaning through explicating (shedding light through
uncovering that what was, is, and will be, as it appears now); synchronizing rhythms
(which happen in dwelling with the pitch, yaw, and roll of human cadence); and
mobilizing transcendence (moving beyond the meaning moment to what is not-yet). Two
recent theories by Christensen (1990) and Montgomery (1993) have conceptualised the
nurse-client interaction following a grounded theory study. Christensen developed the
Nursing Partnership Theory. The three major interrelated elements within the theory are:
1) the passage, "a social process which can be used to describe an experience of
significant change in a person's circumstance" (p. 26); 2) mutual work, "a patterned
interaction between patient and nurse which is essential to the outcome of the patient's
passage" (p. 28) - "nursing is continually shaping and reshaping in response to the
complexities inherent in the present and ongoing circumstances of each patient's passage"
(p. 29); and 3) the context which includes three contextual determinants, episodic
continuity (the contact is episodic but both the nurse and the client view nursing as
continuous), anonymous intimacy (some degree of anonymity in the midst of very
personal or intimate service) and mutual benevolence (goodwill between nurse and
client). The client passage is characterized by four phases in which several concepts
21 Compared to the totality paradigm in which "man is viewed as a bio-psycho-social
being, or the totality of these aspects of Man", "life processes are described as analogous
to a machine, Man is described as separate from environment and a focus is on the parts
interacting in a causal manner; entropy and closed boundaries are assumed" (Parse, 1987,
p. 153).
related to the work of the client and the work of the nurse are described. They are the
beginning of a health-related experience, the settling in, the negotiating and the leaving
of the nursing partnership
Montgomery (1993) developed her theory based on the caring construct and
considers it appropriate for communication or interaction in health care. The Theory of
Caring "is characterized by a great deal of mutuality between caregiver and client." The
intense relationship that develops requires of the care-giver "a certain predisposition, an
existential way of being in relation to others, that allows for and sustains this level of
communication" (p. 41). This predisposition includes seven qualities such as person
orientation rather than role orientation, concern for the human element in health care,
person-centered intention, transcendence of judgement, hopeful orientation, lack of ego
involvement and expanded personal boundaries. Caring in action or at the behavioural
level is characterized by eight properties such as empowerment through the mobilization
of resources, advocacy, authenticity, responsiveness, commitment, being present with,
creating meaning, and hope and competence. Since caring is a participatory act, the
caring function is also dependent on the context, the participation of all involved with the
client, the provider and the health care team. Finally, in the theory, the transformative
effects of caring on the nurse and the client are also addressed. "Caring seems to have an
alchemical quality, an energizing effect on the caregiver that might be described as a
peak experience, one that creates meaning and reinforces commitment" (p. 99). For the
client, the effect is intensified due to heightened vulnerability and manifests itself as
being inspired to self-care, healing and a heightened sense of integrity and being alive.
The nursing theories presented here have either conceptualized a theory of nurse-
client interaction (Peplau, Orlando, Travelbee, Paterson & Zderad, & Christensen) or
incorporated it as a major concept of their theory (Wiedenbach, King, Watson, Parse, &
Montgomery). Several other nursing theories do not address (Henderson, 1966; Johnson,
1980; Neuman, 1989), do not define (Hall, 1966; Orem, 1980; Roy, 1984) nurse-client
interaction. Others subsume nurse-client interaction under other concepts such as
man/environment interaction (Newman, 1986; Rogers, 1980) and conservation (Levine,
1969).
The analysis of these ten nurse-client interaction conceptualizations developed in
the last 50 years, provide a global view of the scholarly work in this domain. The
analysis of these works was carried out in order to review their world view, their scope,
their goal, their level of abstraction and description. Two different world views are
evident in the development of these theories. The presentation of the concept of
interaction varies from a totality paradigm where six of the theories represent the
interaction by specific overlapping processes or phases (Peplau, Orlando, Travelbee,
Wiedenbach, King, & Christensen) to the simultaneity paradigm where the other theories
state that no process can be identified because the interaction is a shared experience that
has no predictive patterns.
The scope of the theories also varies greatly from "grand theories to middle-range
to microtheory".22 The scope is determined by the nature of the phenomena it intends to
explain and the complexity of the theoretical statement. Following her analysis of the
interactionist theories, Meleis (1991) concluded that they were for the most part,
"microtheory" or "single domain theory" (Peplau, Orlando, Travelbee, Wiedenbach, &
Paterson & Zderad). For example, Orlando's theory is concerned with only the
psychosocial aspect of an encounter around illness; Wiedenbach focused on the use of the
deliberative action of the nurse to validate perceptions, thoughts and feelings; and
Travelbee focused on interaction to alleviate suffering and illness. At the other end of the
continuum, Parse's theory is identified as a "grand theory." "Parse has created an abstract
model. The empirical aspects are not as well developed as the structure of the model"
(Phillips, 1987, p. 199). Limandri (1982) adds, "in an attempt to relate her concepts she
falls short of developing propositional statements that can be tested, it is a model" (p.
105). The recent theories can be considered as "middle-range" (King, Watson,
Christensen, & Montgomery). Merton (1964) advocated the development of "middle
22 "The term grand theory is usually used to refer to a theory that tries to handle
phenomena in a general area of a scientific field." " Grand theorists start their theoretical
formulation at the most general level of abstraction, and it is often difficult to link these
formulations to reality."
The term middle-range theory is "a more realistic and testable level of theory."
"The term micro-theory is used to refer to a set of theoretical statements, usually
hypotheses, that deal with narrowly defined phenomena." (Kim, 1987, p. 13).
range" theories because they consider fewer variables related to a phenomenon and these
theories are more open to empirical testing.
The goal of theory construction in nursing is to describe, explain, predict or
prescribe practice (Dickoff, James, & Wiedenbach, 1968; Meleis, 1991). All of the ten
interaction theories described and/or explained the nurse-client interaction. King's Goal
Attainment theory aimed further at predicting outcomes. The theory includes
propositions of an "if (...) then" nature that predict the consequences of certain nursing
strategies. Several other interaction theories include prescriptive propositions to guide
the "how to" obtain a specific outcome. These prescriptions would include Orlando's
"disciplined professional response," Wiedenbach's steps to validation, Travelbee's phases
in establishing "rapport" and Parse's processes in each dimension of practice.
The concepts used in the ten theories are from a low level of abstraction where
the terms used are easily recognized and concrete (Peplau, Orlando, & Wiedenbach) to
very abstract concepts (Travelbee, Paterson & Zderad, Watson, Montgomery, & Parse).
The theories of King and Christensen use concepts that can be considered easy to grasp
even though they are not at a directly observable level. Finally, the element of the
analysis which is particularly important in the area of nurse-client interaction
conceptualization, is the different levels of description. The level of description selected
will influence the kind of questions and outcomes generated from the analysis.
Hofstadter (1979) identifies two levels, holism where the attention is on the generic
property of an object as a whole and reductionism where the focus is on the parts of the
object. Kim (1987) redefined this distinction as holistic or particularistic in these words,
"a set of phenomena can either be viewed as a global happening or as a collection of
several discrete happenings" (p. 15). From that perspective, the review of the ten theories
revealed that four of the theories were particularist because the focus was on a part of the
interaction i.e., the nurse action (Peplau, Orlando, Wiedenbach, & Travelbee) while the
other six were holistic because the focus was on the interaction between the nurse and the
client.
Nurse-Client Interaction Theory Testing

In the past 30 years, without much success, nursing leaders have called for
increased theory validation (Acton, Irvin, & Hopkins, 1991). A review of 720 articles on
nursing practice research published in six major refereed journals 23 between 1977-1986,
revealed that 36 per cent of the articles pertained to intervention or nurse-patient
interaction but only 3 per cent actually tested concepts or hypotheses of an explicit
conceptual or theoretical model (Moody, Wilson, Smyth, Schwartz, Tittle, & Van Cott,
1988). Silva (1986) reviewed the degree to which five nursing theories (Johnson, Roy,
Orem, Rogers, & Newman) were used in research between 1952 and 1985. Out of 62
studies, only nine adequately tested the models or theories. The 53 other studies
identified explicitly a particular nursing model but did not use any part of the theory or
used it only to organize the study or to structure an instrument. Silva (1986) concluded
that the process of theory testing is a complex one and that two impediments should be
addressed by nursing scholars; a lack of commitment and a lack of tolerance of
methodological imperfections. Using Kim's (1987) framework for the nurse-client
interaction domain, Garvin and Kennedy (1990) completed a more specific review of the
research published24 from 1980 to 1989. They introduced the review with these words:
"Although considerable research has been conducted (...) on variables that influence
interpersonal relationships, little of this work has been transferred to nurse-patient
relationships and even less has been tested empirically" (p. 215). All of the research they
reviewed addressed single concepts such as empathy, support, client and nurse
communicative elements or characteristics. None of the research addressed the
interaction from an holistic perspective.
For this reason, it is not surprising to find a dearth of research that tests nurse-
client interaction theories. Eight of the ten theories reviewed have not been tested or have
23 Nursing Research, Research in Nursing and Health, International Journal of

Nursing Studies, Journal of Advanced Nursing, Heart and Lung and Western Journal of
Nursing Research.
24 Studies were obtained through a MEDLINE and CINAHL search followed by a

hand search of seven nursing journals: Advances in Nursing Science, Journal of
International Nursing Studies, Journal of Psychiatric Nursing and Mental Health
Services, Nursing Research, Perspectives in Psychiatric Care, Research in Nursing and
Health and Western Journal of Nursing Research.
received little empirical attention (Christensen, Montgomery, Travelbee, Paterson &
Zderad, Peplau, King, Watson, & Parse). The theories of Christensen and Montgomery
were published very recently and this may explain the absence of further studies.
Travelbee used a field approach to develop her theory but "the complexity of the theory
is demonstrated in the abstractness of the concepts, limited operational definitions and
the potential multiplicity of relationships. Therefore, its use in research (...) appears to be
limited" (Meleis, 1991, p. 364). Several concepts are derived from other theories such as
empathy, sympathy and these concepts have been the focus of much research. Only
one exploratory study utilized Travelbee's theory to identify the nature of nursing actions.
These actions were perceived by terminally-ill patients and their family as supportive,
comforting and easing the suffering (Freihoter & Felton, 1976). The identification was
considered as a first step in planning meaningful nursing approaches. These findings
corroborate Travelbee's theory regarding the purpose of nursing interventions.
No research is reported using the theoretical framework of Paterson and Zderad
except Kleiman (1986). She carried out a case study of the "lived experience" of 25 staff
and 75 patients in a day-hospital. Unfortunately, no information is provided to ascertain
if the results of the study confirmed the theoretical framework. Paterson and Zderad have
used methodologies congruent with their world view such as grounded theory and
phenomenological approaches to articulate the concept of empathy (Zderad, 1970) and to
develop their concept of comfort (Paterson & Zderad, 1976). If the concepts are ever
operationalized, the potential for further research exists.
Peplau's theory is a practice-based theory that was developed from her own
interactions and those of her students. A few recent studies have been reported. One
study was to develop an instrument to measure the phases of the nurse-client relationship
and to begin establishing validity and reliability. The instrument was used for a year with
58 case management clients (schizophrenic clients) and 74 counselling/treatment clients
(acute mental health clients). Content validity was established by agreement between four
independent nurse specialists and the theorist. Interrater reliability was established at 0.41
using Kappa (Forchuk & Brown, 1989). Forchuk (1992) conducted another study to test
the relationship between the orientation phase of the nurse-client relationship and time
span. "Data were gathered retrospectively from records of clients (73) who had received
either case management or counselling for a minimum of one year in the community-
based mental health program" (p. 8). None of the expected relationships about possible
factors influencing the duration of the orientation phase were found. The investigator
recommended further research to examine other variables and/or interpersonal factors
that affect the orientation phase. Forchuk (1994) pursued this work through a
correlational study which included as the independent variables, preconceptions,
interpersonal relationships and anxiety to predict results for the dependent variable, i.e.,
development of Peplau's therapeutic relationship. A sample of 124 newly formed nurse-
client dyads of chronically mentally ill patients were selected. The investigation
supported Peplau's theory that preconceptions of the nurse and the patient and
relationships of the patient were related to the development of a therapeutic relationship.
It did not support the nurse relationships or anxiety as significant variables. The results
gave direction for future refinement of the theory and future research. Morrison and
Shealey (1992) studied Peplau's roles and role actions by carrying out a content analysis
of 62 audiotaped interactions of nurses with psychiatric inpatients. The results were
consistent with Peplau's contention that the primary role of psychiatric nurses is the role
of counsellor. Other roles such as leader, surrogate, resource person and teacher overlap
a great deal. Wooldridge, Schmitt, Skipper, and Leonard (1983) considered that Peplau's
theory was complex and many aspects would need to be operationalized for full
empirical testing such as anxiety levels, meaning of illness for patients, the four phases of
the interaction and their measurement, and the patient's ability to cope or achieve goals.
Some of these questions are starting to be addressed in the literature in the 90s.
The first study reported in the literature that uses King's theory was reported by
King (1981). This study was designed to validate the concept of transaction including
what elements in the nurse/patient interaction lead to transaction, what are the elements
of transaction and what are the essential variables in nurse/patient interaction that result
in transaction. The results of the descriptive study supported the components of the
interpersonal system and contributed to construct validity. In spite of the limitations of
the sample size (17), the biases of the researchers and limited analysis, it is a pilot study
that indicates the potential testability of the theory (Meleis, 1985). In 1982, Rosendahl
and Ross utilized King's theory to test if a group of 25 elderly patients would have a
higher performance on a Mental Status questionnaire if they received purposeful nursing
interaction (or attending behaviour) while the other group of 25 elderly patients did not
receive attending behaviour from the nurse. The results showed that the experimental
group increased their performance rating significantly. The investigator concluded that
these results supported King's theory that the nurse-client interaction leads to transaction.
More recently, Frey (1989) in a descriptive correlational design tested King's theoretical
formulation of social support, family, health and child health. The study included 103
families with diabetic children between the ages of 10 and 16. The hypothesis support
included a positive correlation between parent's social support and child's social support,
a negative correlation between illness factors and child health and a direct positive effect
of parent's social support on family health. "These findings provide empirical evidence
which supports King's conceptual framework in relation to the effect of interaction on
health at least for adults" (p. 146). Hanna (1993, 1994) reported two studies that tested
King's theory. One study was the effect of nurse-client transaction on adherence to oral
contraceptives for female adolescents and the other was the identification and description
of female adolescents' perceptions of oral contraceptive benefits and barriers. The first
study used an experimental design with 51 adolescents who were randomly assigned to a
control and experimental group. The experimental group experienced a transactional
intervention. The experimental group had greater adherence post-intervention and after
three months. The findings support King's proposition that transaction leads to goal
attainment. The second study was a descriptive study composed of 12 adolescents
seeking oral contraceptives for the first time. A self-administered decisional tool and
interviews generated 75 descriptions of perceived benefits and barriers to using oral
contraception. A content analysis for common elements provided support for "King's
assumptions that perceptions are influenced by social systems via interactions with
interpersonal systems" (p. 54).
"Watson's theory has been subject to relatively little testing" (Moody, 1990, p.
207). "At the present time, her model is too global and abstract to be directly testable, it
does, however, provide nurses with a foundation on which to generate new nursing
theories and to derive theories that are both testable and relevant to human care" (Boyd &
Mast, 1989, p. 382). Ryan (1989) believes that Watson's theory cannot be researched by
traditional scientific methods and Watson agrees. The appropriate method that are
relevant to the theory of transpersonal nursing are within a qualitative phenomenological,
naturalistic approach framework where a variety of qualitative methods can be used. This
approach is not without controversy and Ryan contended that Watson "seems to be
describing research methodology for the accumulation of information and not for theory
construction" (p. 240). Watson (1988) reports a descriptive empirical phenomenological
research of loss and caring by a group of tribal Aboriginal men in Western Australia.
Clayton (1989) describes a study with four elderly person-nurse dyads where caring
transactions were explored using a grounded theory method and phenomenological
interviews. Both Clayton's and Watson's findings are congruent with Watson's theory of
caring and the carative factors occurred in all dyads studied. Clayton though made a
series of recommendations such as the need for new research method and the need for
revision of the carative factors following the study of additional caring exemplar cases.
Five studies using phenomenology, descriptive and ethnographic methods were
reported by Parse, Coyne, and Smith (1985). These studies demonstrated similar findings
that complement each other and support part of Parse's theory of Man-Living-Health.
One of these studies was a phenomenological study of health where 400 subjects were
asked to describe a situation where they experienced health. The common elements of
health identified by all subjects were energy, harmony and plenitude. Another health
study with the same methodology examined "persisting in change" and reported that
middle-aged subjects who struggle with certainty-uncertainty at the beginning of a new
project, made evident the concepts of "immersion in movement" and struggle. The same
concepts "immersion in movement" and struggle were evident following an exploratory
study of fire fighters who were exposed to toxic chemicals and decided to stay in the
situation. The last two studies reported by Parse, Coyne, and Smith (1985) dealt with the
concept of contemplative engagement with purposefulness and significant completions in
a population of oldest adults. One was an ethnographic study of making livable changes
in the light of changing reality and while another was a case study of a couple deciding to
retire. The conclusions of all five studies gave support to the theory. Another study
reported by Smith (1989) used a phenomenological method to examine the meaning of
rest for people confined to bed. Sixty individuals participated in the study by writing
descriptions of their experiences. The meaning that was grasped was one of "easy
drifting through paradoxical swinging surfacing in deliberate picturing." 25 This meaning
is related to the theory of "Man-Living-Health" as a way of experiencing health. Phillips
(1987) found that the literature reveals very little research using Parse's model and
believes that it may be due to the fact that qualitative research is time-consuming. The
dearth of research may also be due to the difficulty in grasping the meaning of the words
and sentences used in the model.
The theory that generated the greatest research endeavour is Orlando's
deliberative nursing process. The theory was developed as a result of observations of
nurse-patient interactions in various settings in order to explore the effects of deliberative
nursing actions or process. The initial testing of the theory was to develop a tool to
objectively measure the deliberative process in a group of trained nurses and to assess the
effectiveness of the process. The testing was fraught with reliability problems
(Wooldridge, Schmitt, Skipper, & Leonard, 1983). Because the concept of deliberative
process was defined operationally it was used in a number of experimental studies which
operationalized "deliberative nursing" to test its effect on clients (Anderson, Mertz, &
Leonard, 1965; Dumas & Leonard, 1963; Elms & Leonard, 1966). The "deliberative
nursing" was effective to deal with pain (Barron, 1966), sleeplessness (Gillis, 1976),
stress (Elms, 1964), understanding of patient needs (Gowan & Morris, 1964), to name a
few. Schmieding (1986) completed an extensive review of research based on Orlando's
theory. She concluded that "in general, the results indicate that the deliberative nursing
process is an effective approach to use with different types of patients in different
settings" (p. 20). A similar review was conducted to identify research that was based on
Wiedenbach's theory. The review revealed "two findings: first, both Orlando and
Wiedenbach are cited in most research related to concepts of either theories and second,
25 The language used in Parse's model is difficult to understand. It is not a "user-
friendly" communication tool.
Wiedenbach's ideas are still appearing in the literature as researchers continue to test
propositions emanating from her theory" (Meleis, 1985, p. 268) and from Orlando's
theory.
With so little research in the area of nurse-client interaction, Kim (1987)
formulated a conceptual map to guide the development and testing of nurse-client
theories. "While there has been a great deal of rhetorical emphasis on the importance of
client-nurse interaction in the delivery of nursing care, very little has been done either in
theory development or in empirical testing of the theories (...). Much more work,
therefore, needs to be done to revise and reformulate existing knowledge to explain and
predict phenomena in the client-nurse domain" (p. 107). "There is a need to develop and
refine theories of client-nurse interaction that can be applied to influence the outcomes of
nursing therapies through variations in the quality and process of client-nurse interaction"
(Kim, 1987, p. 104). The conceptual map Kim proposed is congruent with the "Z" nurse-
client including four sets of variables which are related to individuals (1. the client and
the nurse, 2. the context or environment, 3. a process of interaction and 4. outcomes or
clients well-being.
Within the nurse-client interaction scholarly work, Theory "Z" is an initial
conceptualization intended as a middle-range holistic theory of a predictive nature. Some
of the concepts included are at a higher level of abstraction and will need to be
operationalized in order to be tested while others are at a lower level of abstraction and
can be easily tested.
Stress: Nature and Measurement

The dependent variable to be tested in this study is the level of stress of clients.
Over the last 50 years, the concept of stress has been the subject of intense study by
physiologists, psychologists, as well as sociologists. As a result, the knowledge base has
grown exponentially. The first references to homeostasis date as far back as 450 B.C., but
it was the work of Cannon and Selye in this century that propelled the knowledge
development (Chrousos, Loriaux, & Gold, 1988). Cannon (1939) showed that
psychological as well as physical stimuli, could activate the physiological system and
Selye (1956) identified the role of the adrenal cortex in provoking an orchestrated set of
bodily defenses against any noxious stimuli which he called stressors (physical,
psychological and environmental threats). Selye defined stress as the result of the
organism's effort to maintain an internal physio-chemical equilibrium as a defense
against stressors. The stress reaction is referred to as the Generalized Adaptation
Syndrome. In the psychology literature, "stress was, for a long time, implicit as an
organizing framework for thinking about psychopathology, specially in the theorizing of
Freud and later, psycho-dynamically oriented writers. However, anxiety was used rather
than stress" (Lazarus & Folkman, 1984, p. 4). In the sociology literature, the term strain
rather than stress is preferred to mean forms of disruption or stress on a social level
(Lazarus & Folkman, 1984).
Many studies have been carried out on the measurement of stress responses. Selye
reported in 1983, that the library of the International Institute of Stress contains over
200,000 scientific articles and books that deal with the measurement of stress.
Vingerhoets and Marcelissen (1988) reviewed investigative publications in the area of
stress for the decade between 1976 and 1985 and identified that the main core research
has focused on psychobiological research (such as electro-physiological, endocrine or
immunological), psychological research (such as performance, cognitive functioning,
emotional life) and social functioning. There is general agreement among researchers in
the field of stress that the concept is multifaceted and comprised of many interrelated
variables of a contextual and perceptual nature (Scott, Oberst, & Dropkin, 1980; Wong &
Reker, 1986). Some authors have found the concept too broad and ambiguous to be
scientifically useful (Johnson, 1984). The use of different levels of scientific analysis can
also cause great confusion (Lazarus & Folkman, 1984). Others have welcomed the
different levels of analysis (Pearlin, 1989). The study of stress is an inter-disciplinary
field covering many areas of inquiry that examine phenomena at multiple levels of
abstraction (Schwartz, 1982). The macro or highest level of abstraction of stress, is the
field where the universe is considered to be the society. The macro level of stress is not
the object of this study. Psychology is considered an intermediate level because its prime
unit of analysis is the individual and finally, physiology is considered a micro level of
abstraction because the approach entails analysis of tissue and cell reactions. This
conceptualization and the analysis of studies led Lazarus and Folkman (1984) to
conclude that stress experienced at one level may not be experienced at the other level
and that these reactions are partially independent. For example, physiological stress
caused by heat, lack of comfort or illness may exist without any psychological stress.
Psychological stress, such as anxiety or fear, on the other hand, implies the presence of
physiological stress but not necessarily, sociological stress. In light of the multiple level
of analysis of stress, any study should clarify the definition of stress used as well as the
theoretical assumptions. This has not been the case with several nursing studies.
Lyon and Werner (1987) who reviewed all published stress related studies of adults
from 1974 to 1984 in the nursing literature, confirmed that "a large number of the studies
reviewed (22) were atheoretical that is, without a theoretical framework and definition of
stress or had incompatible theoretical and operational definitions. Incompatible
definitions suggested a lack of a sound theoretical foundation" (p. 10). Doswell (1989)
concurred with Lyon and Werner following a review of nursing studies carried out in the
United States between 1977 and 1987 using physiological responses to stress in human
subjects. She added, "that research of physiologic responses to stress has been linked
only nominally to a conceptual framework" (p. 62). Whatever the level of abstraction of
the definition of stress, Selye (1983), Lyon and Werner (1987) and Doswell (1989)
recommended that multiple measures or a battery of measures yielding a stress index,
should be used to monitor stress responses. The majority of nursing studies used only one
dependent variable to monitor stress response. This is considered an important weakness,
as it ascribes to a world view of uni-dimensional causality to stress response in human
beings. Of the 30 nursing studies using physiological measures of stress carried out
during the last 20 years (1970 to 1991), 21 used a single measurement of stress and nine
used two or more physiological measures (Rodger, 1991).
To facilitate the review of research on stress pertaining to the present study, the
organizing framework of Elliott and Eisdorfer (1982) will be used. The examination of
the literature is not exhaustive. The purpose of the review is to characterize the state of
knowledge related to the different elements of the study. In Elliott and Eisdorfer's
framework, the stress continuum is formed of potential stressors, such as illness,
hospitalization and cancer; mediators, such as nurse-client interactions; psychologic and
biologic reactions; and consequences or outcomes. Even though this framework will be
used to organize the review of literature which is categorical and static, this
conceptualisation of stress suggests a dynamic process across the elements of the
framework as well as an interactive process between the individual and the environment.
It is difficult to clearly compartmentalize the different concepts, even for the review.
Stressors: Illness, Hospitalization and Cancer

The stress-illness relationship has been acknowledged in the scientific
community. Illness can be conceptualized as a stressor or as an outcome. As a stressor,
illness provokes the organism's effort to maintain an internal physio-chemical
equilibrium. "The manifestation or symptoms of various diseases can be interpreted as
expression of ongoing stress" (Leidy, 1989, p. 868). "The pathology of the illness, itself,
constitutes a stress that alters biologic functioning in specific ways" (Fagin, 1987, p. 39).
From the psychological literature, illness has also been seen as a stressor and as an
outcome. The cluster of research in stressful life events is a good example of the stress-
illness relationship. Events, such as a life change and personal adjustment, loss and grief,
are correlated with acute and chronic illness (Engel, 1968; Holmes & Masuda, 1974;
Rahe, Meyer, Smith, Kjaer, & Holmes, 1964; Theorell, Lind, & Floderus, 1975). The
occurrence of hospitalization is also a stressful event in its own right (Brink & Saunders,
1976; Elms & Leonard, 1966; Taylor, 1965; Wilson-Barnett, 1976). Additional clinical
studies documented this stress with higher anxiety scores (Lucentes & Fleck, 1972),
verbalization of fright (Barnes, 1961), elevated urinary 17-hydroxy corticosteroids
(Bartter & Delea, 1970), to name a few.
Inspired by the work in this domain, Volicer and Bohannon (1975) developed a
scale to specify the order of stress likely to be experienced by patients in hospital. The
development of the rating scale was conducted in three phases. The initial study included
23 patients, lay people, nurses and physicians. Through interviews they related their
perceptions of the experience of hospitalization. An initial list of 45 stressors was
developed. A group of 216 non-hospitalized individuals were then asked to give a score
to all the 45 stressors listed and to indicate the level of stress each particular item
represented for them. The study was then replicated with 47 hospital patients. Volicer
(1975) reported substantial agreement among respondents (r = 0.88) as to how the events
should be ranked. The experience of hospitalization is a stressor in its own right, ranging
from having a stranger sleeping in the same room with you, to being cared for by
unfamiliar persons, to the perception that the staff is in too much of a hurry to care about
your situation, to medications and treatments that cause discomfort, to not being told
about your diagnosis. Among these stressors "thinking you have or might have cancer"
ranked the second highest on the stressors list.
Studies confirmed that cancer is recognized as both a physiological stressor and a
psychological stressor as well. Physiologically, cancer triggers major bio-chemical
reactions and several studies were carried out to clarify the role of the immune system in
cancer risk and survival (Rosenberg, Longon, & Lotze, 1989). Psychoneuro-
immunology studies of the interactions between the central nervous system, the immune
system, and the influence of psychosocial factors, may elucidate the stress-cancer link
(Sabbioni, 1991). Some studies have included both physiological and psychological
measures of stress following a cancer diagnosis. Katz, Weiner, Gallagher, and Hellman
(1970) found that the greater the affective distress and functional disruption, the higher
were the rates of hydrocortisone production in women awaiting a biopsy. Pettingale,
Greer, and Tee (1977) studied women with breast cancer and assessed both the emotional
expressiveness and the levels of serum immunoglobulin in a longitudinal study at four
different time periods, prior to biopsy, after 3, 12 and 24 months. The results also
confirmed a relationship between emotional expressiveness and immunoglobulin levels.
Mediator: Nurse-Client Interaction

The same stressors may not necessarily lead to the same outcomes. "The largest
responsibility for explaining outcome difference has been placed on constructs that I
refer to collectively as mediators (...) they govern or mediate the effects of stressors on
stress outcomes" (Pearlin, 1989, 249-250). The nurse-client interaction is one of the
many variables which falls under that rubric of mediators since it alters the natural
coping mechanisms.
The research that does study nurse-client interaction as an independent variable
and its effect on stress, is mostly from a particularist perspective, i.e., studying one
element of an interaction. The most common categories could be referred to as the nurse-
client interaction focusing on a specific form of psychological support (Dumas &
Leonard, 1963; Foster, 1974; Putt, 1970), relaxation therapies (Flaherty & Fitzpatrick,
1978; Geden, Beck, Hauge, & Pohlman, 1984; Sitzman, Kamya, & Johnston, 1983),
teaching/information interventions (Boore, 1978; Hayward, 1975; Healy, 1968) and, in
particular, in the area of pre-operative instructions (Johnson, 1984; Leventhal & Johnson,
1983; Wells, 1982; Wilson, 1981). Volicer (1975) reviewed some of these studies and
concluded that they "were limited both by the small numbers of subjects and by the
problem of reproducibility of fairly vague experimental treatments" (p. 55). An example
of the particularist perspective in nurse-client interaction can be found in the work of
Guzzetta (1979). Guzzetta examined the effect of teaching cardiac rehabilitation to male
post-myocardial infarctus patients (N=45) at three intervals after their transfer from the
coronary care unit. The dependent variable was stress measured by urinary cortisol and
an anxiety scale developed by the investigator. No information was provided regarding
the criteria used for instrument construction. Lower anxiety was reported following the
teaching carried out seven days post-transfer and the urinary cortisol did not differ.
Another example is found in the area of therapeutic touch (Kramer, 1990;
Krieger, 1974; Randolff, 1984). Randolff compared therapeutic touch with physical
touch and measured the dependent variable stress with measures of skin conductance,
skin temperature and electromyography responses to a stressor, i.e., a motion picture. His
double-blind study was considered one of the first to significantly improve the research
design in order to address the validity of therapeutic touch. Doswell (1989) noted that the
weakness of his study was the lack of definition of stress and the lack of a theoretical
linkage between therapeutic touch and stress.
One other area of nurse-client interaction and stress is related to the structure of
the interaction, i.e., who interacts with whom. Three nurse-client interactions were
chosen by Schwartz and Brenner (1979) in relating to the reduction of stress levels of a
20 patients at the time of a transfer from the Intensive Care Unit to a medical-surgical
unit. The first interaction with the client included a family communication with a visit
from the receiving unit nurse. The second interaction included just a visit from the
receiving unit nurse and the third interaction was a control group. The dependent
variable, stress, was measured by a paper and pencil self-report of physiological reactions
such as shortness of breath, chest pain, nausea and light-headedness. Creatinine
phosphokinase was also measured from a blood sample. The results indicated that the
family communication with a visit from the receiving unit nurse resulted in a lower
report of physiological discomfort. The ambiguous definition of stress and the
inappropriateness of self-report for physiological measures makes the results
questionable.
Fuller and Foster (1982) examined the effects of patient interactions with two
group of individuals on physiological responses to the stress in an intensive care unit.
The effects of the interaction during the visits of family and friends were compared with
the effects of the interactions with the nurses that were either focused on the tasks or the
interaction for a 15-minute period. The responses measured were heart rate and blood
pressure. No significant differences were found between any types of interaction. The
study sample was small (28), the interaction types were unrefined and some of the
extraneous variables such as diagnosis or clinical differences were not considered.
From an holistic perspective, most studies have been qualitative and are
documented in the first section of this thesis under the rubric "Nurse-client interaction
theory testing." Only a few quantitative studies have been documented in the
investigative literature. Pride (1968) was among the first reported researchers that used as
the independent variable, the nursing approach. Three approaches were structured to
provide stimuli for tactile, auditory and visual sensory pathways. The first approach
could be compared to routine nursing care in the regular environment of the patient. The
second approach went beyond the first procedures to supply more information to the
patient, not only about the hospital but about what can be expected in relation to the staff
and treatments. The third approach included what could be labelled as "therapeutic
communication." The physiological measure of stress was urine potassium and the
psychological measure was the IPAT Anxiety Scale. The three approaches used were
documented on audio-cassette and a panel of four judges generally agreed on the
intended approach that was used. The sample consisted of 108 adult patients from the
medical department in a private hospital. The results indicated that urine potassium was
a sensitive measure that could differentiate nursing approaches and there was significant
difference between the three groups but this was not the case for the IPAT Anxiety Scale.
Following this study, Pride recommended that the independent variable be even more
structured to increase the control over extraneous variables and that multiple measures be
used. She also invited replication in other settings.
Chapman (1970) took on the challenge and studied the effect of three approaches,
an individualized, an informative and a routine nursing approach on the well-being of the
patient and their psychological and physiological responses. The sample for this study
consisted of 53 men undergoing inguinal hernia surgery. The psychological response to
stress was measured using Zuckerman's Affect Adjective Check List (AACL). The
physiological response was measured by the level of plasma nonesterified fatty acids
(NEFA) and eosinophils in the blood, and the patient's welfare measures were the
patient's requirement for analgesics and sedatives and the length of stay in the hospital.
The approaches taped on audio-cassette were assessed by two judges. The percentage
agreement between the judges was 90 per cent during pre-operative interaction and 58
per cent for the post-operative interaction. The results were not significant except for the
number of analgesics and a shorter length of stay.
Most recently, Schwartz-Barcott, Fortin, and Kim (1994) tested the effect of an
active client-nurse interaction in an experimental study of 91 cholecystectomy patients.
Three models of intervention: facilitator, informational and routine treatment were used
to compare their effects on the anxiety and pain of patient. Anxiety and pain were
measured by a State-Trait Anxiety Inventory and the Pain Rating Index of the McGill
Pain Questionnaire. The results showed a significant difference in anxiety for a patient
who experienced the facilitator and informational model of intervention compared to
routine treatment. No differences were found in anxiety scores between the informational
and facilitator models nor in pain scores among the three groups.
Psychological and Physiological Reactions

"While the study of potential stressors and mediators is important to nursing, it is
the study of the emotional and physiological reactions when defence and coping fail, the
understanding of the immediate and perhaps sustained psychological and biologic
reactions, that might have the most impact on the nursing care of patients in a variety of
potential situations" (Lowery, 1987, p. 44). Some examples of behavioural responses to
illness-induced stress can be found in patients with melanoma and breast cancer who
have feelings of depression and anger related to their illness (Derogatis, Abeloff, &
Melisarator, 1979; Temoshok, Heller, Sagabiel, Blois, & Sweet, 1985). Fagin (1987),
commented that in these two studies, "patients in both studies who expressed these
`negative emotions' had a slightly increased survival time. This raises the question as to
the relationship between the behavioural and biologic system when selected coping
responses are implemented. In comparison, a study of psychosocial factors and survival
time in several groups of cancer patients showed no correlation between the patient's
pessimism and survival time (Cassileth, Lusk, Miller, Brown, & Miller, 1985)" (p. 39).
The measurement of emotional upset or some other form of psychological stress
has been difficult, most particularly the differentiation between emotions such as fear,
anger and anxiety (Wilson-Barnett & Batehup, 1988). By far, the most common
psychological reaction "anxiety" (trait or state) has been used in nursing. Anxiety or
psychological stress "is determined by the person's appraisal of a specific encounter with
the environment; this appraisal is shaped by personal factors including commitments,
vulnerabilities, beliefs, and resources and by situational factors including the nature of
the threat, its imminence, and so on" (Lazarus & Folkman, 1984, p. 289). The most
common methods used to assess anxiety are observation and self-report. Observation has
been particularly difficult due to the multiple possible interpretations of behaviour and its
limitation with symptoms observation related to the illness. Kruger (1983) found no
relationship between the nurses' observation of patient anxiety and patient's self-report of
anxiety. Self-report anxiety scales are favoured and seem to be sensitive in a variety of
measurement contexts. The major problem is the threat of social desirability and
distortion due to the subject's defense mechanisms (Derogatis, 1982). In any case,
"anxiety is the psychophysiological signal that the stress response has been initiated"
(Robinson, 1990, p. 942). Fagin (1987) states that the fact the autonomic nervous system
is sensitive to psychologic influences constitutes a major development in stress research.
"The relatively recent advances in measurement of the hormones of stress and the
metabolic products of the stress response have provided investigators in the health-
related disciplines with the potential for studying a range of biologic markers that may
change with the type, length or severity of the stress. Such studies could increase our
understanding of patient behaviour and might lead to improved care" (Fagin, 1987, p.
39). A caution is also needed. Following a careful review of stress research, Mason
(1968) concluded that the secretion of several hormones were affected during stress and
that particular patterns varied with the type of stress. Duffy (1972) in her review of the
activation or arousal research, remarked that the state of knowledge does not permit the
conclusion that correlations exist between accessible physiological measures, intra and
intersubject. This conclusion reinforces the need to use several physiological measures to
increase the likelihood of measuring the stronger response of the subject. But she also
acknowledged that regardless of the pattern in evidence, stress was always associated
with the activation of the hypothalamus-pituitary-adrenal axis (HPA), and the
sympathetic nervous system.
"Manipulation of physiological variables is a problem in research involving
human subjects. Nurse researchers generally, have avoided the use of invasive
techniques, or if used, a cooperative or inter-disciplinary arrangement is frequently
necessary to conduct research in which invasive procedures are required. For the level of
research sophistication necessary for nurse investigators (...) access to consultation,
equipment and laboratories (including the funding for these resources) is of paramount
importance" (Lindsey, 1982, p. 57). The number of physiological measurements
available today for nursing research has increased enormously. The nurse researcher now
has a wide variety of variables to study, which include the adreno-corticotrophic
hormones, peripheral cardiovascular indicators and electrodermal phenomena. As long as
the researcher is cognizant of the limitations of these multiple measures they can be
considered appropriate for examining the stress response (Doswell, 1989).
There is a wealth of knowledge about the physiological reactions to stress and its
measurement in human subjects. The generalized responses elicited by the stressors
includes increased activity of the nervous and endocrine systems, the two principal
pathways of the stress response. Unfortunately, the first mediator and its mechanism is
still unknown. A review of the Physiology of Stress can be found in Appendix A.
Outcomes
What are the consequences of the stress process? The most documented outcome
is illness which can be perceived as a negative outcome. Selye (1976) described the
disease of adaptation that occurs when the body's reactions to demands are excessively
defensive or overly submissive, resulting in maladaptation. There are empirical and
theoretical indications that psychosocial stressors play a role in the evolution of health
problems including cancer (Goodkin, Antoni, & Blaney, 1986; Schmale & Iker, 1971),
coronary heat disease, (Matthews & Glass, 1981; Theorell, Lind, Forbeg, Karlsson, &
Levi, 1972) multiple sclerosis (Mei-Tal, Meyerowitz, & Engel, 1970). Many studies
reviewed by Kagan and Levi (1974) indicated that psychological stimuli are widely
suspected to be causal factors of illness. Field studies suggest statistical relationships
between many kinds of psychological experiences, physiological changes and the onset
of illness. Other outcomes that can be perceived as positive outcomes are also
documented, such as increased well-being, as seen in the previous section on reduced
tension or relaxation (Benson, 1977; Fehring, 1981), or eustress or good stress (Selye,
1983).
In the nursing research literature, the outcomes are mostly in terms of indicators
of well-being. Some examples of indicators are "length of hospitalization, time to
ambulation stage, number of days of post-operative fever, skin condition, use of
analgesics, and incidence of post-operative vomiting and pain" (Volicer, 1975, p. 55).
Summary of Framework
Stress is a complex concept and when used scientifically, the theoretical and
operational definitions must be congruent."Nurses are positioned for conducting studies
of illness-related stress in patient studies that combine both biologic and behavioral
measurements of the stress response (but) such clinical studies are necessarily complex"
(Fagin, 1987, p. 40). For this study some of the obvious general stressors include
diagnosed cancer and hospitalization for treatment which includes painful/tension
producing physical manipulations such as dressings and injections of medications and
encounter with unfamiliar nurses. The mediator studied is the nurse-client interaction in
particular, the "Z" nurse-client interaction. The reactions observed are the physiological
and psychological responses of the client to the stressors. The outcomes of the
improvements in both the physiological and psychological reactions are signs of
improved well-being. This study intends to use a holistic approach i.e., studying the
impact of the interaction as a whole and a battery of measures that are congruent with a
physiological and psychological definition of stress. Stress is the result of
psychophysiological reactions of an individual in an effort to maintain a balanced
condition or homeostasis when exposed to stressors.
3. THE STUDY
The purpose of this chapter is to present an overview of the study. The purpose,
definitions, assumptions, design, setting, sample, data collection procedures, protection
of human subjects and the research instruments are described in detail.
Purpose of the Study

The purpose of this study was to test the following hypotheses:
1. Clients who participate in a "Z" interaction will report a lower level of stress in
one of the following measures when compared with clients who do not participate in a
"Z" interaction:
a. lower muscle tension
b. lower electrical skin conductance
c. higher skin temperature
d. lower cardiovascular activities
2. Clients who participate in a "Z" interaction will have a lower score in either the
State Anxiety Inventory (STAI) or a Subjective Units of Disturbance (SUD) and a more
positive reaction on a Nonverbal Behaviour Worksheet than clients who do not
participate in a "Z" interaction.
The study also provided an opportunity to explore a facet of the theory related to
the similarities and differences of characteristics between the "X" nurse and the "non-X"
nurse and between the "X" nurse and the "Y" client.
Assumptions
1. The nurse-client interaction is an essential element of nursing care.
2. Not all interactions are similar or beneficial to clients.
3. Some nurses and clients have specific characteristics that increase the beneficial effects
of an interaction for the client.
4. Hospitalization, illness and therapy are stress producing events.
5. The stress of the client can be assessed both physiologically and psychologically.
Operational Definition of Terms
"Z" interaction: a type of nurse-client interaction between an "X" nurse and a "Y" client
measured by independent observations of stated characteristics, by two individuals.
Nurse-client interaction: an encounter between a nurse and a client for the purpose of
providing/receiving nursing care. The interaction takes place when a nurse and a client
are in physical proximity and the actions of one person serves as cues for the action of
the other person.
Stress: the result of psychophysiological reactions of an individual in an effort to
maintain a balanced condition or homeostasis when exposed to stressors. For this study, a
change in stress level is measured by a change in one of the following physiological
indicators: the electrical activities of the muscles and the skin, temperature on the surface
of the skin, cardiovascular changes such as systolic, diastolic, mean arterial pressure and
heart rate as measured respectively by electromyograph (EMG), electrodermal graph
(EDG), thermograph (Skin Temp), Dinamap vital sign monitor (Dinamap). Stress is also
measured by a change in one of the following psychological indicators: momentary
subjective anxiety and nonverbal behaviours as measured by Spielberger's State Anxiety
Inventory (STAI), Subjective Units of Disturbance (SUD) and the McCorkle Nonverbal
Behaviour Worksheet.
The Research Design

The design selected for this study was a single subject withdrawal design with
repeated measures (Kazdin, 1982) in which the "Z" and "non-Z" interactions served as
the experimental variable and levels of stress served as the dependent variable. Each
client participated in both "Z" and a "non-Z" interactions. Each client had the "Y"
characteristics and half of the nurses had the "X" characteristics. When a client interacted
with an "X" nurse, a "Z" interaction resulted. When a client interacted with an "non-X"
nurse, a "non-Z" interaction resulted.
"Y" client + "X" nurse = "Z" interaction

"Y" client + "non-X" nurse = "non-Z" interaction
During six of the eight interactions, the client was exposed to a stressful event i.e., an
encounter of two strangers or a stressful treatment. Clients were involved in both
physiological and psychological testing before, during and after each interaction.
The clients served as their own control. The interaction was repeated in the same
order over a period of two days. This design was selected because it was a strong quasi-
experimental design where each subject was a unit of study and their individual
responses to treatments were highlighted. The design was particularly well suited for
studying nursing interventions (McLaughlin & Marascuilo, 1990). The strength of this
design was its internal validity and its weakness was the generalizability of results. Since
this study tested a proposition of a new theory, internal validity was of prime concern.
Following a pilot test, three phases were organized in a sequence and included in
the basic design: Phase A was that period in which the pre and post treatment measures
took place. Phase B was the "non-Z" interaction in which two treatments took place
during a 12-hour shift. Phase C was the "Z" interaction in which two treatments took
place during the following 12-hour shift.
Each client was assigned by the head nurse to one of two sequences, A-B-A - A-
C-A or A-C-A - A-B-A. Since this is a repeated measures design, each assigned sequence
was repeated with each client. Therefore each client received either A-B-A - A-C-A - A-
B-A - A-C-A or A-C-A - A-B-A - A-C-A - A-B-A. The reason for inverting the order of
treatments was to verify if the order of the sequence had any effect on the results.
Phase A took place approximately 30 to 40 minutes before the first encounter
between the nurse and the client. All equipment was installed and initial readings were
taken by the researcher according to the procedure described under the instrument
section, for the EMG, EDM, Skin Temp, Blood pressure and Heart rate measurement.
The client was also asked to complete a STAI and to report his/her SUD number (see
Table 1, Pe).
The next phase started when the nurse entered the room of the client for the first
encounter of the day. The researcher then started recording the EMG, EDM, Skin Temp
which continued for the duration of the interaction. Monitoring of the nonverbal
behaviour began at the same time. The nurse took and recorded the cardiovascular
Table 1 Design Description for Day One
readings with the Dinamap at the beginning of the encounter (see Table 1, B) and before
she left the room (see Table 1, E). As soon as the nurse left the room, post-treatment
readings of the EMG, EDG and Skin Temp were taken. Then the researcher asked the
client her/his SUD number and asked him/her to complete the STAI questionnaire (see
Table 1, Po). During this phase, a second encounter was monitored while the nurse gave
a stressful treatment to the client (see Table 1, 2B). The same measurements were carried
out in the same order as with the first encounter. The next phase of the sequence began
when the nurse entered the room of the client for the first encounter of the following shift
i.e., the encounter of two strangers (see Table 1, 1C). The same measurements in the
same order, were carried out for the first and the second encounters. The full sequence
was then be repeated the next day (Table 1).
The Setting (see Figure 3)

The study was conducted on an acute care unit of a cancer institute. A designated
private room was assigned to the clients who participated in the study. The room
temperature and humidity were set by computer at 23 degree Celsius or below and at less
than 50 per cent relative humidity. The room was equipped with two video cameras and a
microphone mounted on the wall at the head of the bed. All equipment was installed and
tested six weeks before the study began. A physiological monitor with three modules, an
electromyograph, dermograph and thermograph and a Dinamap were set up on a side
table at the head of the bed. A halogen lamp was also used during the times when the
daylight was insufficient for the videotaping (usually, the first and last interactions of the
day). The audio-visual equipment was remotely controlled and monitored 24 hours-a-day
by a research assistant in a nearby room. The video cameras ran continuously at a slow
speed (24 hours/video) for the period of the study, approximately 40 hours per client.
The physiological equipment was used only when these measures were required, as per
the research protocol. The room lights were turned off during the night so they would not
interfere with the client's sleep. Bottorff (1992), who used a similar set-up in the same
institution, for a study on touch, found that the videotaping did not seem to affect any of
the participants. Several clients reported that within a short time, they completely
Figure 3. Layout of research set up.
forgot about the videotaping. This was also true for the current study.
Population and Sample

The target populations were the clients and nurses assigned to this unit. Seven
nurses were selected from the seventeen nurses who volunteered to be in the study. One
nurse was assigned twice. Four clients were selected. During the study, each client was
cared for by one "X" nurse and one "non-X" nurse.
The client population consisted of cancer patients between the ages of 20 to 60
who required ongoing nursing care and who received regular stressful treatments. The
stressful treatments were post-operative dressings and sub-cutaneous [s/c] morphine
which induce pain and tension in the client. Sub-cutaneous morphine was chosen, even if
had a physiological effect on the client, because the medication was given on a
regular basis and no other stressors were available at the time of the study. Clients were
white, English-speaking Canadians of European descent who read, understood and spoke
English in order to minimize cultural differences and the effects of non-verbal
communication styles. Clients had a junior high school education or above and consented
to participate in the study. The population was further restricted in relation to the
instruments selected for the study. Exclusion criteria included diagnosed neurological,
muscular and cardiovascular disease or diagnosed dermatological condition. Some of the
consumed products that may have affected the skin temperature measurements such as
alcohol and tobacco consumption, histamine and lactic acid intake were also excluded.
Clients who drank more than 5 cups of coffee per day were excluded since coffee can
affect cardiovascular measurements. Finally, clients who were interviewed and identified
as a "Y" client by the investigator and the Head Nurse were included.
The nurse population consisted of 17 English-speaking Canadian or American
nurses (see Appendix B) working on the unit where the study was taking place. They
were observed and identified as an "X" or "non-X" nurse by the investigator and the
Head Nurse and had consented to participate in the study. The seven nurses were chosen
on the basis of availability and scheduling once a client was available that met the
inclusion conditions. Demographic information concerning the clients and the nurse
subjects are presented in Tables 2 and 3.
A convenience sample of four clients, two females and two males, was assigned
by the Head Nurse to one of the design sequences. A convenience sample of four "X"
and four "non-X" nurses was also assigned by the Head Nurse to one of the sequences.
Identification of "X" Nurses and "Y" Clients

In order to identify the clients who participated in the study, the Head Nurse met
with each client to discuss the study. During the encounter, she also enquired if the
treatment received was tension/pain producing and informally ascertained if the client
had the "Y" characteristics. When her conclusion was positive or tentative, the
investigator met with both the client and family (when appropriate) and proceeded in the
same way i.e., discussed the study, the treatment and ascertained if the client had "Y"
Table 2
Characteristics of the Client Subjects
Client Sex Age

Education Diagnosis Treatment chosen code
for the study
2 F 43 Jr. High School Vulvar carcinoma Post-operative

resection vulvar dressing
3 F 51 College Diploma Breast cancer with s/c morphine
lung and liver metastasis
4 M 46 Jr. High School Relapsed lymphoma s/c morphine

with abdominal metastasis
5 M 46 Doctorate Relapse lymphoma s/c morphine

with thoracic metastasis
Note. Client 1 was the subject for the pilot test. s/c = sub-cutaneous.
Table 3
Characteristics of the Nurse Subjects
Nurses Age Education Experience (yrs)

code in nursing in nursing
1 42 Diploma 5.0
2* 26 Diploma 6.0
3* 26 Baccalaureate 4.5
4 56 Diploma 20.0
5* 43 Diploma 6.5
6 27 Diploma 4.0
7 46 Diploma 4.0
Note. * = "X" nurse.
characteristics. If additional information or opinions were needed, a discussion with the
client's nurse was undertaken. The results of these two identification processes were
compared and when both the Head Nurse and the investigator agreed, the client was
included in the sample.
In order to identify the nurses who participated in the study, the investigator
observed nurses while they interacted with clients. This non-participant observation was
guided by the characteristics of "X" nurses described in the theory. The Head Nurse was
also asked to identity from her own experience, nurses that had the "X" characteristics.
The results of these two identification processes were compared and when both the Head
Nurse and the investigator agreed on the presence or absence of the "X" characteristics,
the nurses were classified in the "X" or "non-X" group. There was total agreement
between the Head Nurse and the investigator on the classification of four "X" nurses and
thirteen "non-X" nurses. Had there been any disagreement, that nurse would have been
excluded from the sample.
A Myers-Briggs Type Indicator (MBTI) questionnaire (Myers & McCaulley,
1985) was administered to the 17 nurses who volunteered to participate in the study. The
MBTI includes several components that are relevant to the characteristics of the "X"
nurse. They are intuiting, sensing and perceiving. The purpose of using this questionnaire
was to attempt to capture the individual differences of the "X" nurse and "non-X" nurse.
It was also a way to explore and increase the understanding of the process used by the
investigator and the Head Nurse to identify who was an "X" nurse and "non-X" nurse.
The investigator and the Head Nurse also completed the MBTI to verify if any
similarities in their preferences profile might affect the identification process. A Nurse
Data Sheet was completed for each participating nurse (see Appendix C). At the end of
the two-day observation period, an MBTI questionnaire was administered to the client.
Protection of Human Subjects

Prior to the study, meetings with the management, nurses' union and staff of the
institution took place to explain the purpose of the study, i.e., "to know more about the
characteristics of nurse-client interaction and its effects on clients" and to explain the
proposed procedures. A written informed consent was obtained from all participating
nurses (Appendix D).
Potential clients were identified in consultation with the Head Nurse or her
designate. If a client seemed interested, a meeting with the researcher took place to
briefly review the purpose of the study and the procedures. A consent form was left with
the client (Appendix E). If the client decided to participate s/he informed the Head
Nurse. The attending physician was also informed. If there was no contra-indication to
proceed, a follow-up meeting took place to answer the client's, the client's family and the
physician's questions and clarify any information. A written, informed consent form was
then signed by the client and the client's family (Appendix F).
A sign was placed at the client's door to indicate that videotaping was in progress.
If any staff or visitors requested that the taping be stopped before they entered the room,
the taping was stopped. If no request was made, an informed consent form was signed by
all staff and visitors entering the room (Appendix F). Videotaping was interrupted at any
time at the request of any participant in the study.
Anonymity and confidentiality were also assured. No names were retained or
associated with the videorecording. All participants were asked for their permission to
use the data and videorecordings for further educational and research purposes. All tapes
and notes are kept in a locked cabinet separate from consent forms or code lists and will
be retained for at least seven years after the completion of the study. Consent forms will
be destroyed after five years.
Ethical clearances were received from the Faculty of Nursing of the University of
Alberta and the University of Alberta Hospital Joint Ethics Committee and the Cross
Cancer Institute Research Ethics Committee. Authorization was also received from the
Clinical Priorities Committee of the Cross Cancer Institute.
Data Collection
Several methods were used to collect the data in this study: non-participant
observations through a video monitor, interviews, questionnaires and physiological
measures. Data were collected over a period of four months from January 1995 to April
1995. When clients agreed to participate in the study they were transferred to the
designated private room. The following day, two nurses, one "X" and one "non-X", were
assigned by the Head Nurse to care for one client for one complete repeated sequence
i.e., one shift per day for two days. Each nurse was identified by a code assigned by the
Head Nurse. The day before the study began, a Client Data Sheet was completed for each
client and an identification code assigned by the investigator (see Appendix G). Each
client was taught by the investigator how to report their levels of anxiety on the SUD
scale.
The study began at 7:00 a.m. at the start of the day shift. A notice "Video-
recording in progress - please go to room number 123 before entering" was posted on the
door. At least one research assistant was present at all times in the monitoring room to
provide information, get consent forms signed and monitor the videorecording. Before
the first interaction, the SUD scale was reviewed with the client and the instruments were
installed and sensors attached to the client. The equipment was installed and tested 20 to
30 minutes before the first set of measures were taken. The investigator met with the
nurse assigned to the client in order to answer any questions and provide the Dinamap
Reading form (see Appendix H). During the planned interaction, the client's behaviour
was recorded in real time, as well as their physiological and psychological measurements.
The investigator and a research assistant were present in the monitoring room during the
recording of all measurements.
Between the encounters planned in Phase B and C, the sensors were removed to
allow more freedom and comfort for the client. The specific location of each sensor was
marked on the client's skin. Over a 40 hour period all events affecting the life of the
client were recorded by the video camera and noted chronologically in writing by a
research assistant.
Analysis of Data
Physiological Data
All data generated by the EMG, EDG and Skin Temp physiological monitor were
averaged every two seconds and then every two minutes. The data were stored in the
computer and reviewed in detail. The data recorded at the beginning and the end of a
nurse-client interaction were analyzed to ensure that the client was recorded for a
consecutive four minute period during a quiet time (i.e., no health professionals were
present). The recording of the nurse-client interaction started and ended when the nurse
entered and exited the client's room and only the valid data points were included to
generate the trial average (one minute) and the period average (four minutes for the base
data and five minutes for the interaction data).
Once the data were processed, magnitude plots were used for the analysis. Visual
inspection and graphics as a form of data analysis, is a procedure well established in
single-subject design research (Kazdin, 1982; Parsonson & Baer, 1978). "Graphic
analysis of data and flexible, pragmatic research designs combine in a unique way to
produce responsive experimental and treatment programs" (Parsonson & Baer, 1978, p.
109). Particular attention was given to changes of magnitude in the mean. Other analyses
such as changes in level26, trend27 and latency28 were not appropriate or could not be
carried out because of the small number of data points for each subject. A table
highlighting "Z" and "non-Z' interaction was used to present the difference between the
average of EMG, EDG and Skin Temp, for each case.
The cardiovascular data were recorded by the nurse subject and the difference
between the beginning and end readings were calculated and recorded. These differences
were presented in a table which included the differences for the "Z" and "non-Z"
interaction.
The coding accuracy for all physiological data was ensured by taking into account
the known accuracy of the physiological instruments used: three per cent for the EMG,
EDG and Skin temp; 3.5 per cent for the pulse data; 1 mm Hg for systolic and diastolic
data and; 4 mm Hg for MAP data. Calculation of the accuracy was carried out on the
initial results.
26 "Changes in level refer to the discontinuity or shift in the data at each point the
experimental conditions are changed" (Kazdin, 1982, p. 311).
27 The change in trend refers to the celeration or deceleration line which express the
rate of behaviour change (Kazdin, 1982).
28 Latency refers to the rapidity of change in experimental condition versus a change

in performance (Kazdin, 1982).
Psychological Data
The self-reported data were recorded by the client subjects and the difference
between the "before" and "after" nurse-client interaction scores were calculated. The data
were presented in table form highlighting the "Z" and "non-Z" interactions.
For the nonverbal behaviour data, all videorecordings of each nurse-client
interaction were coded by the same two independent observers who were trained to use
the observation tool. The nonverbal behaviour data were reported as frequencies. The
frequency data used an event-triggered coding that was appropriate to find out whether
clients had more positive or negative reactions to their care (Booth & Mitchell, 1985).
Every time the observers saw a behaviour listed in Appendix I they recorded it. The
number of times a behaviour was recorded by each observer over the maximum number
of times the behaviour had been recorded by one observer, was used to determine the
frequency ratio. The frequency data do not allow a determination if there is an agreement
between the observers on any particular behaviour (Johnson & Bolstad, 1973). Even
though it is somewhat ambiguous, the frequency ratio method has still proven quite
useful particularly, if the totals of two observers are within a 10 to 20 percent margin of
error. It serves as a useful indicator that they generally agree (Kazdin, 1982).
Using frequency data from the 32 interactions (four clients X eight interactions) a
coefficient of reliability was calculated with a Pearson correlation (r) to compare to the
extent to which the observers covary in their scores (Traub, 1994). In order to verify the
reliability of the average of the intercorrelations a Spearman-Brown formula for double-
length test was applied (Gulliksen, 1950). A table was used to summarize the reliability
analysis.
Once the reliability of the observers was established the nonverbal behaviour data
were presented in a table for each client. The differences between the average scores of
the two observers for positive and negative behaviour were calculated. If the number of
positive behaviours was higher than the number of negative behaviours it was identified
as supporting the Hypothesis two.
Relationship of Physiological and Psychological Data
To assess if any of the physiological and psychological data confirmed the
hypotheses, a composite of the data for each variable with an analysis of changes in
integral and average numbers is presented in graph and table form for each case.
Even though psychophysiological reactions are specific personal patterns, an
analysis of each variable across the four cases was carried out, using a one-tailed
binomial test. The binomial test was used " to determine the probabilities of the possible
outcomes we might observe if we sampled from a binomial population" (Siegel &
Castellan, 1988, p. 39). In a "Z" interaction, there were only two classes of results, either
the data supported the Hypothesis of stress reduction or the data did not support the
Hypothesis of stress reduction. Each time the data confirmed the effect of the "Z"
interaction, the outcome was coded YES and each time the data did not confirm the
outcome was coded NO. For each dependent variable there were 16 opportunities to
confirm the Hypothesis (four clients X four "Z" interactions). A statistically significant
binomial test would support the fact that in a "Z" interaction this specific variable
supported the Hypothesis. The same test was also carried out for the "non-Z"
interactions. For this sample, there were only two classes of results, either the data
supported the Hypothesis of stress reduction or the data did not support the Hypothesis of
stress reduction. A statistically significant binomial test would confirm the fact that the
"non-Z" interaction also reduces the stress of clients. A one-tailed test was used because
the theory predicted in advance, which category should obtained more data (Siegel &
Castellan, 1988).
Finally, the composite of the data for each variable was inspected to analyze if
any of the data showed a difference between gender and a difference between "Z"-"non-
Z" and "non-Z"-"Z" sequences. The results are presented in table form.
Videorecordings
The analysis of the videorecordings of the nurse-client interactions were
described above. The continuous videorecording of the events in the client's life was
analyzed only to identify any events that could have affected the physiological and
psychological data over the period of the study. The videotaping was accompanied by
chronological notes made by the research assistants to facilitate the tracking of events.
The information was used in the interpretation of the results when appropriate. The video
also provided a wealth of data for further research on theory "Z".
MBTI Data
The MBTI data were displayed in descriptive tables which include the type29
of each nurse and client subjects and the scores on each preference. The scores were then
compared between client and nurses and between "X" and "non-X" nurses. To verify the
stability of the test, a re-test was carried out, four months later, with the nurses who
participated in the pilot and the study. These results are also presented in table form.
Instruments
Stress has many manifestations and as a result it can be measured by a variety of
indicators. The physiological indicators were selected to meet two criteria. First, they
must have an immediate onset to be congruent with the theory which claims that "Z"
interaction has an immediate effect on the client and second, the measurements must be
taken in a non-invasive manner to minimize client discomfort. For the psychological
indicators of "anxiety" the only criterion was to minimize the time required by the client
to complete the measurements.
Physiological Instruments
Electromyography
Many individuals respond to anxiety and other stressful conditions by tensing
their muscles. Jacobson (1952) was the first to show that skeletal muscle tension and
arousal states are highly correlated in a positive way. The level of skeletal muscle tension
29 A type is the combination and interaction of four preferences chosen by the
subjects (Myers & McCaulley, 1985)
can be measured by an electromyograph (Asterita, 1985).
"The activity of the skeletal muscles is triggered by a complex pattern of
electrical impulses originating in the central nervous system. These impulses travel from
the brain and spinal cord through motor nerve pathways which terminate in the muscle
fibers. Innervation of the muscle fibers, and consequent muscle contraction, is brought
about when a significant number of motor nerves in a given area are emitting repeated
electrical discharges. Muscular relaxation occurs when the electrical discharge rate of
the motor decreases. The electrical activity which accompanies muscle action is called
electromyogram" (Autogenic System, 1976a).
Electromyography (EMG) entails the detection, amplification and recording of
the muscle action potentials (MAPs) that are produced when motor units fire (Goldstein,
1972). Sensors are placed on the skin surface and can detect the electrical activity which
occurs in the various underlying muscle groups. The greater the electrical activity, the
higher are the measured levels of tension in the muscle group (Asterita, 1985; Fuller,
1979; Lenman & Ritchie, 1987).
While EMG may be applied to any accessible muscle, the frontal region was
chosen because it appears to be an especially sensitive indicator of muscle tension and is
one of the most difficult muscles to relax (Balshan, 1962; Stoya & Budzynski, 1974).
Previous research has suggested the frontalis may be correlated with muscle tension in
other parts of the body and with other indicators such as heart rate and skin resistance
(Jacobson, 1952; Sainsbury & Gibson, 1954; Stoya & Budzynski, 1974). Furthermore, it
is a convenient site for the client and is in an area with less interference from hair.
Although there is not a standard methodology to evaluate the relative muscle
tension or relaxation, the following general guideline is recommended: tense 5 µV,
relatively tense between 2 and 5 µV, normal between 1 and 2 µV, relaxed 1 µV and very
deeply relaxed .5 µV (Autogenic System Inc., 1976a).
A J & J I-330 computerized electromyograph module model M-501 (Applied
Psychophysiology Institutes, 1988) was used to measure EMG levels for each subject.
Two line electrodes were placed one-inch above the eyebrows of the client vertically
above the center of the eye with a ground electrode mid-way between the two live
electrodes (Budzynski, 1973). The electrodes used were silver/silver chloride electrodes,
embedded in plastic insulator discs. The electrodes were attached to the skin with donut-
shaped adhesive discs following preparation of the skin with alcohol coated gauze to
remove skin oil and facilitate better electrode contact. The gel used in the cups of the
electrodes was a biogel biopotential contact medium.
The EMG activity was displayed on a computer monitor in a filtered, rectified,
averaged microvolt (µV). The microvolts were averaged every two seconds. An average
microvolt level was recorded over a four minute period before and after the nurse-client
interaction while the client was alone lying in bed. This procedure constituted the pre and
post-treatment measure or the baseline and end base for the client subject. The recording
also took place during each interaction described in the procedure for the duration of the
encounter.
An I-330 computer software was used to compute the average EMG activity in
microvolts. The outputs from the EMG module and the other modules (EDG and Skin
Temp) were displayed in graph form simultaneously, on the computer monitor. In this
way, any events could be coded directly on the graph as they happened to explain some
of the changes during the recording. This feature was used specifically, when the
stressful treatment started and ended or when the client made brusque movements that
could affect the recording.
Over the years, the validity of EMG has been established. Even though it is not a
direct measure of muscle tension it is a measure of muscle action potentials (MAPs)
which occur prior to muscle contraction. Wilcott and Beenken (1957) have shown a high
correlation between muscular contractions and EMG amplitude, i.e., .80 and .90. EMG
electrodes are also very sensitive apparatus. They will "detect a continuous firing of
motor fibers even though visible signs of tension may not exit and muscular feelings of
tension may not exist" (Green, Green, & Walters, 1970, p. 7).
To ensure reliability of the instrument, several precautions were taken. The EMG
M-501 is sensitive to static electricity. Anti-static spray was used on all equipment in the
client's room and in the monitoring room every day. The equipment was placed on a
separate table away from other electrical appliances, cables or outlets. Incorporated in the
electromyograph M-501 is a bandpass filter of 100 to 200 kilohertz (Hz) for rejection of
electrical inference. The basic accuracy of the outputs is at ± three per cent. All of the
instructions for assembly and placement of the equipment were followed to conform to
the requirement of the manufacturer.
Other physiological variables were also controlled to maximize reliability such as
motor unit abnormalities, gender and age. "Pathologic abnormalities that affect and alter
the normal physiology of the motor unit will change the (MAP) parameters" (Wiechers,
1988, p. 33). For this study, subjects with known neurological or muscular diseases were
excluded. The age variable has been investigated most fully. Some experimenters have
failed to find that tension varies in a significant way due to age (Bartoshuk, 1959; Martin,
1956) but others have found a relationship in particular, in the elderly subjects (Sacco,
Buchthal, & Rosenfalck, 1962). "The total duration of MAP increases rapidly from birth
until the age of 15-20. The total duration then seems to remain essentially unchanged
until the sixth to seventh decade and then increases to a milder degree" (Wiechers, 1988,
p. 30). Subjects for this study were selected between 20 to 60 years of age. "There is
some evidence that the curves relating muscle tension to EMG changes differ between
sexes. Although the differences are real, they are minimal and appear to be related to
variations in strength" (Goldstein, 1972, p. 333). Malmo, Shagass and Davis (1951)
showed that on the average, the same degree of muscular work is accompanied by more
electrical activity in women. Since each individual is his/her own control, this variable is
of no concern. The additional variable of temperature (muscle and ambient temperature)
was also considered. With decreasing intra-muscular temperature, duration and amplitude
of MAPs increase (Wiechers, 1988). At 30 Celsius (C) the duration of MAPs increase
by 10 per cent per degree and the amplitude by 2-5 per cent per degree compared to
muscles at a normal temperature of 37 Celsius (Buchthal, Guld, & Rosenfalck, 1954).
The atmospheric temperature was also found to be correlated with muscle tension at rest
(Balshan, 1962; Nidever, 1959). The body temperatures of all client subjects were
verified daily and the room temperature and humidity were controlled.
Electrodermal measurement
"A wide variety of terms has been used to designate the electrical activity of the
skin; perhaps the most widely employed is the term galvanic skin response (GSR).
Unfortunately, it has been used to cover several aspects of electrical activity of the skin
and is thus ambiguous" (Venables & Christie, 1973). For the purpose of this study, the
term electrodermal measurement (EDM) will be used. The specific aspects of electrical
activity of the skin which will serve as one of the dependent variables, skin conductance
(SC), will be explained.
Since the discovery of the galvanic skin reflex by Vigouroux (1879), the
electrical properties of the skin have been the subject of many studies and are considered
as an index of human psychophysiological processes or of the person's internal state
(Fuller, 1979; Montagu & Coles, 1966; Wilcott, 1967). "The skin with its nervous
control, serves as an end-organ for stress reactivity and arousal. States of arousal can be
measured on the surface of the skin by a well-known parameter, namely, electrical
activity" (Asterita, 1985, p. 180).
Even though there has been a long history of electrodermal research, most
investigators accept the occurrence without knowing the exact mechanism that underlies
the phenomenon (Hume, 1966). The most widely accepted hypothesis is that the
electrical resistance and conductivity of the skin surface changes as a result of the various
states of arousal due to the activity of heightened subdermal glandular secretions. This
alteration in electrical activity acts as an indicator of the stress response (Asterita, 1985;
Speisman, Lazarus, Mordkoff & Davison, 1964) or a correlate of activation, arousal and
factors associated with emotional experiences (Edelberg, 1972).
There are several basic indicators of electrodermal activities, in this study, skin
conductance has been chosen as the indicator. Skin conductance is defined as "the el
ectrical conductivity of the skin with respect to a constant voltage applied to its surface.
The unit of measurement for skin conductance is the micromho (µmho)" (Autogenic
System Inc., 1976b, p. 3).
An increase in electrical conductance which follows a stimulus is not, in itself, the
response. "The response is an increase in sweat-gland activity. The most biologically
meaningful scale of measurement (...) is (one) that provides a linear relationship with
sweat-gland activity (Montagu & Coles, 1966). Skin conductance is considered directly
proportional to the number of sweat glands (Martin & Venables, 1964; Thomas & Korr,
1957). The advantages in using skin conductance as the measure is the stability of the
measurement and the removal of an artifactual source of the Law of Initial Value
(LIV)30. "Skin conductance units are additive and the size of response due to adding a
conductance unit (... another parallel sweat gland pathway) does not depend upon
existing level of conductance" (Venables & Christie, 1973, p. 98). The level of
conductance refers to the absolute value of electrical conductance detected across a given
area of the skin. It is also called the "basal skin conductance." The term "skin
conductance response" refers to a rapid fluctuation in the skin conductance level
following a psychophysiological situation response to discrete stimuli (Autogenic System
Inc., 1976b).
Electrodermal measurement (EDM) of the skin conductance level and response
entails the detection, amplification and recording of the electrical conductivity between
two selected contact sites on the skin (Basmajian, 1989). When a constant-voltage
method is used instead of constant-current method 31, it possesses distinct advantages.
First, since theoretically, the current flowing through each sweat gland is independent of
the state of activity of the other glands, it ensures that the total current will vary with the
number of sweat glands of each individual and the density of the current per active gland
will remain the same, regardless of their number (Montagu & Coles, 1966). Second,
constant-voltage provides a direct measure of conductance. Deflections are directly
proportional to the conductance change and a constant response criterion, such as 0.1
µmho, can be used throughout (Edelberg, 1972). For this study, constant-voltage was
30 Law of Initial Value (Wilder, 1967): "Given a standard dose of stimulus and a
standard period of measurement the response, that is, the change from the initial (pre-
stimuli) level, will tend to be smaller when the initial value (IV) is higher; this applies to
function raising-stimuli. For functions-depressing or function-inhibiting stimuli this
negative correlation becomes positive" (p. 1211).
31 The constant-current method is recorded by passing a steady current through the

object and recording the voltage developed across it. The constant-voltage method is
recorded by applying a steady voltage across the object and recording the current flowing
through it (Montagu & Coles, 1966 p. 266).
used with a voltage of 0.166 volts.
Sensors or electrodes could be placed on several surfaces of the body but since
sweating is not uniform over the body surface and furthermore, may be regulated by
different mechanisms, the palmar and plantar surfaces are the common sites for EDM.
Kuno (1956) claims that the sudomotor activities in the palmar, plantar and axilla areas
are less involved in the thermo-regulatory activity of the body and primarily associated
with mental excitation. Wilcott (1962) found that both alerting and thermal stimuli
produced increased sweating in the palmar region.
For this study, the palmar region of the index and middle fingers of the non-
dominant hand was used while controlling for room temperature. Skin conductance
levels generally range from 1 - 100 µmhos/cm2 per electrode. If there are two active
electrodes of 1 cm2, as used in this study, then this range should be divided by two to
become .5 to 50 µmhos/cm2. "There are no specific µmho limits which can be defined as
norms for determining tension and relaxation. Rather, patterns of response and baseline
levels are highly idiosyncratic to the (individual) and should be assessed in relative terms
for each individual" (Autogenic System Inc., 1976b).
A J & J I-330 computerized dermograph (EDG) module model T-601 (Applied
Psychophysiology Institutes, 1988) was used to monitor palmar skin conductance
response for each subject. The electrodes were identical to the EMG electrodes but
mounted on velcro strip. The two active electrodes were attached to the middle pads of
the fingers. The gel used in the cups of the electrodes was a biogel biopotential contact
medium. The EDG activity was displayed on the computer monitor in micromhos. The
micromhos were averaged every two seconds. The same baseline, recording and graph as
described in the EMG section were used.
The validity of EDM has been established over the years. Even though an
increase in conductance is not a direct measure of electrodermal activity but of the
increase in sweat-gland activities which occurs prior to the electrodermal changes.
Wilcott (1962) and Adams and Vaughan (1965) using similar stimuli have reported
correlations between palmar sweating and SC ranging from .82 to .95 (p <.01 for all
values). Edelgerg (1964) found a much lower range of correlations from -.13 to +.57
when using a wide variety of stimuli.
The same precautions described in the EMG section applies for the EDG T-601.
The output accuracy is reported at ± three per cent. In light of the results of previous
studies, other variables need to be controlled. The environmental variables are: room
temperature, humidity and time of day (Montagu & Coles, 1966; Venables & Christie,
1973). Several earlier studies on room temperature found no relationship between room
temperature and conductance levels (Duffy & Lacey, 1946; Wenger, 1948). Other studies
found no relationship of those two parameters with healthy subjects but a correlation of .
35 with neurotic patients (Eysenck, 1956) or no correlation with healthy subjects when
the temperature was 23 Celsius or lower (Venables, 1955). As previously mentioned, the
room temperature was set to take into account this extraneous variable. For the humidity
variable, several works have found no evidence of a relationship between conductance
and humidity (Eysenck, 1956; Wenger, 1948). But Venables (1955) was able to obtain
evidence of a negative correlation between conductance and humidity when the humidity
was between 54 to 66 per cent. For this reason, the humidity was set below 50 per cent.
Another environmental variable is related to the time of day. Biological rhythms or
circadian rhythms have been studied in relation to physiological processes (Halberg,
1959; Mills, 1966). Only a few early studies have found any relation of conductance with
the time of day. Farmer and Chambers (1925) found minor variations around meal-time
and Weschler (1925) found that the conductance level is at its highest at mid-day. This
study is primarily interested in conductance responses. The time of the measures stimuli
was at approximately the same time each day and none of the responses were measured
at meal times. The organismic variables are: age, gender, race, personality traits
(Montagu & Coles, 1966; Venables & Christie, 1973). No relationship has been
established between skin conductance and age in the adult population. As for gender,
adult female subjects display greater intra-individual variability over a 28 day period
(Montagu, 1963). This may have been related to the menstrual cycle. Since this study
will be over two consecutive days, the possible variations was minimized and
information will also be collected related to the menstrual cycle of the female subjects.
Johnson and Corah (1963) have observed a lower skin conductance for black subjects
compared to white subjects. To control for race, only white subjects were selected. There
is no conclusive evidence related to personality traits of introversion/extroversion and
skin conductance.
Skin temperature
One of the most common physiological measures of anxiety is the temperature of
the skin (Fee & Girdano, 1978). Several studies concluded that a decrease in skin
temperature is one of the physiological reactions accompanying anxiety or stress (Ax,
1953; Duffy, 1972; Green & Green, 1989; Schachter, 1959).
The cardiovascular mechanisms which regulate a change in skin temperature
related to arousal or stress are caused by the activity of the sympathetic division of the
autonomic nervous system. When the sympathetic nervous system is stimulated, the
sympathetic nerves release norepinephrine that excites the heart, stimulates the veins and
the arterioles and also causes the adrenal medullae to secrete both norepinephrine and
epinephrine (Guyton, 1991). "When the sympathetic function is activated, the smooth
muscles surrounding the blood vessels near the skin surface are likely to contract,
resulting in increased pressure on the vessels. This increased pressure will cause the
diameter of these vessels to decrease. As a result, the flow of blood to the area will
decrease (vasoconstriction). As decreased quantities of blood flow through the capillaries
to the tissues near the skin surface, the skin temperature will drop" (Autonomic System
Inc., 1976c, p. 1). Conversely, in a relaxed state, an increase in temperature is brought
about by vasodilatation. Asterita (1985) confirmed that changes related to the stress
response can be easily detected by skin temperature measurement.32
Skin temperature measurement entails the detection and recording of Fahrenheit
32 Core and skin temperature: "the temperature of the deep tissues of the body - the
"core" - remains almost exactly constant, within +/- 1F, day in and day out except when
a person develops a febrile illness. Indeed, the nude person can be exposed to
temperatures as low as 55F or as high as 140F in dry air and still maintain an almost
constant internal body temperature... The skin temperature, in contrast to the core
temperature, rises and falls with the temperature of the surroundings" (Guyton, 1991, p.
797).
or Celsius degrees at the skin surface. Minute changes in skin temperature can be
assessed by the placement of probes on the skin surface of any portion of the limbs of the
body (Asterita, 1985). The palmar surface of the fingers is most commonly used because
of its high sensitivity to psychophysiological changes and most individuals react with a
decrease in blood volume in this region during the elicitation of the stress response
(Asterita, 1985; Fuller, 1979). For this study the palmar region of the small finger of the
non-dominant hand was used. Although each individual differs in terms of the
temperature level of the palmar fingertips, the following correlations between
temperature changes and sympathetic activation, represent a general view: high over-
activation, below 70F; significant over activation, between 70F and 80F; moderate
over activation, between 80F and 85F; moderately relaxed, between 85F and 90F;
quite relaxed, between 90F and 95F; and deep relaxation, above 95F (Autogenic
System Inc., 1976c,).
A J & J I-330 computerized thermograph module model T-601 (Applied
Psychophysiology Institutes, 1988) was used to measure the peripheral skin temperature
for each subject. A thermal sensor was taped with microspore tape to the fingertip of the
small finger of the non-dominant hand. The temperature level was displayed on the
computer monitor in degrees Fahrenheit. The degrees were averaged every two seconds.
The same baseline, recording and graph as described in the EMG section were used.
The validity of the thermograph as a measure of peripheral skin temperature has
been established over the years and is used with biofeedback in the treatment of migraine
headaches (Green & Green, 1977), Raynaud's disease (Sedlacek, 1989) and hypertension
(Fahrion, Norris, Green, Green, & Snarr, 1986) and several other applications.
The same precautions described in the EMG section applies for the EDG T-601.
The output accuracy is reported at ± three per cent. Other variables that affect skin
temperature had to be controlled in order to maximize reliability. These factors include
the room temperature, skin condition, blood viscosity and the presence or absence of
certain chemicals in the blood (Autogenic System Inc., 1976c). The room temperature
has been addressed above. Subjects with known dermatological problems were excluded
from the study. The blood viscosity and the chemical levels in the blood were most likely
to remain constant during a given series of temperature measurements, so the momentary
temperature changes recorded were a function of immediate psychological changes.
Fuller (1979) also reported in his review of studies that bio-chemical factors such
as alcohol intake, tobacco, histamine, lactic acid and carbon dioxide could influence skin
temperature. In order to control for those variables, any intake of these products was
considered as exclusion criteria in the selection of subjects.
Blood pressure and heart rate measurement

The measurements of blood pressure and heart rate are two psychophysiological
processes which can be easily and accurately assessed during the stress response which
exerts an influence on the heart. "The cardiovascular system focuses on the heart itself,
on the vasculature, on systematic blood flow, and on blood pressure. This system taken
as a whole, has been considered to be a major end-organ for the stress response"
(Asterita, 1985, p. 181).
The relationship between psychological factors and change in blood pressure and
heart rate have been widely recognized for many years. Several studies have
demonstrated that stressful experiences increase blood pressure and/or heart rate.
Examples of these studies are quite diversified and include experimental situations in
which a wide variety of emotional stress were presented and an increase of systolic blood
pressure was found (Landis & Gullette, 1925); apprehension before a needle was inserted
in subjects provoked a sharp rise in arterial pressure (Wolf, Cardon, Shepard, & Wolff,
1955); increases in fear and anxiety was accompanied by heart rate increases (Blanchard
& Epstein, 1977); a predictor of uncontrolled hypertension was the perceived high level
of stress by subjects (MacDonald, Sawatzky, Wilson, & Laing, 1991); psychological
stress questionnaires have shown a significant relationship between identified stressors
and an increase in blood pressure in black women (Johnson, Beard, Valdez, Mott,
Hughes, & Fomby, 1987). Studies have also shown that relaxation techniques used with
patients undergoing cardiac catheterization can lower the heart rate and the systolic and
diastolic blood pressure (Markut, 1989); that meditation decreases the heart rate
(Coleman & Schwartz, 1976); that biofeedback has been successful in decreasing the
blood pressure (Hahn, Ro, Song, Kim, Kim, & Yoo, 1993) and that the actual decrease in
blood pressure was as much as 17 millimetres of mercury (mm Hg) on the manometer
(Benson, Shapiro, Tursky, & Schwartz, 1971; Goldman, Kleinman, Snow, Bidus &
Korol, 1975). Altschule (1953) concluded in his study that diastolic pressure appears to
be somewhat less responsive than systolic pressure to changes in the stimulus situation.
But Elder, Ruiz, Deabler, & Dillenkoffer (1973) have shown that the diastolic blood
pressure is as responsive as the systolic pressure to stressful stimuli. The crucial feature
in the reactivity of blood pressure and pulse to stressful events seems to be whether the
subjects actively or passively are coping with stress. Some stressful tasks, where the
subjects actively responded, elicited increases in systolic blood pressure and pulse but not
necessarily an increase in diastolic blood pressure (Del Rio, Velardo, Zizzo, Avogaro,
Cipolli, Della Casa, Marrama, & MadDonald, 1994; Obrist, 1981). Other stressful events,
where the subjects tolerated passively the events, resulted in greater diastolic blood
pressure increase and lesser increases of systolic blood pressure and pulse (Obrist,
Gaebelein, Teller, Langer, Grignolo, Light, & McCubbin, 1978).
The measurements of blood pressure (systolic, diastolic and mean arterial
pressure) and pulse are sensitive measures to stress even if the subject is not always
aware of it. "The cardiovascular system of an individual may respond in a major way to
life situations without the subject's awareness of any significant emotional relationships"
(Gunn, Wolf, Block, & Person, 1972, p. 458). Duffy (1962) concluded from his review
of several studies that "a number of physiological functions have demonstrated that
measures of these functions (such as blood pressure and pulse) show, in most instances,
consistent variations with changes in the apparent demands of the stimulus situation.
They show changes in one direction when demands increase, or stimulation is more
intense, and changes in the opposite direction when demands decrease, or stimulation is
less intense, the extent of the change being roughly proportional to the intensity or
significance of the situation to the individual, or the impact upon the organism of the
stimulation presented" (p. 81). The physiology of blood pressure, mean arterial pressure
and heart rate is summarized in Appendix J.
The blood pressure measure is an indirect (auscultatory) technique. For this study,
a DINAMAP Monitor model 1846X (Critikon, 1988) was used. It is a non-invasive
automatic microprocessor which determines blood pressure and pulse by oscillometric
techniques. An inflatable cuff is wrapped around the upper arm of the client. The cuff is
inflated when the monitor switch is activated. By incrementally deflating the cuff, the
Monitor measures the pressures pulse at each step. The client's systolic, diastolic, mean
arterial pressure and the pulse rate is recorded and displayed on the front panel of the
Monitor. Studies have shown that DINAMAP Monitor and direct arterial measurements
have a strong positive correlation (Ramsey, 1979; Zsigmond, 1981). Mean arterial
pressure seems to be the most stable measure. When the two methods are compared, the
differences in mean arterial pressure are insignificant even when both the systolic and
diastolic measures shows a significant difference (Venus, Mathru, Smith, & Pham,
1985). The Dinamap was calibrated by the technician of the Medical Physics department
of the institution where the study was conducted. After calibration the accuracy level of
the blood pressure was ± 1 mm Hg for blood pressure between 0 and 200 mm Hg; the
MAP was ± 4 mm Hg for MAPs between 50 and 150 mm Hg (Critikon, 1988, p. 44); and
the pulse rate accuracy was ± 3.5 per cent (Critikon, 1988, p. 8).
In normal young adults the systolic pressure is about 120 mm Hg and the diastolic
pressure is about 80 mm Hg. The normal range of systolic, diastolic and mean arterial
pressure increases with age due to the effects of aging of the long-term blood pressure
control mechanisms, such as the kidneys. After age 60, there is a major rise of systolic
pressure due to atherosclerosis (Guyton, 1991). For this study, no subjects were selected
in that age category. Fuller (1979) identified some general limits for diastolic pressure.
Diastolic pressure of 90-105 are considered 'mildly hypertensive'; 105-120 'moderately
hypertensive' and greater than 120 'severely hypertensive'. He did not propose any
categorization for the systolic pressure because it is more variable and difficult to
categorize. Since blood pressure may change a great deal from occasion to occasion,
measurements are generally repeated two or three times to obtain a reasonable average.
The radial pulse is also and indirect measure of the left ventricle contraction. In
normal young adults, the pulse is about 72 beats per minute. A pulse faster than 100 beats
per minute would be consider tachycardia and less than 60 beats per minute bradycardia
(Guyton, 1991).
During this study, blood pressure and pulse were taken by the investigator three
times over a 20-minute period while the subject was at rest at the beginning of the day to
establish a comparison with the other measurements taken during the day. Other readings
were taken at the beginning and the end of every interaction as described in the
procedure.
The blood pressure and the pulse measurements have been used extensively but to
maximize reliability, there is a need to overcome some basic shortcomings. These
include the subjectivity of the operator's such as hearing acuity, arm chosen to take the
blood pressure and site of the cuff placement. The Dinamap controls for hearing acuity
since the results are digital. A mark was made on the subject's arm to increase the
reliability of the procedure. For this study, the same nurse took the blood pressure before
and after the interaction. All nurses chose the same arm and placed the cuff about one
inch above the elbow crease for each client. Even though the blood pressure is a very
labile phenomenon, variation of the intermittent occlusive technique is the only means at
present, for observing blood pressure semi-continuously in human subjects (Brown,
1972, p. 191).
Other factors have been identified as having a direct effect on blood pressure or
pulse such cardiovascular disease. In normotensives, caffeine in high doses (Rall, 1985)
and alcohol (Puddey, Beilin, Vandongen, Rousse, & Rogers, 1985) also have a direct
effect. For this study, these variables were exclusion criteria.
Psychological Instruments
The concept of stress and anxiety are not well defined or circumscribed in the
literature due to the complexity of the phenomena, the ambiguity and the vagueness
found in theoretical conceptions and the lack of appropriate measures. As a result, the
psychological measurement of stress or anxiety in subjects is all the more complex
(Spielberger, Gorsuch, Lushene, & Jacobs, 1983). For this study, the magnitude of the
stress-relaxation continuum experienced by the subject during the interaction with the
nurse, was of great importance. Wolpe (1969) believes that "the assessment of a patient's
ability to relax depends partly upon his reports of the degree of calmness that relaxing
brings in him and partly upon impressions gained from observing him" (p. 122). For this
reason, two of the psychological instruments were self-reports, a subjective anxiety scale,
i.e., Subjective Units of Disturbance (ranging from extreme calm to extreme anxious
feelings) and Spielberger's State Anxiety Inventory (ranging from anxiety-absent to
anxiety-present feeling-states) and one instrument was an observation report of nonverbal
client behaviour (ranging from positive to negative behaviour toward the nurse, during
the interaction).
Subjective anxiety scale

A subjective anxiety scale measured by Subjective Units of Disturbance (SUD)
was developed by Wolpe & Lazarus (1966) based on the belief that:
Knowledge of the magnitude of the patient's anxiety responses to specific
stimuli is indispensable (...) in several ways: in the grading of stimulus
situations for their relative anxiety-arousing effects, in judging the
efficacy of relaxation (...) in determining the anxiety baseline prior to and
during the main procedure, and in assessing the anxiety aroused by present
stimuli. Verbal descriptions are not very informative. A subjective scale is
therefore, used where the patient reports his anxiety levels on a private
scale. (Wolpe, 1982, p. 141)
Each client was asked at a specific time to report verbally on her/his level of anxiety
using a multiple points subjective rating scale where zero represents the state of being
absolutely calm and relaxed and the other end of the scale represents an extremely high-
anxiety reaction. Wolpe (1969) considers that a five to ten point scale can be regarded as
satisfactory. So an 11-point scale was used, zero meaning calm and relaxed and ten
meaning extreme high anxiety. The validity of the scale has been tested in questioning to
what extent such a subjective scale correlates with psychophysiological indicators of
anxiety. Thyer, Papsdorf, Davis, & Vallecorsa (1984), found significant correlations in
20 subjects between SUDs and two indices, heart rate and peripheral vasoconstriction.
The reliability cannot be calculated, since it is a subjective self-report and the numerical
range is set arbitrarily.
The utilization of SUD was carried out with the same protocol that Davis,
Maguire, Haraphongse, & Schaumberger (1994) used in their experiment with patients
that underwent an invasive medical procedure. Before the start of the experiment, the
subjects were taught how to use the scale to report their levels of relaxation or anxiety
when requested by the nurse.
During the training procedure the subject was informed that a zero SUDS
represented being entirely calm, comfortable, at peace, relaxed or in other
words experiencing no distress whatsoever and that a ten rating
represented feeling extremely apprehensive, frightened, anxious, or
distressed. The subject was then asked to give examples of experience
and/or events that he/she would have rated as a zero, a ten, a five, a three
and a seven. The nurse-researcher then drew a zero-to-ten SUDS scale on
a sheet of paper and summarized the subject's exemplars opposite the
corresponding SUDS training. Following verification of this summarize
SUDS scale with the subject, the nurse-researcher used the subject's
SUDS exemplars to make the following points: (a) people often differ in
how they cognitively appraise and rate the same event and (b) there are no
"right " or "wrong" SUDS ratings, only "subjective" SUDS ratings. Lastly,
in order to assess the adequacy of the SUDS training procedure, the nurse-
researcher asked the subject to identify his/her lowest and highest SUDS
ratings since entering hospital and to describe the associated events. (p.
141-142)
The SUD training took place the day before the beginning of the study. The client
was asked for his/her SUD number before and after each interaction with the nurse as
described in the procedure.
Spielberger's State Anxiety Inventory (STAI)

The Spielberger's State Anxiety Inventory (STAI) was first published in 1970.
Spielberger and his colleagues developed STAI as a result of their "interest in the
relationship between anxiety and learning and the fact that no single instrument was
available that provided indices of both state and trait anxiety" (Chaplin, 1984, p. 626). In
1978, a revised version of the STAI separated the scale to measure the trait anxiety from
the state anxiety and received laudatory scientific reviews. "STAI represents a relatively
efficient, reliable, and valid way to assess individual differences in both anxiety-
proneness and phenomenological experience of anxiety in normal, as well as in patients
population" (Katkin, 1978, p. 1096). For this study, only the State Anxiety Inventory was
of interest. The state anxiety refers to a momentary or temporary feeling of anxiety or
calm experienced at a certain level of intensity by each subject. Spielberger et al., (1983)
define the anxiety state as being "characterized by subjective feelings of tension,
apprehension, nervousness, and worry, and by activation or arousal of the autonomic
nervous system" (p. 1).
The S-Anxiety scale (Form Y) consists of 20 "anxiety-present or anxiety-absent"
statements related to how the respondent feels "right now." The subject rates his degree
of agreement with the statements on a four-point, Likert-type scale labelled, "Not at all,"
"Somewhat," "Moderately so" and "Very much so." The items are written below the
sixth-grade reading level. Subjects may require up to ten minutes to complete the
questionnaire the first time but with repeated administrations, they require only five
minutes or less. The scoring of each item is straightforward. A subject's score is the sum
of the responses to the 20 items on the scale. The only complication is that the responses
to the ten "anxiety-absent" items on the State-anxiety scale need to be reversed (i.e., 1=4,
etc.) before they are totalled. In this way, a rating of four indicates high-anxiety and a
rating of zero indicates being relaxed. The range of scores then, can be between 20 to 80
on the State-anxiety scale (Spielberger et al., 1983).
The STAI is recognized as the most widely used measure of anxiety in several
fields, including nursing. In 1983, Spielberger et al., reported over 2,000 studies using
the STAI and extensive work in further improving the instruments. The State-anxiety
scale has a high degree of validity. There is evidence that the scale discriminates between
stressful and non-stressful events, such as military recruits in a stressful training program
and high school students in non-stressful situations, or university students experiencing
both normal, relaxed and stressful conditions (Chaplin, 1984; Katkin, 1978; Spielberger
et al., 1983). In spite of this high level of validity, one caution has been noted. It is very
easy for the subject to fake his/her responses (Chaplin, 1984; Katkin, 1978). Spielberger
et al., (1983) recommend two approaches to overcome this potential problem. First, the
researcher needs to establish a trusting relationship with the subject by communicating
that their honest and candid responses will be of great importance for the study. Second,
to always refer to the STAI scale as a self-evaluation questionnaire, not a measure of
anxiety. Both these elements were incorporated in the study procedure.
The test-retest reliability for the State Anxiety Inventory measure is low. After a
one-hour interval to after 104 days, the correlations are from 0.16 (females), 0.033
(males) to 0.31 (females), 0.033 (males). Since State Anxiety measure is a momentary
phenomena, it is expected that the test-retest reliability would be low. The internal
consistency measured on the other hand, ranges from .86 to .95 alpha coefficient for
working adults, students and military recruits (Chaplin, 1984; Katkin, 1978; Spielberger
et al., 1983). The State Anxiety Inventory was administered pre and post-interaction as
described in the procedure.
Nonverbal Behaviour Worksheet

The Nonverbal Behavior Worksheet was developed by McCorkle (1974) based on
Baldwin's (1970) Worksheet and inspired by Bales (1951). Nonverbal communication or
behaviour has received little attention compared to verbal interactions used by nurses in
relation to the client's emotional needs (Ward & Lindeman, 1979). Bales (1970) contends
that individuals are usually more attentive to what they say than to what they convey in
their manner which is intuitively understood by most of their listeners. A language of
manner (or behaviour) exists along with explicit language which reveals attitudes and
feelings. This language can be observed if a systematic method is used.
The Nonverbal Behaviour Worksheet is a systematic method of observation
designed to measure four broad categories of nonverbal client behaviour that the research
assistant observes or interprets, they are: facial expressions - any form the client's face
takes; body movements - any change of position or lack of change made by the client's
body; eye contact, i.e., face-to-face contact between the client and the nurse; and general
response of the client which is an overall category where the research assistant notes the
overall impressions of the client's response to the nurse. Each client is observed during
the interaction with a nurse and the nonverbal behaviours are recorded in the appropriate
category. Each category is sub-divided into positive or neutral or negative responses of
the client toward the nurse. Some adaptation of the worksheet was made for the present
study following suggestions by the author for the reorganization of some categories
(Ward & Lindeman, 1979) such as the neutral category which was eliminated because it
was not useful in her study. The facial expression "crying" was replaced by "relaxes
facial muscles" as a sign of relief. With these adaptations, the facial expression were
recorded as positive if the client smiles, laughs, relaxes muscles, or nods his head and as
negative, if the client yawns, sighs, frowns, moans, groans or moves his head from side
to side. The other categories and responses were maintained as originally developed but
the descriptions on the worksheet were enlarged to provide more complete cues for the
scoring. The worksheet had a column indicating "Number of times" and a column
indicating "Total" for recording the observations along with accompanying definitions
for each behaviour. The number of times the described nonverbal behaviour occurred
were summed to provide a total of the positive and negative reactions (see Appendix I).
Validity and reliability data were provided in McCorkle's study (1974). "The
discriminatory validity of the instrument was demonstrated by its distinguishing between
an experimental group of patients (n=30) who were touched and verbally stimulated, and
a control group who were only verbally stimulated" (Ward & Lindeman, 1979). Using
the Kolmogorov-Smirnov statistics, two sample tests indicated that at p = <0.01 a
significantly greater number of patients in the experimental groups responded positively
with facial expressions (D = -0.17) and a significantly greater number of control patients
responded negatively with their facial expression (D = 0.20). No difference was found
related to the positive body movements but the experimental subjects had significantly
fewer negative body movements (D = 0.14). The interrater reliability based on two
observer ratings of 60 subjects, ranged between 93 and 100 per cent (McCorkle, 1974;
Ward & Lindeman, 1979).
Prior to the study, two research assistants became familiar with the use of the
Worksheet, through training sessions with taped and live nurse-client interactions.
During the pilot test, one observer recorded the nonverbal behaviour from direct
observations while the other recorded them concurrently from observations of the video
monitor. The two research assistants recorded again the same nonverbal behaviour but
this time from the videotape only. A comparison of the observations recorded by the two
observers showed that the video observations were reliable. This result was the
determinant for the decision to use the observations from the videotape alone. During the
experimental phase, recording by two observers took place during each specific
interaction between the client and the nurse.
Additional Psychological Instrument

Myers-Briggs Type Indicator (MBTI)
The MBTI was administered to all nurses and clients participating in the study.
The purpose was to compare clients and nurses results to verify if any similarity in the
preference profiles of clients and nurses could affect the occurrence of a "Z" interaction
or the effect size on the client. The results were also used to determine if there were any
similarities or dissimilarities of preferences between and among the "X" and "non-X"
nurses.
The MBTI grew out of the interpretation of Carl Jung's theory of psychological
types by Isabel Briggs Myers (Myers & Myers, 1980). "The essence of the theory is that
much seemingly random variation in behaviour is actually quite orderly and consistent,
being due to basic differences in the way individuals prefer to use their perception and
judgement" (Myers & McCaulley, 1985, p. 1). The MBTI is a self-report on easily
recognized situations which aims at identifying the basic preferences of people in regard
to their perceptions and judgement.
The MBTI contains four separate preference indices Extraversion/Introversion
(EI), Sensing/Intuitive (SN), Thinking/ Feeling (TF), Judgement/Perception (JP).
Each dimension has two dichotomous (polar) preferences with only one
preference from each categorization ascribed to any one individual. The
first dimension is a general attitude toward the world, either extraverted
(E), in which the personal direction is actively outward to other persons
and objects, or introverted (I), where the attention and energy is directed
inward to focus on internal, often unspoken, representations of events.
The second dimension, perception, describes a function and is divided
between sensation (S) and intuition (I). Sensing refers to attending to
actual sensory realities and, cognitively, to facts and details. Intuition, on
the other hand, is more global, even unconscious, focusing on insight and
possibilities within the data a person receives. The third dimension, also a
function, is that of judging. Once information is received, it is processed
in either a thinking (T) or feeling (F) style. Thinking refers to a reliance
on reasoning and logic in decision-making. Conversely, feeling means that
perceptions are compared on a value basis. In the feeling style, decisions
are more personal and subjective, and are particularly attuned to how the
person relates to others. (Willis, 1984, p. 482)
The results of the four indices can produce 16 different combinations called "types"
which are represented by the four letters of preference.
This instrument was selected because several concepts included in the MBTI were
congruent with concepts discussed in the "Z" nurse-client interaction theory such as
sensing, perceiving, intuiting and feeling. The MBTI (Form G: self-scorable) consists of
94 multiple choice statements related to the statement the respondent prefers. The
questionnaire was in three parts. The items in Part I and III were estimated to be at
seventh to eighth grade reading level, while the words used in Part II was above the
fourth grade reading level. There was no time limit for completing the questionnaire. On
the average, it took from 20 to 30 minutes. The scoring of each item could be carried out
by the subject or the investigator. All responses were marked on a top sheet of NCR
forms and scoring directions appeared on the second sheet. Essentially, each response to
a question was weighted zero, one or two points. The total of the weighted scores for
each pair of preferences was compared and the smaller number was subtracted from the
larger number. The difference was converted into preference scores which ranged from
one to 49 or 67 depending upon the particular preference (Myers & McCaulley, 1985).
The MBTI is probably the most widely used instrument for non-psychiatric
populations. Willis (1984) reported in his critique an extensive bibliography of research
reports and references in over 130 journals, 300 dissertations, 15 books and in a
dedicated journal on the topic i.e., Journal of Psychological Type. The validity of MBTI
has focused on whether the scales accurately measure Jung's construct. To examine the
construct validity, MBTI has been compared with several tests with similar constructs.
Carlyn (1977) concluded from these numerous correlational studies that "a wealth of
circumstantial evidence has been gathered and results appear to be quite consistent with
Jungian Theory" (p. 469). Willis (1984) also concluded that examination of the data on
individual scales suggest a strong argument for construct validity. Mitchell (1985) added
that "the correlations between corresponding dimensions are moderately high and
statistically significant" (p. 1031). Pittenger (1993) questioned the validity of MBTI as a
test of Jung's theory because Myers' theory ignores the concepts of the unconscious and
the development of the compensatory processes in the unconscious. He concluded that
MBTI needs to be considered as a psychometric instrument not as a test of Jung's theory.
Most reliability assessments have been performed with Form F but Forms F and
G can be used interchangeably since almost no difference exists on the questions that are
scored. Stability in type-category score has been reported using test-retest intervals of up
to six years (McCaulley, 1981). Mitchell (1985) considered the test-retest coefficients of
several studies (Carskadon, 1977; Carlyn, 1977; Levy, Murphy & Carlson, 1972; Stricker
& Ross, 1964) and concluded that the coefficients were good, ranging from .87 seven
weeks later to .48 fourteen months later. McCarley and Carskaton in a later study (1983),
found that 50 per cent of their subjects scored different preferences on one or more of the
four scales within a 5-week interval. Pittenger (1993) concluded that the MBTI types are
not stable personality characteristics. As a measure of "type," the assessment cannot be
accurate and durable for those subjects who score close to the zero point.
4. THE PILOT
A pilot test was conducted to verify if videotaping alone or with face-to-face non-
participant observation was the appropriate vehicle to capture the "Z" interactions and
their effect on clients. For the purpose of the pilot test, one sequence of the A-B-A -
A-C-A design was implemented with the presence of two blind observers, one observer
in the room with the client and the other, observing a videorecording of the interaction.
The recording of the actions/reactions of the nurses and clients was carried out on an
observation grid developed by the investigator and consisting of the empirical referents
of "Z" interaction (see Appendix K). This grid was used to record the first interaction of
the client with the "X" and "non-X" nurse or the encounter of the two strangers. For the
second interaction between the client and the same nurses, the Nonverbal Behaviour
Worksheet (McCorkle, 1974) was used (see Appendix I).
The pilot test also included a verification of the functioning of the physiological
instruments, the computer program, the synchronization of the instruments' recording
with the videorecording and the planned sequences of the physiological and
psychological measures. These verifications enabled the investigator to solve any
problems before the implementation of the protocol. The pilot test also was to verify the
research plan for one A-B-C sequence of the proposed design (see Table 4).
Sample
Client one was a 59-year-old English speaking caucasian Canadian man of
German descent who graduated from a trade school. He was admitted to the hospital
because of a bowel obstruction. He had been operated for a left posterior thorax
melanoma four years previous and again in the last year for a melanoma of the left
cervical chain. At the same time, he was further diagnosed as having an adrenal
metastasis. The stressful treatment studied during the pilot test was a s/c morphine 2.5
mg q4h. Additional medication was part of his regime but did not interfere with the
study. They were: Ceftozadine 2 mg IV q8h at 8:00, 16:00 and 24:00 hours and; Normal
Saline 1\2 with 20 meq KCL/L 75 cc/hr. The subject also had a naso-gastric tube
Table 4
Design description using sequence A-B-C
PHASES A 1B 2B 1C 2C
B E P B E P B E P B E P
EMG X --- --- --- --- --- --- --- ---
EDG X --- --- --- --- --- --- --- ---
TEMP X --- --- --- --- --- --- --- ---
CARDIO X X X X X X X X X
STAI X X X X X
SUD X X X X X
BEHAVIOURS --- --- --- --- --- --- --- ---
Note. X = measures taken at the specified time; --- = measures taken continuously; B = beginning of the
encounter; E = end of encounter; P = immediately post encounter.
91
attached to a low Gomco suction machine. His body temperature was normal at 36.2
and 37 Celsius at 8:00 and 16:00 hours.
The nurse subjects were two diploma graduate in nursing with six and five years
of clinical nursing experience respectively. The first sequence was a "non-Z" interaction
followed by a "Z" interaction.
The Protocol
The setting for the study was judged appropriate with three exceptions. The
lighting levels early in the morning and late at night, were not sufficient to get adequate
resolution on the video monitors due to short daylight period at the time of the study. A
halogen lamp was added to increase the light levels in the room. The other exception was
the sound recording which was very faint so the microphone was successfully remounted
on the wall at the head of the bed. The ambient temperature was verified twice during the
day and both times it was over 23 Celsius. As part of the study it was agreed with the
technician of the Building System Department to set the computerized room temperature
at 23 Celsius or below and to program an hourly print out reporting the room
temperature.
The procedure was implemented as planned. Phase A was the baseline data, Phase
B, one and two were the two "non-Z" interactions and Phase C, one and two were the
two "Z" interactions. Interaction 1B lasted seven minutes, 2B 28 minutes, 1C nine
minutes and 2C nine minutes. The protocol was respected without difficulty.
Instruments
Both the physiological and psychological measuring instruments performed as
expected. The pilot test provided a good opportunity to fine-tune the installation and
operation of the physiological equipment. The investigator was able to solve
implementation problems with both the computer program for reporting and the graphic
procedures for recording the EMG, EDG and the Skin Temp. The computer data for the
second interaction was lost during the process.
92
Adjustment to the video equipment for the real time and lapse time recording
units were made by the technician. In the process, interaction one and two were only
recorded in lapse time.
Analysis of Data
The results of the EMG, EDG and Skin Temp were averaged every two seconds
and then, every minute. An averaged minute was labelled by the program as a trial and
the average of five trials was labelled as a period. Finally, the total interaction plus the
base readings were labelled as a session. The results of the trials in numbers and graphs
(see Table 5 and Figure 4) and the results of the periods in numbers and graphs (see
Table 6 and Figure 5) were inconclusive. This design was planned with only one Phase A
or one baseline data. The graphs showed where the baseline data was situated compared
to the data for each interaction. Unless base data were added before and after each
interaction, it would be impossible to make any comparison of the overall effect of the
interaction on the client. The base data taken in the morning were not sufficient for the
three other interactions due to the physiological change of the client during the day.
Unless base data were added at the end of the interaction the comparison would have
been between a client at rest and a client in a tense situation. So the design was changed
to include additional base data and the new design became an A-B-A - A-C-A sequence.
Adjustments were made to the computer program to include a four-minute base line at
the beginning and end of each recorded session. The cardiovascular measurements were
found to be adequate.
The self-reports by the client were implemented without difficulty. The other
psychological measurements were more complicated. All interactions were observed by
two research assistants twice. The first time, one research assistant accompanied the
nurse into the room of the client and scored the behaviour of the client as it happened
while the second research assistant also scored the interaction as it simultaneously
appeared, on the video monitor. The second time, both research assistants independently
scored the behaviour observed on the video monitor during play back of the session
previously recorded. The first interaction of the day shift and the first interaction of the
93
evening shift i.e., the meeting of two strangers, were observed and scored on the "Z"
94
Table 5
EMG, EDG and Skin Temperature trial results in numbers
(table continues)
95
Table 5 (continued)
Note. Temp = skin temperature in Fahrenheit; EDG = electrodermal measurement in

microhms; EMG = electromyography activities in microvolts; Tr# = trial number
equivalent to one minute; FB# = period number equivalent to the sum of trials.
96
Figure 4. Skin temperature, EDG, and EMG trials results
97
Table 6
EMG, EDG and Skin Temperature period results in numbers
Note. Temp = skin temperature in Fahrenheit; EDG = electrodermal measurement in

microhms; EMG = electromyography activities in microvolts; FB# = period number
equivalent to the sum of trials.
98
Figure 5. Skin temperature, EDG, and EMG period results
99
Interaction Grid (Appendix K). The "Z" observation grid was developed using Bakeman
& Gottman sequential data coding model (1992, p.53) and the process of the "Z"
interaction as the codable event. The "Z" interaction process was a series of progressive
and interdependent behaviours of the client and the nurses during an initial encounter.
The labelling of the observed behaviour was adapted from Bales (1951) Interaction
Process Analysis. The results of the live and the video observations (see Table 7) showed
that these observations were very unreliable when live observations and videotaped
observation sequences were compared. Several causes may have contributed to these
results. First, the observers had to report only the first time they observed the behaviour
instead of all behaviours for the duration of the interaction. Second, the analysis was
concerned with the occurrence of discrete behaviours recorded by each observer instead
of their agreement or disagreement about the behaviours and sequences. Finally, the
lighting in the client's room during the pilot test made the identification of the behaviours
more difficult.
The second interaction of the day shift and the second interaction of the evening
shift i.e., the stressful treatment, was observed and scored on the Nonverbal Behaviour
Worksheet (see Appendix I) which measures the frequency of positive and negative
behaviour. The results of the live observations were compared with the results of the
video observations and showed that the video observations were more reliable than the
live observations, particularly, during the interaction 2B. This difference could be
explained by the difficulty of capturing every nonverbal behaviour while recording and
therefore looking at the form for a few seconds instead of observing the interaction.
Furthermore the video play back capacity helped confirm many observations. The poor
lighting significantly decreased the resolution of the video tape and made the judging of
interaction 2C very difficult. In spite of this, the reliability coefficient of both the live
and video recording for this interaction were the same (see Table 8). So, for the study,
only analysis of video recording interaction was used.
As a result of the pilot test, which indicated that the filmed observation was more
reliable than the observer in the room, videotaping observations were chosen for the
protocol. The initial design was modified to conform to the design described in the
100
Table 7
Comparison of sequential observations scored by two observers of live
and video recordings using the "Z" Interaction Observation Grid for the
nurse-client interaction 1B and 1C
Interaction 1B Sequential Behaviours
Live
Observer 1 1 4 2 5 8 3+9 7 Y
Observer 2 1 4 3 8 5 Y
Video
Observer 1 1 2 5 3+9 N
Observer 2 1 8 4 2 3+9 5 7 Y
Interaction 1C
Live
Observer 1 1 5 2 4+7 8+9 3 6 Y
Observer 2 1 2 4 7 8 9 3 6 5 Y
Video
Observer 1 1 4 5 3 9 2 Y
Observer 2 2 4 8 9 3 5 7 6 Y
Notes. The sign + is used when the observer scored the two behaviours
simultaneously.
previous chapter. A series of adjustments were made to the lighting, the video and
physiological equipment and to the computer program. The pilot test was very useful in
verifying the function of all the equipment, the implementation of the protocol and the
adjustment of the setting.
Table 8
Reliability coefficient of the nonverbal behaviour of the client tallied by two observers as it happened (live)
and on video recordings using the Nonverbal Behaviour Worksheet for the nurse-client interaction 2B and 2C
Interaction Behaviour Video scores Video Live scores Live

Number Obsv. 1 Obsv. 2 (diff/average) Obsv. 1 Obsv. 2 (diff/average)
2B Positive 78 75 3/76.5 = 0.04 73 118 45/95.5 = 0.47

Negative 61 62 1/61.5 = 0.02 49 97 48/73 = 0.66
Total 139 137 2/138 = 0.01 122 215 93/168.5= 0.55
2C Positive 17 28 11/22.5 = 0.49 43 31 12/37 = 0.32

Negative 17 19 2/18 = 0.11 25 19 6/22 = 0.27
Total 34 47 13/40.5 = 0.32 68 50 18/59 = 0.31
Note. Obsv. = Observer; (diff/average) = the differences between the scores of each observer were divided
by the average of their combined scores.
102
5. RESULTS
The major findings of this study involve the responses of each client to the nurse
patient interaction. Each client will be presented separately in relation to their
demographic information and their physiological and psychological reactions. To
reiterate, Client One participate in the pilot test and is not covered in this chapter. The
summative results of all 4 clients will be found in the next chapter.
Client Two
The client was a 43-year-old, Canadian woman who graduated from a trade
school and who was English speaking. She was admitted to the hospital with a diagnosis
of vulvar carcinoma for a bilateral node dissection and excision of vulvar lesion. At the
time of the study, it had been 15 days since the first day of her last menstruation cycle
and she had regular menses. The stressful treatment chosen was a post-operative
dressing of the vulva region which was very sensitive. Client two was a stoic type of
individual with a sense of humour. She was from out-of-town and did not have any
family or friends living close by. Her only visitor, other than staff and volunteers from
the institution, was another patient with whom she shared a room prior to joining the
study. The medications prescribed were not clinically related to the physiological
measures see Table 9.
The subject also had a Foley catheter which was removed on day one in the morning. Her
body temperature was normal at 36.6 and 36.4 Celsius on day one and day two.
The nurse subjects were nurse one and nurse two. The sequence for this case was
a "non-Z" interaction followed by a "Z" interaction.
Physiological reactions (Hypothesis One)

The mean changes in EMG, EDG and Skin Temp were recorded for each minute
of the interaction and of the initial and end base periods. Since Hypothesis One stated
that the client will report a lower level of stress after a "Z" interaction, the initial base
measure pre-interaction was compared with the end-base measure post-interaction. The
103
Table 9
Time (international units) of medications administered to client 2 during the study
Medications Day one Day two
Tylenol #3, 2 tab q4h po 8:30 10:00
Morphine 10 mg, q4h po 11:15 23:00
Heparin 5000 u, q12h s/c 10:00
Surfax 1 tab, BID po 20:00
Senokot 2 tab qhs po 20:00
Dulcolax supp 22:00
Note. tab = tablet; q(x)h = every x hours; po = by mouth; s/c = subcutaneous; BID =
twice a day; qhs = every evening; supp = suppository.
mean changes for each period (4 minutes for the base and 5 or less minutes during the
interaction) of each interaction are presented in graph form in Appendix L. The
difference between the means of the pre and post-base measures of EMG, EDG and Skin
Temp, for each interaction, are presented in Table 10.
Changes in the mean of the EMG showed a reduction in stress level for five of the
eight interactions. Of these five, three interactions were of "Z" type while two were "non-
Z" interactions. Of the two "non-Z" interactions, one interaction showed a difference of
0.1 µV between the pre and post interaction measures which were recorded while the
client was sleeping. This result is not clinically significant. The EMG results, for client
two, showed that for three out of four "Z" interactions a reduction of stress level was
reported compared to one out of four "non-Z" interactions. For the other physiological
measures there was no clear pattern of change. The EDG showed an increase of stress
following all interactions except one. The Skin Temp did not support
104
Table 10 Client 2 Results by Interaction: Reduction or Non-reduction of Stress
105
106
107
the predictive Hypothesis for this client. Five measures were within a margin of error and
three measures showed stress increase. These three readings were following three of the
four interactions which included a dressing change.
The changes in cardiovascular measures did not show any particular pattern. Most
of the data are classified as uncertain because they fall in the margin of error or because
there is no difference between the pre and post-measures (see Table 10). The detailed
cardiovascular results are presented in Table L1 (see Appendix L).
In summary, Hypothesis One was supported. The EMG results showed a lower
level of stress following a "Z" interaction than following a "non-Z" interaction. The EDG
showed an increase of stress after all interactions except one and the Skin Temp showed
an increase of stress after three of the four dressing changes. The cardiovascular
measures were inconclusive.
Psychological Reactions (Hypothesis Two)

Since Hypothesis Two stated that the client will report a lower level of stress after
a "Z" interaction, the SUD and STAI initial base measures pre-interaction were compared
with the end-base measures post-interaction. Both SUD and STAI results supported
Hypothesis Two. Client two reported a lower SUD after three of the four "Z" interaction
compared to two of the four "non-Z" interactions and a lower STAI after all the "Z"
interactions compared to two of the four "non-Z" interactions. Furthermore, the
differences reported for the "Z" interactions were larger than those reported for the "non-
Z" interactions (see Table 10). The detail results of the SUD and STAI scores are
presented in Table L2 (see Appendix L).
Table 10 also represents the difference between the number of positive and
negative behaviours of the client toward the nurse during each interaction. Client two
exhibited more positive than negative behaviours toward the nurses during all
interactions. The "Z" interactions are characterized by more positive behaviours than the
"non-Z" interactions. The detailed results for each behaviour are found in Appendix L,
Table L3.
108
Client Three
The client was a 51-year-old, Canadian woman and College graduate who was
English speaking. She was admitted to the hospital for fever of unknown origin with a
diagnosis of breast cancer with lung and liver metastasis. She had not had a menstrual
cycle for over a year. The stressful treatment chosen was a sub-cutaneous morphine
injection which induced a stinging sensation. Client three was a calm, serene individual
who was aware of her prognosis and discussed freely with her mother about the
arrangements for after her death. She died eight weeks following the data collection. She
was surrounded by a close-knit family. Her mother and husband were regularly with her,
her daughter and several co-workers visited every day. The medications prescribed were
not clinically related to the physiological measures of the study (see Table 11). Her body
temperature was normal at 37.2 and 37.1 Celsius on day one and day two.
The nurse subjects were nurse three and nurse four. The sequence for this case
was a "Z" interaction followed by a "non-Z" interaction.
Physiological Reactions (Hypothesis One)

The mean changes in EMG, EDG and Skin Temp for each period of each
interaction are presented in graph form in Appendix M. The difference between the
means of the pre and post-base measures of EMG, EDG and Skin Temp, for each
interaction, are presented in Table 12.
Changes in the mean of the EMG showed a reduction in stress level for four of
the eight interactions. Of these four, three interactions were of "Z" type while one was a
"non-Z" interaction. These results supported Hypothesis One. For the other physiological
measures there was no clear pattern of change. The EDG showed an increase of stress
following all interactions except two, one "Z" and one "non-Z" interaction. The Skin
Temp did not support the Hypothesis for this client because six measures were within a
margin of error and classified as uncertain.
The changes in cardiovascular measures did not show any particular pattern. Most
of the data were classified as uncertain because they fell within the margin of error or
because there is no difference between the pre and post-measures (see Table 12). The
109
Table 11

Lasix 20 mg, TID po 10:00 - 16:00 - 22:00 10:00 - 16:00 - 22:00
Aldactone 5 mg, BID po 10:00 - 22:00 10:00 - 22:00
Doxycycline 100 mg, BID po 10:00 - 18:00 10:00 - 18:00
Prednisone 25 mg, qd 10:00 10:00
Morphine 2.5 mg, q4h s/c 2:00 - 6:00 - 10:00 2:00 - 6:00 - 10:00
14:00 - 18:00 - 22:00 14:00 - 18:00 - 22:00
Surfax 1 tab, BID po 10:00 - 20:00 10:00 - 20:00
Gravol 50 mg, q4h s/c prn 10:00 10:00
Cophylac 15 gtts, BID 10:00 - 22:00 10:00 - 22:00
Ativan 1 mg, qhs po 22:00 22:00
Robitussin 5 ml, q4h po 10:00 - 14:00 - 18:00 10:00 - 14:00 - 18:00
22:00 22:00
Note. TID = three times a day; BID = twice a day; po = by mouth; qd = every day; q(x)h
= every x hours; s/c = subcutaneous; tab = tablet; prn = as needed; gtts = drops; qhs =
every evening.
detailed cardiovascular results are presented in Table M1 (see Appendix M).

Table 12 represent changes in scores between pre-interaction measure and the
post-interaction measure for both the SUD and STAI reports. The SUD results supported
Hypothesis Two. Client three reported a lower SUD after three of the four "Z"
interactions compared to two of the four "non-Z" interactions. The values reported were
110
111
112
113
also similar or larger for the "Z" interactions than for the "non-Z" interactions. The STAI
results showed a reduction of stress following all interactions except two. Detailed results
of the SUD and STAI scores are presented in Table M2 (see Appendix M).
negative behaviours toward the nurse during each interaction. For all interactions client
three exhibited more positive than negative behaviours toward the nurses. The "Z"
interactions are characterized by a greater number of positive behaviours than the "non-
Z" interactions. The detailed results for each behaviour are found in Appendix M, Table
M3.
Client Four
The client was a 46-year-old, Canadian man of Jewish descent who graduated
from Junior High school and who was English speaking. He was admitted to the hospital
for a possible bowel obstruction with a diagnosis of relapse lymphoma with abdominal
metastasis. The stressful treatment chosen was a sub-cutaneous morphine injection which
induced a stinging sensation. Client four was a tense individual concerned about his
prognosis. He was from out-of-Province and did not have any family or friends living
close by. His only visitor was a co-worker who came to get a check signed. Client four
was particularly concerned about a possible visit from his brother and mother. He did not
want his mother to see him "so sick." The first day of the study he discussed this issue
with almost everyone who entered his room while the second day of the study (expected
day of the visit) he refused to talk about it with anyone. As the day progressed without
any news from his family he got more withdrawn and tense. The medications prescribed
were not clinically related to the physiological measures but the quantity of Morphine
taken by client four affected his alertness (see Table 13). His body temperature was
normal at 36.8 and 37.1 Celsius on day one and day two.
The nurse subjects were nurse five and nurse six. The sequence for this case was a
"Z" interaction followed by a "non-Z" interaction.
114
Table 13
Albumin 75 gm, qd 13:30 13:30
Aldactone 100 mg, qd po 10:00 10:00
Ranidine 50 mg, IV q8h 12:00 - 20:00 12:00 - 20:00
Mycostatin 500,00 u, m/w qid po 12:00 - 16:00
Morphine 15 mg, q4h s/c 3:00 - 7:00 - 11:00

15:00 - 19:00 - 23:00
Morphine 20 mg, q4h s/c 3:00 - 7:00 - 11:00

15:00 - 19:00
Morphine 7.5 mg, q4h s/c 1:30 - 5:30 - 17:30

20:30
Morphine 10 mg, q4h s/c 0:01 - 6:00 - 17:00
Maxeran 10 mg, q4h IV 10:00 - 14:00 - 18:00
Haldol 2 mg, s/c 1:00
Gravol 50 mg, IV 1:00
Note. qd = every day; po = by mouth; IV = intravenous; q(x)h = every x hours; m/w =

mouth wash; s/c = subcutaneous.

interaction are presented in graph form in Appendix O. The difference between the
115
None of the physiological changes supported Hypothesis One. Both "Z" and
"non-Z" interactions showed a decrease and increase of stress level. The EDG showed an
increase of stress following all interactions except one, a "non-Z" interaction. The Skin
Temp measures were all within a margin of error except one, a "non-Z" interaction which
showed an increase in stress level. The systolic blood pressure decreased following
seven of the eight interactions and the exception was within the margin of error. The
diastolic blood pressure decreased for five of the eight interactions regardless of the type
of interaction. The other three interactions showed changes within the margin of error.
As for the mean arterial pressure and the pulse, half of the interactions showed a decrease
of stress while the other half were within the margin of error regardless of the type of
interaction (see Table 14). The detailed cardiovascular results are presented in
Table N1 (see Appendix N).

Table 14 represents changes in scores between pre-interaction measure and the
post-interaction measure for both the SUD and STAI reports. The STAI results supported
Hypothesis Two. Client four reported a lower STAI after three of the four "Z"
interactions compared to two of the four "non-Z" interactions. The values reported were
similar or larger for the "Z" interactions than for the "non-Z" interactions. The SUD
results showed a reduction of stress in half of the interactions regardless of the type of
interaction and the other half showed and increase of stress or no effect. The detailed
results of the SUD and STAI scores are presented in Table N2 (see Appendix N).
The difference between the number of positive and negative behaviours toward
the nurse during each interaction are presented in Table 10. Client four exhibited more
negative than positive behaviours toward the nurses during all interactions . The detailed
results for each behaviour are found in Appendix N, Table N3.
116
117
118
119
Client Five
The client was a 46-year-old, Canadian man who graduated with a doctorate and
who was English speaking. He was admitted to the hospital for chemotherapy with a
diagnosis of relapsed immunoblastic lymphoma with thoracic metastasis. The stressful
treatment chosen was a sub-cutaneous morphine injection which induced a stinging
sensation. Client five was a calm and cheerful individual who was well aware of the
consequences of his relapse and hopeful to prolong his life. He was surrounded by a
close knit family. His wife was regularly with him and their two teenage daughters and
several co-workers visited every day. The medications prescribed were not clinically
related to the physiological measures but during the study the client developed some
complications i.e., thromboses in his left arm and then in the sub-clavian vein.
Physiologically the reactions during the two last interactions where clinically very
unstable. The investigator discussed with the client the possibility of discontinuing the
study. The client refused and wanted to complete the project in spite of his difficulties.
Table 15 presents the complex medication protocol for client five. His body temperature
was normal at 37.2 and 37.0 Celsius on day one and day two.
The nurse subjects were nurse seven and nurse two. The sequence for this case
was a "non-Z" interaction followed by a "Z" interaction.

interaction are presented in graph form in Appendix O. The difference between the
Changes in the mean of the EMG showed a reduction in stress level for three of
the eight interactions. Of these three, two interactions were of "Z" type while one was
"non-Z" interactions. During the two last "Z" interactions client five was experiencing
major physiological complications and was very concerned. The EMG showed an
increase of tension in the frontalis muscle. In spite of this situation the EMG results
showed that the other two "Z" interactions reduced the stress level of the client. For the
120
Table 15
Chemo day3
Heparin bolus 5,000 u /1hr 17:00 - 18:00
Heparin 25,000 u in 250 D5W 19:00
Cisplatin 1000 ml/6hr 21:00
Lasix 50 cc 21:30
Post hydration 1000 cc/3 hr 21:30
NS w KCL 20 mq 21:30
Chemo day 4
pre hydration 1000 w KCL 20 mq/3hr 8:30
pre hydration 1000 w KCL 20 mq/3hr 11:30
VP16 - Etopside 500 ml 11:30
VP16 - Etopside 500 ml 13:30
CPPD - Cisplatin 1050 ml/6hr 13:30
Methyprednisone 500 mg 13:30
Morphine 10 mg, q4h s/c 2:00 - 6:00 - 10:00 2:00 - 6:00 - 10:00
14:00 - 18:00 - 22:00 14:00 - 18:00 - 22:00
Surfax 1 tab, BID po 8:00 - 20:00 8:00 - 20:00
Senokot 2 tab qhs po 22:00
(Table continues)
121
Table 15 (continued)
Zofran 8 mg, q8h IV 4:00 - 12:00 - 20:00 4:00 - 12:00 - 20:00
Maxeran 10 mg, q4h IV 2:00 - 6:00 - 10:00 2:00 - 6:00 - 10:00

14:00 - 18:00 - 22:00 14:00 - 18:00 - 22:00
Coumadin 10 mg 16:00
Ativan 2 mg 4:00
Note. q(x)h = every x hours; s/c = subcutaneous; tab = tablet; BID = twice a day; po = by
mouth; qhs = every evening; IV = intravenously.
other physiological measures no clear pattern of change supported Hypothesis One. The
EDG showed a reduction of stress following all interactions recorded. The Skin Temp
were all within a margin of error.
The changes in cardiovascular measures did not show any particular pattern to
support Hypothesis One. Most of the data are classified as uncertain for mean arterial
pressure and pulse because they fall in the margin of error or because there is no
difference between the pre and post-measures. The other data for systolic and diastolic
pressures showed an increase of stress in five of the eight interactions which can be
explained by the extreme demand on the cardiovascular system of the client from the
chemotherapy which included large amount of liquid given IV and the formation of
thromboses. So these results are not clinically valid (see Table 16). The detailed
cardiovascular results are presented in Table O1 (see Appendix O).

Table 16 presents changes in scores between pre-interaction measures and the
122
Table 16 Client 5 Results by Interaction: Reduction or Non-reduction of Stress measures
123
124
125
post-interaction measures for both the SUD and STAI reports. The STAI results
supported the Hypothesis Two. Client five reported a lower STAI after three of the four
"Z" interactions compared to one of the four "non-Z" interactions. The SUD results
showed a reduction of stress in three of the eight interactions. Two of the interaction
were "Z." The other five scores showed no effect and in one instance the score showed an
increase of stress (the last interaction). Asked for explanation, the client gave his SUD
score at the end of a telephone conversation which he identified as stressful. The detailed
results of the SUD and STAI scores are presented in Table O2 (see Appendix O).
negative behaviours toward the nurse during each interaction. Client five exhibited more
positive than negative behaviours toward the nurse during all "Z" interactions. Two of
the four "non-Z" interaction showed positive behaviours. The "Z" interaction are
characterized by more positive behaviours than the "non-Z" interactions. The detailed
results for each behaviour are found in Appendix O, Table O3.
126
6. SUMMATIVE RESULTS
This study is based on a sample of four clients and seven nurses. Only one of the
nurses was assigned a second time to the study. Figure 6 shows each threesome, the
client and the two nurses (one "X" and one "non-X") who participated in the interactions
under study. How the nurse and client were paired determined both the type of
interaction that was observed and in what sequence.
Each client participated in eight interactions, four "Z" and four "non-Z"
interactions for a total of 32 interactions. The interactions ranged from 3 to 22 minutes.
Table 17 presents the duration of each interaction and data on the means and standard
deviations of time spent in "Z" and "non-Z" interactions. There was a significant
difference in the mean duration for each type of interaction indicating that the amount of
time spent with the client is one of the elements that characterises a "Z" interaction. One
exception in the data was with client three where the averaged "non-Z" interactions were
longer by 2.25 minutes than the "Z" interactions. The standard deviation for each type of
interaction was close, reflecting that the variation in duration of the interaction does not
characterize the type of interaction.
All the interactions were videotaped and analyzed. The results are presented in
the psychological reactions section. The continuous videorecording ranged from 34 hours
and 32 minutes for client two, to 36 hours and 2 minutes for client four. The data
provided information to interpret some results. The recorders were turned off only three
times. Once for a two hour period at the request of the wife of client five, while the client
was experiencing some complications and a 10 minute period while a laboratory
technician was taking a blood sample from client five. The third time was for
a twenty minute period at the request of the husband of client three, while she was
coughing and nauseous.
127
Figure 6. Client-nurse triads and resulting interaction sequence.
128
Table 17
Duration of "Z" and "non-Z" interactions
Client "Z" "non-Z"

2 13 22 11 20 5 14 5 16
3 11 10 10 6 14 8 11 13
4 15 15 8 9 3 8 5 6
5 9 13 11 8 6 10 8 5
Mean 11.94 8.56
SD 4.33 3.98
t-test -2.30*
Notes. The numbers represent minutes. The duration was established using the trials (1
minute) data. *p <.05, two tail.
The design and each step of the protocol were precisely followed. The room
temperature and humidity were monitored by computer on an ongoing basis and
remained between 22.33 and 23.31 Celsius and below 32.5 per cent relative humidity.
Due to problems with the building automation computer during the study of client five,
the report of temperature and humidity was not available.
The first interactions of the day and of the evening took place within one hour of
the beginning of the shift and the second interactions for each shift took place at different
times during the day depending on the scheduled time for treatment. Even though the
time of the treatment varied between clients, for each client the time of the treatment was
the same over the two days. The treatments chosen were a dressing for one client and s/c
morphine for the other three clients.
All the measurements took place as planned and the data were recorded and
stored in the computer with one exception. The EMG, EDG and Skin temp readings of
the first interaction with client five were not saved properly and are considered missing
data. All other data are used to report the results of the study.
The physiological and psychological data for each client confirmed that
129
physiopsychological reactions follow specific personal patterns. The summary of results
regarding the reduction of stress associated with the "Z" interaction, for all clients is
presented in Table 18. The results showed that "Z" interactions were more likely to
reduce the stress level of clients than the "non-Z" interactions. One physiological
measure, the tension in the frontalis muscle (EMG), was reduced following the "Z"
interactions for three of the four clients. For all clients from one to three of the
psychological measures showed a reduction in stress associated with the "Z" interactions.
The nonverbal behaviour data showed that both the "non-Z" interactions as well as the
"Z" interactions positively affected the client. While client two and three had more
positive than negative behaviours toward the nurse during every interaction, the "Z"
interactions were characterized with a larger amount of positive behaviours (see Table 10
and 12).
Other analysis were carried out across cases. A visual inspection of the graphs
and tables for client two and three compared with the data for client four and five
supported the conclusion that patterns of reactions are individual and not gender specific.
The changes recorded on all measures showed that the reactions of each male and female
client were different. A regrouping of similar data, on the basis of gender, could not be
constructed in regard to the direction of change or amplitude of effects.
The other relevant analysis was the verification of the carry-over effect of "Z"
interactions. As discussed earlier two sequences were implemented for the study. A "Z" -
"non-Z" - "Z" - "non-Z" interaction sequence provided two opportunities for "Z"
interaction to precede and influence the results of a "non-Z" interaction. And a "non-Z" -
"Z" - "non-Z" - "Z" interactions sequence provided one opportunity for "Z" interaction to
precede and influence the results of a "non-Z" interaction. Since there was ten different
measures (or variables) for each client and two clients participated in one or the other
sequence, this created 60 opportunities to verify if a carry-over effect existed (see Table
10, 12, 14 and 16).
2 clients X 2 opportunities X 10 measures = 40 opportunities

2 clients X 1 opportunities X 10 measures = 20 opportunities
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Total = 60 opportunities
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Table 18 Summary: Reduction of Client's Stress Associated with "Z" or any Nurse-Client
Interactions.
132
When almost all interactions were shown as not reducing the stress level of client (e.i.,
EDG measures) these interactions were excluded from the review, since a carry-over
effect could not be claimed (see Table 18). Of the remaining opportunities, only once did
a "Z" interaction, showing a reduction of stress, precede a "non-Z' interaction which also
showed a reduction of stress (i.e., client two, interaction four and five [see Table 10]).
The aggregate data did not support a carry-over effect of "Z" interaction.
In summary Hypothesis One was supported for three of the four clients.
Hypothesis Two was supported for all four clients. Gender had no effect on the stress
reactions patterns of the clients. "Z" interaction had no carry-over effect on the other
nurse-client interaction. The duration of the interaction is significantly related to "Z"
interaction. From the aggregate data of the four clients further conclusions were drawn:
the scores on STAI reports were significantly lower for the "Z" interactions; the positive
nonverbal behaviours were significantly higher for the "Z" interaction; the electrical skin
conductance was significantly higher following all nurse-client interactions.
Effectiveness of the Tools

Among the physiological and psychological measures chosen to record the
changes in stress level of the clients, certain measures were more sensitive than others.
The stress reduction following "Z" and "non-Z" interactions is presented in Appendix P
for each variable across cases. A binomial test was performed to determine the
probability that the results obtained for each variable would confirm the Hypothesis One
and Two. The test was carried out for the "Z" and "non-Z" interactions and the results are
found in Table 19. The results confirmed that following a "Z" interaction the changes in
nonverbal behaviour and state anxiety were statistically significant. The EMG for the "Z"
interactions and the Nonverbal Behaviour for the "non-Z" interactions were not
statistically significant but showed a trend as an important indicator of stress changes
with the aggregate data.
Interobserver Reliability
Interobserver reliability was checked using all frequencies from all interactions.
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Table 19 One-tailed Binomial Test Summary Table: Proportion of Cases with Reduction
of Stress During "Z" and "Non-Z" Interactions
134
Even though all positive and negative behaviours were included for the 32 interactions,
one behaviour "touches nurse" was not observed and two behaviours "turns away from
the nurse" and "relaxes facial muscles" were observed only two and three times. The
results of the Pearson (r) correlation and the Spearman-Brown double length test are
shown in Table 20. The results indicate that the reliability of most measures was
adequate (.80 or above) with few exceptions. The behaviours "turns away from the
nurse" and "relaxes facial muscles" had a low reliability coefficient which is expected
with very few data points because a change by one score may represent a difference of r
between zero and one.
These results should be interpreted with some caution for several reasons. First,
frequency counts reflect the total observations of each observer and the correlations
assessed the tendency of the scores to go together. Neither of these methods reflect
agreement. Second, observers were instructed to score behaviour conservatively,
meaning not record borderline behaviour. Third, certain factors such as the quality of the
video tape, the lighting or the position of the nurse in relation to the client made it
difficult to score some behaviours. With this caution in mind, these findings indicate a
high correlation between the two observers for positive and negative behaviours tallied
over the entire course of the study.
Myers-Briggs Type Indicator (MBTI)

A summary of the preference profiles and scores of the 17 nurses who
volunteered to participate in the study is presented in Appendix Q. Table 21 demonstrates
that there is no difference in preferences and scores between "X" and "non-X" nurse. The
MBTI results did not confirm a preference by the "X" nurses for the concept related to
the theory. The four "X" nurses reported a preference for the concept "sensing" over the
concept "intuition." This was in line with the preferences of most nurses who had
volunteered for the study (17 nurses). Two of the "X" nurses preferred the concept
"feeling" while two "X" nurses preferred the other pole of that scale, "thinking." Finally,
three of the "X" nurses preferred "judgement" over "perception." The self-selection of the
seventeen volunteers may have caused a distortion of the sample particularly in the
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Table 20
Pearson correlation (r) and Spearman-Brown (2r/1 + r) estimates for client's nonverbal
behaviour
BEHAVIOUR TYPE r 2r/1 + r
FACIAL EXPRESSIONS
Smiles or laughs +ve .99 .99
Relaxes muscles +ve .04 .08
Nods head up and down +ve .69 .82
Yawns or sighs -ve .93 .97
Frowns -ve .76 .86
Moves head side to side -ve .93 .96
Moans or groans -ve .83 .91
BODY MOVEMENTS
Touches nurse +ve -- --
Turns toward nurse +ve .95 .97
Turns away from nurse -ve .47 .64
Nervous body movements -ve .89 .94
EYE CONTACT +ve 1. 1.
Looks at nurse +ve .99 1.
Looks away from nurse -ve .99 1.
GENERAL RESPONSE
Seems interested +ve 1. 1.
Seems rejecting -ve 1. 1.
Notes. Type = behaviours classified as either positive (+ve) or negative(-ve); behaviours

described in Appendix D.
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Table 21 Myers-Briggs Type Indicator (MBTI) Preference Scores of Seventeen "X" and
"Non-X" Nurses
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comparison to the preference scores of a large sample of nurses. A data bank of MBTI
scores of 3,103 registered nurses (Myers & McCaulley, 1985) identified that 56 per cent
of the nurses preferred "sensing." The results of the current study were 82.4 per cent
"sensing" and 17.6 per cent "intuition." The sample is also different on the next
thinking/feeling scale. The data bank identified 36.2 per cent of nurses preferred
"thinking" while 63.7 per cent preferred "feeling." In the current study 88.2 per cent
preferred "thinking" and 11.8 per cent preferred "feeling." The percentage was close only
on the "judgement/thinking" scale. "judgement" was 63.5 per cent and "perception" 36.4
per cent in the data bank while it was 58.8 per cent "judgement" and 41.2 per cent
"perception" in the study.
Table 22 compared the "X" and "non-X" nurses' preference profiles with the 16
MBTI types. The majority of nurses (13 out of 17) were classified in a combination of
types identified as "practical and matter-of-fact types," represented by the first column of
data. The next larger combination of types, 8 out of 17 nurses, were the "decisive
introvert types," represented by the first row of data and the "realistic decision-makers
types," represented by the left half of the first and last rows of data. The four "X" nurses
were in the later category, the "realistic decision-makers types." There were no other
identifying characteristics between the "X" and "non-X" nurses. The four preferences of
the Head Nurse and the investigator were also different, they were ISTJ and ENFJ. The
"X" and "non-X" characteristics of nurses are not corroborated by the MBTI data.
In order to verify if the test would confirm the same preference profiles four
months later, a retest was carried out with the seven nurses who participated in the study
(see Appendix Q). Three of the seven nurses maintained the same preference profiles
while four reclassified from one to three of the preferences. These results did corroborate
the study conducted by McCarley and Carskadon (1983) which found that within a five-
week period, 50 per cent of the subjects reclassified on one or more of the four scores.
Howes and Carskadon (1979) showed that the majority of individuals with a change in
the initial profile had a low score between 1 to 15. Appendix R demonstrates that when
there is a change in a letter of the preference profiles at retest, there is an initial score
between 1 and 15 with one exception, nurse six with score of 45 on E (extrovert). These
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Table 22 Myers-Briggs Type Indicator (MBTI): Classification of Seventeen "X" and

"Non-X" Nurses Based on MBTI Sixteen Types
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findings support Pittenger (1993) conclusion that the four-letter type code is not a stable
personality characteristic.
The preference profiles and scores of clients and nurses who interacted during the
study are presented in Table 23. Each combination of four preferences yielded a type
which has its own patterns and attitudes. The characteristics of each type follow from the
interplay of these four preferences in a unique way (Myers & McCaulley, 1985).
To determine if similarities of MBTI results had an influence on the stress reduction of
client, all nurse-client pairs were analyzed. Only two clients and two nurses shared the
same preference profiles even though the scores of each preference were different,
meaning the strength of these preferences were different for each individual. Client two
and nurse one were an ISTP type and client five and nurse seven were an ESTP type. The
results for client two showed that out of ten measures of stress, during eight interactions,
five measures were inconclusive, four measures showed that the "Z" interactions reduced
stress and one measure showed that both "Z" and "non-Z" interactions reduce stress. The
interactions of client five showed that out of ten measures of stress, six were
inconclusive, three showed that the "Z" interactions reduced stress and one showed that
both "Z" and "non-Z" interactions reduce stress. In both cases the nurses with identical
preference profiles were "non-X" nurses and therefore participated in the "non-Z"
interaction. Since "non-Z" interactions seemed to have very little effect, similar
preference profiles are not associated with the reduction of stress of the client.
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Table 23
Summary of preferences and scores on the Myers-Briggs Type Indicator (MBTI) for each
client and nurse who participated in the study
Preferences Index
Ex/In S/N T/F J/P
Client 2 I(05) S(23) T(07) P(23)

Nurse 1 I(09) S(13) T(17) P(11)
Nurse 2* E(45) S(11) F(31) J(13)
Client 3 I(21) S(09) T(09) J(05)

Nurse 3* I(09) S(05) F(01) J(03)
Nurse 4 E(03) N(01) T(11) J(17)
Client 4 I(11)
N(07) T(11) P(11)
Nurse 5* I(01) S(13) T(13) J(01)
Nurse 6 I(05) S(17) T(01) P(05)
Client 5 E(01)
S(05) T(07) P(07)
Nurse 7 E(09) S(21) T(11) P(05)
Nurse 2* E(45) S(11) F(31) J(13)
Note. Ex/In = Extraversion/Introversion; S/N = Sensing/Intuition; T/F =

Thinking/Feeling; J/P = Judgement/Perception; * = "X" nurse.
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7. DISCUSSION OF FINDINGS
The purpose of this study was to test one of the relational propositions of a new
nurse-client interaction theory which states that "Z" interaction reduces the stress level of
client. The first step in the validation process was chosen because the apparent reduction
of stress of clients was the element that lead the investigator to conceptualize the cause,
later labelled as a "Z" interaction (Rodger, 1990). The methodological approach chosen
was a single subject design because it was well suited to observe the reactions of each
individual client to particular nurse-client interactions. The main contribution of this
study is a first validation of the theory and an effective strategy to study the impact of
nurse-client interactions on the well-being of clients.
The purpose of this section is to discuss the findings in relation to the elements
that strengthened the study as well as the elements that should be improved. The
discussion will address the following topics: selection of the "Z" interaction components,
research methods, implications for Theory "Z," nursing practice, and nursing research.
The chapter will end with a summary of the study.
Selection of "Z" Interaction Components

The identification process of the "X" nurse was a non-participant observation by
the investigator and the Head Nurse of 17 nurses who volunteered for the study. To be
classified as "X" the nurse needed to have the set of defined characteristics (see Chapter
One). The Head Nurse based her selection on her knowledge of these nurses for a
minimum of four years and the investigator on an observation of the nurses in interaction
with clients during a twelve-hour period. These two non-participant observation
processes were carried out independently. The comparison of results validated that four
nurses classified "X" met the set of criteria. The 17 nurses were aware of the general
purpose of the study but were not aware of the "X" and "non--X" classification. Even
though the Head Nurse and the investigator had a clear understanding of who met and
who did not meet the set of characteristics following the observations, they both were
concerned at the time of comparison, that interpretation of the set of characteristics or
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influences from other theories could have blurred their selection process. This was
discussed after the written classification was shared. In order to verify if the MBTI
preference profiles could have played a role in the identification processes, both the Head
Nurse and the investigator completed and shared the results of MBTI questionnaires.
Three of the four preferences were different, so similarity of preferences was ruled out as
an influence in the selection process. In previous work the Head Nurses in other nursing
units in another institution were also able to identify "X" nurses following the description
of the set of characteristics (Rodger, 1990). This validation process only confirmed, in a
more structured fashion, what had been observed previously.
The identification process of the "Y" client was an interview by the Head Nurse
and the investigator using the characteristics described earlier of the "Y" client and the
list of exclusion criteria. To be classified as "Y" the client needed to have the set of
prescribed characteristics. The Head Nurse did the first interview and when she
concluded that the client would be a possible candidate for the study, the investigator did
the second interview with the client and the family when appropriate. During the time
with the client, the existential abilities of the client were assessed. A discussion of
findings between the Head Nurse and the investigator followed the two interviews. The
selection process was completed if the client met all the characteristics. A few times,
further discussion took place to ascertain if the client was alert, responsive to the nurses,
collaborating, etc. Two criteria were added to interpret more strictly the characteristics of
being a "fully-conscious adult person and able to communicate." Fully-conscious was
interpreted as well-oriented in time and place and alert. Some clients who were
considered fully-conscious were under the influence of large doses of pain medication
which could have created an additional extraneous variable. Being able to communicate
was restricted, to verbal communication because it was the principal means to asses the
existential characteristics of the client.
The setting chosen for the study met all the characteristics of the environment
described in the theory and the encounter was assured when the nurse met the client to
provide nursing care. While the environment and the encounter characteristics were
relatively easy to meet for this study, the selection of the "X" nurse and the "Y" client
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were more complicated. The procedures implemented were designed to minimize a threat
to internal validity and to validate the identification of the "X" nurses and "Y" clients by
two different persons in two independent processes. The process worked well for this
study but a more structured tools for the selection of the "X" nurse and "Y" client would
facilitate the identification process.
Research Method
Design Issues
Bias
Bias could have been easily introduced in the study particularly because the
investigator was testing her own theory. Attention was given to controlling possible
biases and the investigator was not directly involved in the selection of the sample nor
most of the collection and analysis of data. Random sampling techniques were not an
appropriate way to select the clients in this design. Each subject who met the criteria, was
accepted in the study and served as his/her own control. Once a client was available, the
assignment of the nurses was done exclusively by the Head Nurse from two pools of
nurses one "X" pool and one "non-X" pool. The organizational imperatives did not allow
a random assignment from each pool but the assignment was carried out in relation to
who was already scheduled to work for the next two days and on what shift. The Head
Nurse then matched the availability of the "X" and "non-X" nurses with the possible
sequences and the client's gender. Twice the Head Nurse had to change the schedule of
the nurses to ensure the presence of an "X" nurse. This was not necessary for the "non-X"
nurse since the pool was much larger. The investigator was informed the morning of the
study what sequence and what nurses were assigned to the client. This process was
implemented to avoid any bias on the part of the investigator.
For the data collection, the physiological measures were recorded by the
computer or by the nurses directly from the client, the videorecording was carried out by
the research assistants. The client, the nurses and the research assistants were all blind to
the sequences being studied. The only collection of data done by the investigator was
getting the completed STAI questionnaires from the clients and requesting the SUD
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numbers. All manipulation of data for analysis was carried out by blind research
assistants or on the computer. The computer analyzed the EMG, EDG and Skin Temp
data stored and produced the graphs and statistical analysis used in the report. The other
data were calculated twice by two research assistants before the investigator completed
the final analysis and interpretation. The only data where judgement was required, was
the scoring of the nonverbal behaviours and this was carried out by two research
assistants. The design of the current study was constructed to control for bias and the
implementation followed the design without difficulty.
Passage of time in clinical setting

Events in the life of the client constituted a threat to the internal validity of the
study. To minimize this threat a video camera continuously documented the events in the
life of the client for the duration of the study. The extraneous variables could not all be
controlled but some could be explained. When client five increased his SUD scores
following the last interaction, it was possible to verify what happened to explain this high
score. The interaction was completed, end-base physiological measures were taken and
the client had completed his STAI questionnaire. The telephone rang in the room of the
client before the investigator could ask for his SUD number. The conversation was short
but this affected the client. His SUD number went up while the other psychological end-
base measures had decreased. When asked he identified the telephone conversation as the
cause of his high score. This was an example of an event that affected the measures and
masked the effect of the nurse-client interaction. A better understanding of the events in
the life of the client facilitated an interpretation of data and increase the internal validity
of the study. Internal validity remains a concern because this current study was a field
experiment (Brink & Wood, 1989).
Measurements Issues
Physiological instruments
Any results that were within the uncertainty range were not considered as
supporting or not supporting the Hypotheses. One measurement of the EMG, EDG and
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the Skin Temperature (the data of the first interaction ["non-Z" interaction] for client
five) was lost during the study. The analysis was limited by this missing data.
This study provided evidence that EMG was an effective measure of stress that
can be used in future nursing studies. The suggested correlation in the literature between
changes in frontalis muscle and changes in heart rate was not supported, probably
because of the demands on the cardiovascular system of the client from serious illness
and other unknown causes.
The EDG for skin conductance did not as EMG to differentiate between types of
interactions. The EDG measures did show an increase of stress following the nurse-client
interactions. These results may be explained by unexpected sympathetic nervous system
reactions or by changes in the cardio-vascular and peripheral circulation. The cardio-
vascular and peripheral measures did not prove satisfactory either. The state of health of
the client and the multiple medications may have been responsible for these effects.
Further study would be needed to clarify these results. In the last few years,
electrodermal indicators have been used more frequently in nursing studies that include
stress as a concept. A "researcher cognizant of (EDM) limitations (...) should not
abandoned (it) as one of a set of multiple measures for examining the stress response"
(Doswell, 1989, 66). The lack of sensitivity may have been evident in the results of this
study. In spite of these results, EDG should be retained only as a gross measure of nurse-
client interactions.
The Skin Temp results showed that most of the changes between the initial base
and end-base temperature were classified as uncertain because they fell within the margin
of error of the thermograph. This indicator may not be sensitive enough to record
changes which were recorded by two of the other physiological measures EMG and EDG
or it may be a problem of the reliability of the measure. Blood viscosity was identified as
one of the many factors affecting the reliability of Skin Temp. For client five, the
formation of a thrombose may have been a factor affecting the reliability of the measure.
Only a more in depth study of each case in relation to Skin Temp could provide
additional information on the causes of the non-performance of this indicator and guide
recommendations.
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The cardiovascular measures were not sensitive to the effect of nurse-client
interactions except for client four were a change in systolic and diastolic blood pressure
was recorded. Several reasons for the absence of this effect could be considered. There is
an increasing number of studies which associate larger cardiovascular reactivity to stress
from hypertensive or borderline hypertensive subjects than from normal individuals, in
particular, if there is an history of hypertension in the family (Ewart, Harris, Zeger, &
Russell, 1986; Hastrup, Light & Obrist, 1982; Light, 1981). Sources may differ slightly,
but the borderline hypertensive subjects can be defined with a blood pressure in the range
of 140/90 to 160/100 mm Hg (Kaplan, 1982). One of the interesting findings in the
present study is that most of the clients were hypotensive with an approximate blood
pressure of 100/60 mm Hg. The only exception was client five who was borderline
hypertensive with an averaged blood pressure of 145/90 mm Hg. For clients two and
three, the lack of reactivity may be caused by hypotension but this rational would not
hold true for client four who showed an effect on the systolic and diastolic blood pressure
and client five who showed borderline hypertension. No data were available on the
family history of the clients to complete their profiles. Other possibilities for the lack of
reliability of these measures for three of the clients would include the impact on the
cardiovascular system of the combination of medications and the quantity of intravenous
fluids administered or the effect of the formation of a thrombose. More information and
in depth analysis of each case would need to be carried out to provide plausible
explanations for these findings.
Self-reports
The reliability of the self-reports was expected to be low because the influences
of transient situational factors. The STAI data were, with the EMG data, the most
discriminating for the "Z" interaction and a binomial test confirmed that the changes
were significantly different for the "Z" interaction. The STAI questionnaire was well
accepted by the clients and completed without any problems. The SUD training was also
well accepted and easily understood by the client. The SUD scale was more difficult to
use for two clients. The issue of reliability was raised by client three regarding the
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transferability of the SUD scale made from her previous experiences to the unique
experience she was currently experiencing. Because she thoughtfully reported her scores
and was determining them from the same vantage point, the investigator considered that
her dilemma was not problematic for the integrity of the scoring. The other issue was
related to the construction of the SUD scale with client five who gave the mid-point of
his scale as "teaching to a large class of students" and the extreme point of his scale as
"being informed of the relapse of his cancer." In light of the level of stress he was
experiencing during the study, he could not give any scores at or below the mid-point of
his scale. So, his most relaxed state was at point six on his scale. This left him a small
range within which to identify his SUD scores. This situation was not problematic
because the changes in scale by half a point were more meaningful for him than other
clients and the single design can accommodate individual ranges. It would have been an
issue if this scale was used to compare between subjects.
Videorecordings
The data were assessed with regard to interrater reliability. Most of the behaviour
scored had an important reliability coefficient. These results were a strength of the
nonverbal behaviour observations. With training, the observers improved the accuracy of
their measurements. The meaning of the reliability coefficient could have been improved
if the investigator had used a schema to verify interobserver agreements and
disagreements instead of frequencies. The frequencies count did not confirm if the
observers agreed on specific behaviour and if the same behaviours were rated.
Nevertheless, both observers rated most nonverbal behaviours approximately the same
frequency. The behaviours that had a Pearson correlation and a Spearman Brown double-
length test below .8 were few. They were "relaxes facial muscles" and "turns away from
the nurse." The "relaxes facial muscles" was a replacement behaviour for what McCorkle
(1974) described as "crying." She identified crying as a positive behaviour as a sign of
relief. The "relaxes facial muscles" was chosen as a replacement because it had been
observed in previous work and was part of theory "Z." The behaviour was observed only
with two clients, once with one client and twice with the other. Such low frequencies
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made the correlation irrelevant and the investigator concluded that the behaviour should
be removed from the worksheet.
The behaviour "turns away from the nurse" also had a low correlation but in that
case there were many observations across all cases. This reliability issue may be due to
an interpretation of the behaviour by the observer. "Turns toward" and "turns away"
mean the turning of the body not the head. In contrast a "turns toward" behaviour had a
high correlation because most of the time the client while turning the head toward also
turned the upper part of the body while this was not the case when they "turned the head
away." They did not turn the upper body with the head probably as a courtesy to the
person with whom they were interacting. More training for the observers may have
improved the scoring of that behaviour. This difficulty was not readily visible at the time
of training. Two other behaviours had a correlation of .69 "nods head up and down" and .
76 "frowns" but the Spearman Brown correlation for double length test over .8. Finally,
one behaviour "touches nurse" did not have any scores. This was not surprising. Bottorff
(1992) found in her study on touch that 92.1 per cent of the touches were initiated by
nurses in a data set of 1711 touch events. For the present study, this category was not
useful and could have been deleted.
The McCorkle nonverbal behaviour worksheet has an adequate reliability and
with the few changes mentioned above and more training of the observers for one of the
behaviours ("turns away") it is recommended for other nursing studies. Further the
binomial test confirmed that the changes in nonverbal behaviour were statistically
significant indicator of a "Z" interaction.
Myers-Briggs Type Indicator

An attempt was made to document some of the characteristics of the "X" nurse
using an MBTI questionnaire. This attempt was not useful and the use of MBTI not
recommended for further study into the characteristics of the "X" nurses. The need to
corroborate the existential abilities of the "X" nurse is an important one in order to
increase knowledge of the phenomenon but the tools available are limited. It should be
possible to identify individual existential abilities such as intuition but it may not be
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possible to identify the set of characteristics of "X" due to the limitations in our
knowledge. Further, a set of characteristics implies a synergetic effect of each individual
characteristic on each other and on the client's set of characteristics. More study is
required to develop appropriate strategies to increase knowledge of this part of the
theory.
The use of the MBTI had a positive impact with the nurses and the clients. The
questionnaire generated lots of discussion about individual characteristics. Since all the
concepts were expressed positively, it provided some reinforcement for individual
strength.
Implications for the Z" Interaction Theory

The results of this study demonstrated that even though "Z" interactions are
embedded in the way the participants are in the world, their manner of being or their
"isness" it was possible to capture the effects of the "Z" interaction using scientific
methods. To transpose one of Hans Selye's (1983) expressions, whatever the nature of
"Z" interaction, its existence is assured by its effects, which have been observed and even
measured. The clients who participated in a "Z" interaction reported a reduction of stress
in at least one or more of the psychological indicators and three of the four clients who
participated in a "Z" interaction reported a reduction of stress in one of the physiological
indicators. This study was the first confirmation of the proposition that the "Z"
interaction reduces the stress level of the client.
The focus of the study was on the effect of the interaction for the client but it was
also an opportunity to attempt to verify other elements of the theory, such as the process
of the "Z" interaction. The "Z" interaction observation grid was an attempt to observe the
beginning of the "Z" and "non-Z" interactions. It was not successful but should be
pursued even with secondary analysis of the videotapes. The analysis of the "Z"
interaction process could be carried out in a more structured sequential analysis.
"X" Nurses
Two observations may help to refine the characteristics already identified. One
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observation concerned the empirical referent of the existential ability identified as "set
aside one's own ego." Several times "non-X" nurses used themselves as an example to
relate to the client's situation. Expressions like "Yes I know what you mean (or what you
feel), I had a similar experience...." were used. The "X" nurses rarely referred to herself
to establish contact or show understanding of the client's situation. The second
observation was related to the cues sent by the nurse which may influence his/her "ability
to sense the competence of a provider." When nurses started their shift, following the
report from other colleagues, and were responsible to care for clients they did not know,
it was sometimes difficult to have all the information regarding the client before the first
encounter. Sometimes, the nurse had to provide care right away before having access to
additional information. In order to ascertain the additional information needed, the "X"
nurse never directly asked questions of the client but gathered the information by indirect
means by letting the client discuss an issue or a concern. "Non-X" nurses seem to use a
different approach by letting the client know they did not have the information using
expressions such as "how do you do that?" "what did your doctor think of that?" These
two additional observations added to the empirical referents of the "X" nurse and should
be included in a selection instrument.
The study also provoked additional reflections on another issue, the intensity of
the "X" nurse "isness". As mentioned above, to be identified as "X" one needed to
possess all of the abilities. But could there be a range of intensity of the set of existential
abilities which in turn, would provoke a range of detectable effects on clients? In the
study, two of the "X" nurses seemed to have very strong characteristics. One nurse was
assigned twice, first to female client two and then to male client five. In both instances,
physiological and psychological indicators of stress showed a reduction. In the case of
client five, the effect was impressive because he was very ill, with many complications,
many medications and worries about his last chance to live if the chemotherapy was able
to control his cancer relapse. In spite of all these extraneous variables, the effect of the
"Z" interaction was evident. In contrast, client four, who was assigned another "X" nurse,
had the weakest effect and the least differentiation of the "Z" versus "non-Z" interaction.
This could be the result of a less intense set of "X" characteristics or an error of selection.
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The issue of intensity of "X" characteristics and its impact on the detectable effects for
client needs to be studied further.
"Y" Client
The assessment of who met the "Y" client characteristics was conducted over a
very short period of time through two interviews by two different people. With client
four both the Head Nurse and the investigator discussed on the second day of the study if
the client still met the characteristics of a "Y" client i.e., was he able to sense the
benevolence of a provider, accept the nurse to his world and if he was able to relax.
These discussions took place because he displayed some erratic behaviour regarding the
impeding visit of his mother and brother. Client four met the required characteristics but
needed to be monitored closely for the remainder of the day. When initially assessed, the
client did not exhibit erratic behaviour. The question remains whether the client had the
"Y" characteristics in other word was the client a "non-Y" client or whether a longer
observation period would have been beneficial. An assessment period similar to the
process used for the nurses, coupled with some psychosocial data on each client, would
have improved the process of selection. Alternatively, if a client is judged extremely
anxious, calling in a specialist in anxiety reduction may have brought the client's anxiety
level to a manageable level. If the same "X" nurse had been assigned to several clients we
could have known if the client or the nurse was at issue.
Some of the "Y" characteristics were given additional interpretation to facilitate
the research i.e., "fully conscious" was interpreted as well-oriented in time and place and
alert. "Able to communicate" was restricted to verbal communication. Another situation
which was encountered during the selection process could have some importance for a
future study. A male client had a very anxious wife who had taken on a controlling role
over every event in his life. The nurse hardly had any communication from the client
including the most intimate type of data. This situation made it difficult to gather a
certain type of data such as self-reports and the like. There is a need to explore further
the question of exclusion criteria for the "Y" client such as social isolation, personality
disorder and alike. Finally, the comments made regarding the study of the "X" nurse
characteristics equally apply to the "Y" client characteristics.
152
Implication for Nursing Practice and Research
Nursing Practice
It is too early in the development of this theory to have recommendations for
practice. In fact, the study represents the first test of one of 21 propositions which are
part of the theory. Theory testing research rarely has an immediate practice utility. "The
primary value of theory-testing research is to stimulate further study and theory
development that will add to empirical knowledge upon which practice can be based"
(Chinn & Jacobs, 1987, p. 165). The development of knowledge regarding the "Z" nurse-
client interaction and its effects on clients is very significant for nursing practice. It
focuses on one aspect of nursing care, the interaction, which is not well understood at
this time. It also focuses on the effects of nursing care which is not well documented. A
better understanding of the types of interaction can help improve the effectiveness of
care. Further, additional knowledge about the outcomes of nurse-client interactions is
important at a time when health care systems around the world are being redefined.
Even though this study could not have direct implications for practice in regard to
the testing of the theory, some findings can be used by practitioners. The study showed
that all nurse-client interactions had a beneficial effect on clients. A reduction of stress
for the four clients was evident following the interaction of the clients with all of the
nurses who participated in the study (see Table 14). It is important for nurses to be aware
of their effects on clients, to continue to document the impact of care givers and use the
information to improve the utilization of registered nurses. This study contributed to that
effort.
A question that is often raised regarding the characteristics of the "X" nurse is
whether the "X" nurse is born or made. This question has professional significance
because the answer would require different strategies for the profession. If the "X"
characteristics are acquired, then the next question is how can it be acquired by more
nurses and students. If the "X" characteristics are innate, then the next question is
whether who can they be recognized in the selection of future nurses and better
utilization of nursing resources. The challenge will be to document the characteristics.
The question of innate or acquired should have a priority on the research agenda once
153
more knowledge is available concerning the phenomenon.
Nursing Research
The testing of one proposition for the first time is a good start but not sufficient
validation. Replications of this study should be conducted in other settings to further the
theory development. A similar design could be tested with a healthy population and a
different stressor in a laboratory environment to improve the control of the extraneous
variables. Studies of "X" and "non-X" nurses with diversified clinical experiences, varied
ethnic representation, gender differences and other factors, should be conducted.
An extension of the present study could be pursued by secondary analysis of the
information collected on videotape. A comparative study of the unfolding of a "Z"
interaction to a "non-Z" interaction and to the theory could be carried out using
sequential analysis techniques (Bakeman & Gottman, 1986). A descriptive study of the
"X" and "Y" characteristics present during the process of interaction could add to future
development of a selection tool. Analysis of the nurse-client interaction comparing "Z"
and "non-Z" interactions could also be conducted. The re-analysis of the nonverbal
behaviours of the client by two observers looking at agreement and disagreement and
reliability coefficient would strengthen the results of the present study. A correlation
study of events during the interaction with the physiological reactions in muscle tone,
skin conductance and skin temperature could be the basis of another study.
The theory has, to date, 21 propositions, nine that are descriptive and 12
relational which include association or causation. Every one of these propositions needs
to be tested. "A good theory must (...) suggest new hypotheses that are capable of being
tested empirically. Consequently, a theory must have the capacity to guide research as
well as to summarize the result of previous research. This means that there is a constant
interaction between theory and empirical observations (Christensen, 1988, p. 29). In
order to develop this theory a program of research needs to be considered which would
include the study of the essential components of the theory, their interactions and their
effects. The classification of the propositions is available to guide the type of research
required.
154
To answer some of the questions would require a multidisciplinary approach.
Issues regarding effects would benefit from the contribution of disciplines such as
physiology, psychology and sociology. Issues regarding the uniqueness of the
phenomenon to nursing situations will need the contribution from other fields which are
also involved in providing service to humankind such as, education, psychology and
other health disciplines.
Summary
This study tested the first proposition of a new theory on nurse-client interaction
which states that a "Z" interaction will reduce the stress level of client. The "Z"
interaction is the result of the encounter of a "X" nurse and a "Y" client for the purpose
of providing/receiving nursing care. The "X" and the "Y" characteristics, described in the
theory, are the existential qualities of the individuals. The presence of these
characteristics are necessary for a privileged instantaneous link to be created between the
client and the nurse. The strength of this link produces an exclusive, shared,
phenomenological field between the nurse and the client.
Knowledge in the area of nurse-client interactions is one of the essential
components of the discipline of nursing. Yet, in the last 50 years only ten nursing
theorists have contributed to this area and little empirical testing has been carried out.
The "Z" nurse-client interaction is a conceptualization of one type of interaction and, is
intended as a middle-range holistic theory of a predictive nature.
In order to test the prediction that "Z" interaction will reduce the stress level of
client, a single subject design with withdrawal and repeated measures was selected. The
choice was determined by the need to study the reactions of each individual client who
provided his/her own control.
Four clients (two males and two females) and seven nurses participated in the
study over a two-day period. The subject were selected by the Head Nurse and the
investigator, independently, using the description of "X" and "Y" characteristics. Each
"Y" client was cared for by an "X" nurse for one shift and followed by care from a "non-
X" nurse, for the following shift. This order was reversed for the next client of the same
155
gender in order to verify if the order of the "Z" and "non-Z" interactions had an effect on
the results of the study. During each shift, two interactions were monitored, the initial
meeting of the client and the nurse at the beginning of the shift and the encounter of the
client and the nurse for a stressful treatment, such as post-operative dressing change or
sub-cutaneous injections. Each client experienced four "Z" and four "non-Z" interactions
over a period of two days.
The stress level of the client was measured by multiple physiological and
psychological indicators which were congruent with the definition of stress and the
physiopsychological reactions of an individual to maintain a balanced condition or
homeostasis when exposed to stressors. The hypotheses tested were that: 1. Clients who
participated in a "Z" interaction demonstrate a lower level of stress in one of four
physiological measures when compared with clients who did not participate in such an
interaction:
a. lower muscle tension measured by electromyography (EMG); b. lower electrical skin
conductance measured by electrodermograph (EDG); c. higher skin temperature
measured by a thermograph (Skin Temp) and; d. lower cardiovascular activities
measured with a Dinamap.
2. Clients who participated in a "Z" interaction will report a lower score in one of the
three psychological measures than clients who did not participate in a such interaction: a.
lower State Anxiety Inventory (STAI); b.lower Subjective Units of Disturbance (SUD)
and; display more positive nonverbal reactions.
The physiological measures were taken before and after each interaction for a
four-minute period, to establish initial and end-base data, and also during the interaction.
Cardiovascular measures were taken by the nurses at the beginning and the end of their
interactions. Psychological measures were completed by the client before and after each
interaction. All interactions were videotaped for further analysis of the nonverbal
behaviour of the clients by two independent observers.
The study also provided an opportunity to explore a facet of the theory related to
the similarities and differences of characteristics between the "X" nurse and the "non-X"
nurse and between the "X" nurse and the "Y" client. A Myers-Briggs Type Indicator
156
(MBTI) scale was used to compare the preference profiles of the nurse subjects and the
client subjects. There were no identifying patterns for the "X" and the "non-X" nurses.
No effects could be attributed to similarities on MBTI results between clients and nurses.
Conclusion
Hypothesis One was supported for three of the four clients and Hypothesis Two
was supported for all clients. Gender had no effect on the stress reactions patterns of the
clients and the "Z" interactions had no carry-over effect on the other nurse-client
interactions. The duration of the interaction was significantly longer for the "Z"
interaction. The scores on STAI reports were significantly lower for the "Z" interactions
and the positive nonverbal behaviours were significantly higher for the "Z" interactions.
The results discriminated the effects of the "Z" interactions.
The results of the study are a validation of one proposition of this new theory.
The study confirms that the "Z" interaction is powerful enough to create effects that are
visible in spite of the extraneous variables of clinical research with a very sick
population. This research should be considered as the first step in a program of research
in an essential area of the discipline of nursing and as a contribution to the empirical
testing of a nursing practice theory. The next step in the test of this theory should be to
repeat the same design with a healthy population and an appropriate stressor in order to
validate the results of this study. Only then should testing of other propositions in this
theory be pursued.
157
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American Medical Association, 245, 703.
179
APPENDIX A
Physiology of Stress
When the maintenance of homeostasis is threaten by internal or external factors,
numerous biochemical and structural changes take place. Many of the changes are
known and identified under the expression "General Adaptation Syndrome." The factors
capable of stimulating such a response are called stressors and the condition they produce
is called stress. The generalized responses elicited by the stressors include increased
activity of the nervous and endocrine systems. Following a careful review of stress
research, Mason (1968) concluded that the secretion of several hormones were affected
during stress and that particular patterns varied with the kind of stress experienced.
These hormones were: catecholamines, glucocorticoids, aldosterone, growth hormone,
insulin, thyroxin and various gonadal steroids including testosterone and oestradiol. He
also acknowledged that regardless of the pattern in evidence, stress was always
associated with the activation of the pituitary-adrenal axis, known today as the
hypothalamus-pituitary-adrenal axis (HPA), and the sympathetic nervous system. These
two principal pathways of the stress response will be described using as a base two
physiology textbooks Human anatomy and physiology (Hope, 1990) and Medical
physiology (Guyton, 1991). Where appropriate, the author will describe succinctly the
anatomy and the functions of the organ or substance, followed by the process of the
stress response.
First Mediator
The link between the stressor and the hypothalamus is still unknown. The
identity of the alarm signals may be metabolic by-products released during activity or
damage, or they may be caused by the lack of some vital substance consumed whenever
any demand is made on an organ (Selye, 1983). The effect of corticotropin-releasing
factor (CRF) within the brain may be sufficient to initiate the stress response and be
designated as the first mediator (Dunn, 1989) or CRF may not be the beginning of the
chain but may be regulated by norepinephrine release (Malagelada, 1989). Redmond
(1977) hypothesized that the centre of the first alarm may be the locus ceruleus in the
brain stem, since chemical and electrical reaction of this area resulted in manifestation of
180
physical anxiety in animals.
But whatever the nature of the first mediator, Selye (1983) came to two
conclusions: first, "since the only two coordinating systems that connect all parts of the
body with one another are the nervous and the vascular systems, we can assume that the
alarm signal uses one or both of these pathways. It is probable that often, if not always,
the signals travel in the blood. Alternatively, perhaps no one substance or deficiency has
a monopoly on acting as an alarm signal; instead, perhaps a number of messengers carry
the same signal" (p. 6).
Second, "whatever the nature of the first mediator, ... its existence is assured by
its effects, which have been observed and even measured. The discharge of ACTH
(adrenocorticotrophic hormone), the involution of the lymphatic organs, the enlargement
of the adrenals, the corticoid hormone content of the blood, the feeling of fatigue, and
many other signs of stress ( are) produced by injury or activity in any part of the body"
(p. 6).
Hypothalamus
Through this first mediator, the stressor eventually excites the hypothalamus.
The hypothalamus is part of the brain stem and located in the lower wall and the floor of
the 3rd ventricle. It is composed largely of grey matter organized into nuclei (nerve
cells). Each nucleus is situated in an area or control centre of the hypothalamus and its
vegetative and endocrine control functions can be generally described as: cardiovascular
regulation; regulation of body temperature; regulation of body water; regulation of
uterine contractility and of milk ejection from the breasts; gastrointestinal and feeding
regulations; control of anterior and posterior pituitary hormones; and secretion of
releasing hormones or factors. The area of the hypothalamus that causes specific
activities are not nearly as accurate as suggested in the above listing. It is not known
whether the effects noted result from the stimulation of specific control nuclei or whether
they result merely from activation of fiber tracts leading from control nuclei located
elsewhere.
Nevertheless, the hypothalamus plays a central role in the "General Adaptation
Syndrome." It is a bridge between the brain and the endocrine system interconnected by
181
nerve fibers to the cerebral cortex, thalamus and to other parts of the brain stem. Its key
role is to maintain homeostasis by serving as a link for the nervous and endocrine system
and by regulating the visceral activities. Its role of transmission as part of the autonomic
nervous system and of production of secretion for the posterior lobe of the pituitary
gland, will be discussed later under the heading "nervous system." But its role in the
production and secretion of releasing or inhibiting hormones or factors will be further
developed here.
The hypothalamus receives and transmits impulses. The resulting nervous signals
reach certain neuron cell bodies that are located in some of the control centres of the
hypothalamus, such as the paraventricular nucleus (PVN), the arcuate nucleus and part of
the ventromedial nucleus. The axons from these nuclei project to the median eminence
(ME) which is an enlarged area of the infundibulum of the hypothalamus. It is there that
the nerve terminals actually secrete releasing hormones or factor s. The hypothalamus
secretes seven substances in total, of which one is of special interest in the stress
response: corticotropin-releasing hormone (CRH). These secretions are released in high
concentrations in the hypophyseal portal vein. The target of these releasing hormones is
the anterior pituitary gland.
Corticotropin-Releasing Hormone (CRH)
The critical event in stress is considered to be the stimulation of hypothalamic
CRH. CRH has been well-documented to elicit changes in neuroendocrine activity since
it was first demonstrated (Vale, Spiess, Rivier, & Rivier, 1981). In recent years, the
Hypothalamus-Pituitary-Adrenal (HPA) axis has been described as the neuroendocrine
pathway of stress. Other factors may participate with CRH in the activation of the HPA
s"a substance that has the actions of a hormone but has not been purified and identified as a
distinct chemical compound is called a factor. Once it has been so identified, it is thereafter
known as a hormone" (Guyton, 1991, p. 821).
sThe major hypothalamic releasing or inhibiting hormones (or factors) are the following: 1.
Thyrotropin releasing hormone (TRH). 2. Corticotropin-releasing hormone (CRH). 3. Growth
hormone releasing hormone (GHRH). 4. Growth hormone inhibitory hormone (GHIH). 5.
Gonadotropin-releasing hormone (GnRH). 6. Prolactin inhibitory factor (PIF). 7. Prolactin-
releasing factor (PRF) (Guyton, 1991 ; Hope, 1990).
182
axis such as vasopressin in the release of adrenocorticotropic hormone (ACTH) or β
endorphin in the decrease of luteinizing hormone (LH) (Rivier, 1989).
It is also believed that CRH elicits autonomic and behavioural activity similar to
those observed in stress but dissociated from the activation of the HPA axis (Irwin,
Hauger, Jones, Provencio, & Britton, 1990). There is evidence that CRH may play a
neurotransmitter-like role and studies involving CRH administered into the brain show it
to be an extraordinary potent activator of stress response (Dunn, 1989).
While there are complex regulatory mechanisms that are not yet well known, the
importance of CRH as a key hormone in the stress response, and as an important
modulating factor in specific stress response, is unchallenged (Dunn, 1989).
Dunn (1989) reviewed and summarized the state of research on the effect of CRH
and concluded that studies "suggest that CRF administration can reproduce many of the
well characterized endocrine, physiological, neurochemical and behavioral responses in
stress" (p. 19). To the point that he recommended a new definition of stress or a stressful
event as one that provokes the secretion of the chemical messenger corticotrophic-
releasing factor and "that experimental manipulation that does not result in CRF secretion
should not be regarded as stressful" (p. 19).
In summary, when the body is exposed to stressors, the General Adaptation

Syndrome includes the mobilization of the first mediator, the hypothalamus and the
secretion of CRF (See Figure A1.)
Endocrine System
The endocrine pathway is a slower, long-lasting type of stress response compared
to the autonomic nervous system, but it reflects the nature of endocrine activities.
Anterior Pituitary Gland
The pituitary gland lies in the sella turcica at the base of the brain and is attached
to the hypothalamus by the pituitary stalk or the infundibulum. The anterior portions of
the gland secretes hormones that are controlled by releasing hormones or factors.
183
Figure A1. Stress central pathway.

184
As mentioned earlier, CRH is transmitted by blood in the vessels of a capillary
net which merge to form the portal veins that pass downward along the pituitary stalk
and give rise to a capillary net in the anterior lobe. The anterior lobe of the pituitary
gland is enclosed in a dense capsule of collagenous connective tissue, and consists largely
of epithelium tissue arranged in blocks around many thin-walled blood vessels. Within
the epithelial tissue, there are five types of secretory cells which have been identified that
produce six important hormones and several less important hormones. One type of
secretory cell that is of particular importance to this paper, is the corticotrope cell that
secretes adrenocorticotropic hormone (ACTH).
The neurons of the anterior pituitary gland also secrete neuropeptides. One of
them is β-endorphin which is thought to play an important role in relieving pain
sensations but also seems to be associated with the secretion of ACTH.
Adrenocorticotropic Hormone (ACTH)
The presence of stressors activate the release of CRH which in turn, excites the
anterior pituitary causing a discharge of ACTH into the general circulation. As
mentioned above, CRH represents the major physiological modulator of ACTH but
vasopressin which is also produced by the hypothalamus but released in the posterior
pituitary, is an additional modulating factor (Rivier, 1989). The target of this hormone is
the adrenal gland, more specifically, the adrenal cortex. The principal effect of ACTH is
on adrenocortical cells and its action, is to control the secretion of certain hormones
which are released during the stress response.
β-Endorphin
"Recent reports indicate that β-endorphin is secreted in response to stress
(Guillemin, Vargo, Rossier, Minick, Ling, Rivier, Vale, & Bloom, 1977; Rossier,
French, Rivier, Ling, Guillemin, & Bloom, 1977). More interestingly, it has been shown
that β-endorphin and (...) ACTH, are secreted concomitantly, in almost equimolecular
amounts, as a result of the elicitation of the stress response (Guillemin, Vargo, Rossier,
s"They are somatotropes that secrete GH (growth hormone), mammatropes that secrete PRL
(prolactin), thyrotropes that secrete TSH (thyroid-stimulating hormone), corticotropes that
secrete ACTH (adrenocorticotropic hormone), and gonadotropes that secrete FSH (follicle-
stimulating hormone) and LH (luteinizing hormone)" (Hope, 1990, p. 482).
185
Minick, Ling, Rivier, Vale, & Bloom, 1977).(...) Amir, Brown, and Amit (1979) also
present evidence that the endorphins may play a role in stress, and may be linked to the
secretion of ACTH" (Asterita, 1985, p. 156).
Adrenal Cortex
The adrenal glands are composed of two distinct parts: the adrenal medulla
(which will be discussed under the heading of the nervous system) and the adrenal
cortex. The adrenal cortex is the outer portion of the gland and makes up the bulk of the
adrenal gland. It is composed of closely-packed masses of epithelial cells arranged in
layers. The cells are well supplied with blood vessels and these layers under the
stimulation of ACTH, secrete different groups of hormones called corticoids. The outer
and very thin layer of cells called the zona glomerulosa, secretes aldosterone a
mineralocorticoids, the middle layer, the zona fasciculata and the deep layer, the zona
reticularis, secrete glucocorticoids and androgens.
Corticoids
There are two major types of adrenocortical hormones, the mineralocorticoids
and the glucocorticoids and in addition to these, a small amount of androgenic hormones
that resemble male and female sex hormones. The mineralocorticoids, such as,
aldosterone which account for nearly 90 per cent of mineralocorticoid activity, specially
affects the electrolytes of the extracelluar fluids in particular, the conservation of the
sodium ions and the excretion of the potassium ions. The glucocorticoids, such as
cortisol, which account for 95 per cent of all glucocorticoid activity, exhibit an important
effect in increasing blood glucose concentration and have an additional effect on both
protein and fat metabolism, such as, the inhibition of the protein synthesis and the
promotion of fatty acid release.
ACTH controls almost entirely, the secretion of corticoids and under stress, these
secretions are greatly enhanced by as much as 20 times. "Many investigators have
suggested that the glucocorticoids are particularly important to a person's ability to
combat...stress. Since a major response to overwhelming stress is vasodilation and
circulatory failure, it has been proposed that the glucocorticoids combat stress by
permitting norepinephrine to induce vasoconstriction while at the same time preventing
186
an excessive vasoconstriction that can lead to tissue ischemia ... by acting directly on
vascular smooth muscle and stimulating the heart muscle. It has also been suggested that
the metabolic effects of the glucocorticoids ... are particularly important in mobilizing
the body's resources to resist ... stress" (Mason, 1983, p. 371).
The corticoids also facilitate various other enzyme responses and suppress
immune reactions as well as inflammation, thereby helping the body to
coexist with pathogens. Usually secreted in lesser amounts, are the pro-
inflammatory corticoids, which stimulate the proliferative ability and
reactivity of the connective tissue, enhancing the `inflammatory potential.'
Thus, they help to build a strong barricade of connective tissue through
which the body is protected against further invasion. (Selye, 1983, p. 8)
Cortisol and aldosterone are transported in the blood. Cortisol combines with
globulin and to a lesser extent, with albumin and the rest, about six per cent, are
transported in a free form. In comparison, aldosterone combines only loosely with the
plasma proteins so that about 50 per cent is in a free form. The hormones are transported
throughout the extracelluar fluid compartment. In general, the hormones become fixed
in the target tissues within an hour or two for cortisol and within about 30 minutes for
aldosterone.
Biofeedback Loop
This chain of events is cybernetically controlled by several biofeedback
mechanisms. For instance, if there is a surplus of ACTH, a short-loop feed-back returns
some of it to the hypothalamus-pituitary axis, and this axis shuts off further ACTH
production. In addition, through a long-loop feed-back, a high blood level of corticoids
similarly inhibits too much ACTH secretion.

Syndrome includes the mobilization of the endocrine system as per Figure A2.
187
Figure A2. Endocrine system pathway.

188
Nervous System
Within the nervous system the HPA axis also plays an important role in stress.
But there is another pathway of the stress response which is immediate and independent
from the (HPA) axis. It is the autonomic nervous system. The following reviews the
elements of the nervous system and its known involvement in the General Adaptation
Syndrome.
Central Nervous System (CNS)
To this point, the only part of the CNS that has been mentioned is the
hypothalamus as a link between the nervous and endocrine systems. As with the
endocrine system, the hypothalamus plays a central role in the nervous pathway of stress
response. Signals from the hypothalamus and even from the cerebrum, can affect the
activities of almost all the lower brain stem autonomic control centres. For instance,
stimulation in appropriate areas of the hypothalamus can activate the medullary
cardiovascular control centres strongly enough to increase the arterial pressure to more
than double the normal amount.
The other areas of the CNS that plays multiple roles in relation to the excitement
of the autonomic nervous system are: the limbic system; the midbrain; the pons; the
medulla oblongata; and the reticular formation.
The hypothalamus is the most important of the motor output pathways of the
integrating nervous complex called the limbic system. It is comprised of portions of the
cerebral cortex in the medial parts of the frontal and temporal lobes that are
interconnected with the hypothalamus, thalamus, basal ganglia, and other deep nuclei.
The limbic system is involved in emotional experience and expression and can modify
the way a person acts. More specifically, it seems to recognize upsets in a person's
physical and psychological condition that might threaten their survival. Stress will cause
increased activities of the limbic system especially, in the region of the amygdala and
hippocampus both of which will transmit signals to the posterior medial hypothalamus.
The midbrain joins the lower part of the brain stem and spinal cord with higher
parts of the brain with nerve fibers. It acts as the reflex centre for certain visual reflexes,
auditory reflex and reflexes concerned with maintaining posture.
189
The pons relays impulses to and from the medulla oblongata and the cerebellum,
to the cerebrum and from the peripheral nervous system, to the higher brain. Within the
medulla oblongata, it regulates the rate and depth of breathing.
The medulla oblongata is an enlarged continuation of the spinal cord and all the
ascending and descending nerve fibers connecting to the brain and the spinal cord pass
through it. Other nuclei function as control centres for the cardiac, vasomotor and
respiratory system and also for some non-vital reflexes, such as coughing, sneezing,
swallowing and vomiting.
The other integrating complex that plays a role in the stress response, is the
reticular formation of nerve fibers that interconnect centres of the hypothalamus, basal
ganglia, cerebellum, and cerebrum with fibers in all the major ascending and descending
tracts. The reticular formation seems to act as a filter for incoming sensory impulses to
free the cortex of continual bombardment of sensory stimulation.
To some extent, the autonomic centres in the lower brain stem act as a relay
station for control activities initiated at higher levels of the brain. And the higher area of
the brain can alter the function of the whole autonomic nervous system or portions of it,
strongly enough to cause severe autonomic-induced disease, such as peptic ulcers,
constipation, heart palpitation and even heart attacks.
Posterior Pituitary
Embryologically, the posterior pituitary is an outgrowth of the hypothalamus.
The cell bodies of the cells that secrete the posterior pituitary hormones are not located in
the posterior pituitary gland itself but instead, are located in the supraoptic and
paraventricular nuclei of the hypothalamus; the hormones are then transported to the
posterior pituitary glands in the axoplasm of the neuron's fibers passing from the
hypothalamus through the pituitary stalk to the posterior pituitary gland.
The posterior pituitary is formed from neural tissue that acts as a supporting
structure for large numbers of terminal nerve fibers and terminal nerve endings from
nerve tracts that originate in the hypothalamus. The nerve endings are bulbous knobs
containing many secretory granules that lie on the surface of capillaries onto which, they
secrete two hormones. Secretion is controlled by the nerve signals from the
190
hypothalamus. The two hormones released in the blood by the posterior of the pituitary
are the antidiuretic hormone (ADH) and oxytocin (OT).
ADH produces its antidiuretic effect by acting on the kidneys and causing them to
reduce the amount of water they excrete. In this way, ADH is important in regulating the
water and sodium concentration in the body fluids. When ADH is present in high
concentration, such as during the stress response, it causes contractions of certain of
certain smooth muscles including those in the walls of some blood vessels. As a result,
the blood pressure in these vessels increases. For this reason, it is also called
vasopressin. The OT also has an antidiuretic action but weaker when compared to ADH.
In addition, it has other functions that are not specifically of interest for this paper.
Peripheral Nervous System (PNS)
The PNS consists of the nerves that branch out from the CNS and connect it to
the other body parts. It is composed of the somatic system which connects the central
nervous system (CNS) with the skin and the skeletal system which is involved with
conscious activities. But it is the autonomic system that is most interesting in relation to
the stress response.
Autonomic Nervous System
As mentioned above, the autonomic nervous system is activated mainly by
centres located in the spinal cord, brain stem and hypothalamus. The autonomic system
includes those fibers that connect the CNS with visceral organs such as the heart,
stomach, intestines and various glands. Thus, the autonomic nervous system is concerned
with unconscious activities. This system is composed entirely of all efferent or motor
fibers. It operates by means of visceral reflexes and helps control arterial pressure,
gastrointestinal motility and secretion, urinary bladder emptying, sweating, body
temperature and many other activities. Some of the activities are controlled almost
entirely and some only partially controlled by the autonomic nervous system. One of
the most striking characteristics of the autonomic nervous system is the rapidity and
intensity with which it can change visceral functions. The efferent autonomic signals are
transmitted to the body through two major subdivisions: the sympathetic division which
is concerned primarily with preparing the body for energy-expending, stressful, or
191
emergency situations and conversely, the parasympathetic division which is most active
under ordinary restful conditions. It counterbalances the effects of the sympathetic
division and restores the body to a resting state following a stressful experience.
"In contrast to somatic efferent pathways, in which a single neuron extends from
the central nervous system to the structure innervated, the autonomic pathways that
extend from the central nervous system to the effectors are composed of two neurons.
One of these neurons, called a preganglionic (presynaptic) neuron, has its cell body
located within the central nervous system. The axon of a preganglionic neuron travels to
a ganglion located outside the central nervous system, where it synapses with a second
neuron, called postganglionic (postsynaptic) neuron. The axons of postganglionic
neurons travel to the various effectors" (Mason, 1983, p. 173).
Sympathetic Nervous System
The cell bodies of the preganglionic neurons of the sympathetic division of the
autonomic nervous system are located within the intermediolateral horn of the spinal
cord. The ganglion of the sympathetic division are generally located close to the spinal
cord or halfway between the spinal cord and the innervated organ. The sympathetic
preganglionic fibers release a chemical transmitter acetylcholine and these fibers are
called cholinergic fibers. In contrast, most of the postganglionic fibers secrete
norepinephrine and are called adrenergic fibers. When the sympathetic nervous system is
activated by stress, the neural impulses are transmitted by the release of neurotransmitters
acetylcholine and norepinephrine to the effectors. In general, the effect of this
stimulation is that most of the endodermal structures are inhibited. The other metabolic
effects are summarize below.
When large portions of the sympathetic nervous system discharge at the same
time, i.e. a mass discharge, this increases in many different ways, the ability of the body
to perform vigorous muscle activity. In summary, these ways include: 1. increased
arterial pressure. 2. Increased blood flow to active muscles concurrent with decreased
blood flow to organs such as the gastrointestinal tract and the kidneys that are not needed
for rapid motor activity. 3. Increased rates of cellular metabolism throughout the body.
4. Increased blood glucose concentration. 5. Increased glycolysis in the liver and in
192
muscle. 6. Increased muscle strength. 7. Increased mental activity. 8. Increased rate of
blood coagulation.
The sum of these effects permits the person to perform far more strenuous
physical activity than would otherwise be possible. Because it is mental or physical
stress that usually excites the sympathetic system, it is frequently said that the purpose of
the sympathetic system is to provide extra activation of the body in states of stress: this is
often called the sympathetic stress response" (Guyton, 1991, p. 676).
Adrenal Medulla
The adrenal medulla is the central portion of the gland and represent a distinct
gland which secretes different hormones. It consists of irregular shaped cells that are
arranged in groups around blood vessels. These cells are connected with the sympathetic
division of the autonomic nervous system. In fact, these medullary cells possess similar
physiological and biochemical properties to those of the sympathetic nervous system and
are modified postganglionic neurons. The preganglionic autonomic nerve fibres lead to
the adrenal medullae without synapsing. There they end directly on modified neuronal
cells. The cells of the adrenal medulla produce, store and secrete into the blood stream,
two closely related hormones, epinephrine (adrenalin) and norepinephrine
(noradrenaline). These secretory cells embryologically are derived from nervous tissue
and are analogous to postganglionic neurons; indeed, they even have rudimentary nerve
fibers, and it is these fibers that secrete the hormones. Both these substances are amines
(catecholamines) and they have similar molecular structures and physiological functions.
In fact, epinephrine is produced from norepinephrine. These hormones are stored in tiny
vesicles much like the neurotransmitters are stored in neurons.
Stimulation of the sympathetic nerves to the adrenal medulla causes large
quantities of epinephrine (80 per cent) and norepinephrine (20 per cent) to be released
into the circulating blood and these two hormones in turn, are carried by the blood to all
tissues of the body. The circulating epinephrine and norepinephrine have almost the
same effects on the different organs as those caused by direct sympathetic stimulation as
described above, except that the epinephrine intensifies these response and prolongs their
effects by 5 to 10 times, because these hormones are slowly removed from the blood.
193
Syndrome includes the mobilization of the autonomic nervous system as per Figure A3.
194
Figure A3. Nervous system pathway.

195
References
Amir, S., Brown, Z. W., & Amit, Z. (1979). The role of endorphin in stress: evidence
and speculations. Neuroscience & Biobehavioral Reviews, 4, 77.
Asterita, M. F. (1985). The physiology of stress. New York: Human Sciences Press, Inc.
Dunn, A. J. (1989). CRF as mediator of stress responses neurochemical and behavioral

aspects. In L. Bueno, S. Collins & J. -L. Junien (Eds.), Stress and digestive
motility. London: John Libbey Company Ltd, 13-22.
Guillemin, R., Vargo, T. M., Rossier, J., Minick, S., Ling, N., Rivier, C., Vale, W., &
Bloom, F. (1977). B-endorphin and adrenocortico-tropin are secreted
concomitantly by the pituitary gland. New England Journal of Medicine, 197,
1367.
Guyton, A. C. (1991). Textbook of medical physiology (8th ed.). Philadelphia, PA: W.

B. Saunders Company, 8th edition.
Hope, J. W. (1990). Human anatomy and physiology (5th ed.). Dubuque, IA: Wm.C.
Brown Publishers.
Irwin, M., Hauger, R. L., Jones, L., Provencio, M., & Britton, K. T. (1990). Sympathetic
nervous system mediates central Corticotropin-Releasing Factor induced
suppression of natural killer cytotoxicity. The Journal of Pharmacology and
Experimental Therapeutics, 255(1), 101-107.
Malagelada, J. (1989). Concluding remarks. In L. Bueno, S. Collins & J. -L. Junien

(Eds.), Stress and digestive motility. London: John Libbey Company, 257-258.
Mason, E. B. (1983). Human physiology. Menlo Park, CA: The Benjamin/Cummings

Publishing Company.
Mason, J. W. (1968). A review of psychoendocrine research on the pituitary

adrenocortical system. Psychosomatic Medicine, 30, 576-607.
Redmond D. F. Jr. (1977). Alteration in the function of the nucleus locus ceruleus: A
possible model for studies of anxiety. In I. Hanin & E. Usden (Eds.), Animal
models in psychiatry and neurology. Oxford: Pergamon Press, 293-304.
Rivier, C. (1989). Stress: definition and neuroendocrine evaluation. In L. Bueno, S.

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Collins & J.-L. Junien (Eds.), Stress and digestive motility. London: John Libbey
Company.
Rossier, J., French, E., Rivier, C., Ling, N., Guillemin, R., & Bloom, F. E. (1977). Foot
shock induced stress increases β-endorphin levels in blood but not in brain.
Nature, 270, 618.
Selye, H. (1983). The Stress Concept: Past, Present, and Future. In C. L. Cooper (Ed.),
Stress Research - Issues for the Eighties. New York: John Wiley & Sons.
Vale, W., Spiess, J., Rivier, C., & Rivier, J. (1981). Characterization of a 41- residue
ovine hypothalamic peptide that stimulates secretion corticotropin and β-
endorphin. Science, 213, 1394-1397.
197
APPENDIX B
Characteristics of the Nurse Population
Nursing Nursing
Nurse Age Education Experience
1p 46 Diploma 4
2*p 43 Diploma 6.5
3*p 26 Baccalaureate 4.5
4 36 Diploma 9
5p 56 Diploma 20
6*p 26 Diploma 6
7 34 Diploma 13
8 32 Baccalaureate 10
9p 42 Diploma 5
10p 27 Diploma 6
11*p 39 Diploma 5
12p 31 Diploma 6
16 55 Diploma 33
17 30 Diploma 5
Note. p = participated in the study or pilot test; * = "X" nurse; nursing experience in
years.
198
199
APPENDIX C
Nurse Data Sheet
Nurse ID Code
Age (in years)
Gender 1. Female 2. Male Ethnic/Racial
Identity
1. Caucasian European
2. Caucasian Canadian
3. Caucasian American
4. Caucasian other
First Language
1. English
2. French
3. Other
Nursing Education (highest degree)
1. Nursing diploma
2. Certificate
3. B.Sc.N. or B.N.
4. M.Sc.N. or M.N.
5. D.N.Sc. or Ph.D.
6. Other
Experience in nursing (in years)
MBTI results
200
APPENDIX D
Page 1 of 3
NURSE-CLIENT INTERACTION AND ITS EFFECT ON CLIENTS.
(A study of ways nurses and patients interact with each other).
CONSENT FORM
(for participating nurses).
This Consent Form, a copy of which has been given to you, is only a part of the process
of informed consent. It should give you the basic idea of what the research project is
about and what your participation will involve. If you would like more detail about
something mentioned here, or information not included here, you should feel free to ask.
Please take the time to read this carefully and to understand any accompanying
information.
PURPOSE: to observe the effect of nurse-client interactions on the client.
PROCEDURE: This will be done by videotaping clients and nurses who interact with
each other and by taking physiological and psychological measures of the client's
reactions during certain care episodes. For the videotaping, verbal and nonverbal
behaviours will be recorded by two cameras. The video recording will be taken from the
camera that provides the best view of each interaction. The videotaping will continue for
two days (50 continual hours). The cameras and the microphone will be fixed to the wall
of the patient's room so they will not interfere with nursing care activities. The
videotaping will be monitored by a researcher in a near-by room. Researchers will not
(or will also) be in the patient's room. Panning and zooming of the cameras may make
close-ups of the interactions.
To monitor the client's reaction, electrodes will be placed on the forehead, the
arm and the hand of the client and recording equipment will (may) be at the head of the
bed behind a divider. These electrodes will be removed when recording is not necessary.
You will also be asked to complete a Myers Briggs Type Indicator questionnaire.
You will be asked to take eight additional blood pressures readings on the patient. The
amount of time you may spend in your participation should not exceed one hour. This is
in addition to the videotaping of your interaction with the client.
PARTICIPATION: Whether you join this study is entirely up to you. Participation in this
study may be of no personal benefit to you. However, based on the results of this study,
it is hoped that, in the long-term, patient care can be improved. There will be no harm
Participant initials Date

201
Page 2 of 3
to you if you participate in this study. The study will include some loss of privacy
through the use of videotaping. You do not have to be in this study if you do not wish to
do so. You may drop out at any time by telling the researcher. You may request that the
researcher stop videotaping if you change your mind or the situation is such that you
would prefer the videotaping be stopped. These requests may be made directly to the
researcher monitoring the videotaping or indirectly through the cameras. Taking part in
this study or dropping out will not affect your work at the hospital. If any information
from the study becomes available that could influence your decision to continue in this
study, you will be promptly informed.
During the project, only the researcher, her assistants and the researcher's
supervisory committee will view the videotapes. All videotapes will be stored and
viewed in the researcher's office. Although you may be recognized on the film, your
name will not be used. Instead of a name, only a code number will appear on any forms
or question sheets. The researcher will erase your name and any other identifying
material from the notes and the tapes. All tapes and notes will be kept in a locked
cabinet separate from consent forms or the code list and will be retained for at least seven
years after the completion of the study. Consent forms will be kept for five years. All
material or data may be used for another study in the future without obtaining further
consent from you. However, each study arising as a result of information obtained in this
study will be submitted for ethics approval.
The videotapes will be the property of Ginette Lemire Rodger. By consenting to
take part in the project any rights to these videotapes are waived. The information and
findings of this study may be published, presented at conferences, or for educational
purposes, but your name or any material that may identify you will not be used.
UNDERSTANDING OF PARTICIPANTS
My signature on this form indicates that I have understood to my satisfaction the

information regarding my participation in the research project and agree to participate as
a subject. In no way does this waive my legal rights nor release the investigators,
sponsors, or involved institutions from their legal and professional responsibilities.
I am free to withdraw for the study at any time without jeopardizing my employment.
My continued participation will be as informed as my initial consent, so I am free to ask
for clarification or new information throughout my participation.
I understand that the following persons at their respective telephone numbers or 492-
202
8771 (CCI switchboard) will answer any questions that I have about the research project:
Investigator: Supervisor:
Ginette Lemire Rodger, Ph.D. Candidate Dr. Pamela Brink
Faculty of Nursing, CSB, Room 5-122 Faculty of Nursing,
University of Alberta, Edmonton University of Alberta
Tel: (403) 492-6836 (U of A) Tel: (403) 492-2097 (U of A)
(403) 433-5928 (Residence)
If at any time during the course of this study I feel that I have been inadequately
informed of the risks, benefits, or alternatives, or that I have been encouraged to continue
in this study beyond my wish to do so, I can contact the Chairman of the Research Ethics
Committee at (403) 482-9366.
A copy of this consent form will be given to me to keep for my records and future
reference.
________________________________ ____________________________
(Name of Subject) (Signature of Subject)
_______________________________ ____________________________
(Name of Witness) (Signature of Witness)
_______________________________ ____________________________
(Name of Investigator) (Signature of Investigator)
________________________________
(Date)
---------------------------------------------------------------------------------------
REQUEST FOR SUMMARY OR RESULTS OF THE MBTI:
If you wish to receive a summary of the study when it is finished or the result of the
MBTI questionnaire, please complete the following section:
Summary of study:
Results of MBTI:
Name:
Address:
203
APPENDIX E
Page 1 of 3
CONSENT FORM
(for adult patients).
information.
PURPOSE: to observe the effect of nurse-patient interactions on the patient.
PROCEDURE: This will be done by videotaping patients and those they interact with in
hospital. The videotaping will use a system like the surveillance cameras used in stores
and other public places for security purposes. Two cameras record voices and actions.
One camera will focus on the upper part of the patient's body. The other camera will
record the actions between the patient and the nurse. Panning and zooming of the
cameras may make close-ups of the events.
Your physician has given permission for you to participate in this study, however
it is up to you to decide. If you agree to take part in this study, the videotaping will
continue for two days (50 continual hours). Cameras are on a wall in your room. They
do not interfere with your care or ability of the patient to move about. A researcher in a
near-by room will watch the videotaping. Researchers will not (may) be in the patient's
room.
During the project, the researcher will ask you at certain times to provide
information. The information is about feeling tense or relaxed. You also will answer a
short questionnaire which will take ten minutes or less.
At certain times of the day, electrodes will record your reactions to the care
provided. Electrodes are installed on your forehead, arm and hand. These electrodes
do not hurt. They are like the ones used for other tests you have had before, such as
ECG. Blood pressure will also be taken at certain times during the day.
Within the days following the completion of the study the researcher will ask you

204
Page 2 of 3
to complete another questionnaire. The results will help identify types of individual
preferences. The purpose is to compare your type with the preferences of the nurses who
have cared for you. The total amount of time you may spend to complete the
questionnaires should not be more than one and half hours. The time required for
additional blood pressure readings and preparation should not exceed 30 to 40 minutes
per day.
PARTICIPATION: Whether you join this study is entirely up to you. Participation in this
study may be of no personal benefit to you. However, based on the results of this study,
it is hoped that, in the long-term, patient care can be improved. There will be no harm to
you if you participate in this study. The study will include some loss of privacy through
the use of videotaping. You will experience some inconvenience in movement with the
use of electrodes.
You do not have to be in this study if you do not wish to do so. You may drop
out whenever you wish by telling the researcher. The patient or his or her family may
request that the researcher stop the videotaping. Anyone can change their mind. You
can make a direct request to the researcher monitoring videotaping or indirectly through
the cameras. Taking part in this study or dropping out will not affect your regular
nursing care. Your physician has consented that you be approached for participation in
the study. If any information from the study becomes available that could influence your
decision to continue in this study, you will be promptly informed.
During the project, only the researcher, her research assistants, and the
researcher`s supervisory committee will view the videotapes. The researcher will store
all videotapes and view them in her office. Although it is possible to recognize you on
film, we will not use your name or other identifying information.
The researcher will erase your name and any other identifying material from the
notes and the tapes. All tapes and notes are kept in a locked cabinet separate from
consent forms or the code list. They are retained for at least seven years after the
completion of the study. Consent forms are kept for five years. The researcher may use
all material or data for another study in the future without obtaining further consent from
you. However, each study arising as a result of information obtained in this study will be
submitted for ethics approval.
take part in the project you waive all rights to the videotapes. The information and
findings of this study may be published or presented at conferences or use for educational
purposes. Your name or any material that may identify you will not be used.

205

I am free to withdraw for the study at any time without jeopardizing my health care. My
continued participation will be as informed as my initial consent, so I am free to ask for
clarification or new information throughout my participation.
8771 (CCI switchboard) will answer any questions that I have about the research project:
Tel: (403) 492-6836 (U of A) Tel: (403) 492-2097 (U of A)
(403) 433-5928 (Residence)
in this study beyond my wish to do so, I can contact the Patient Advocate at (403) 482-
8585.
reference.
________________________________ ____________________________
(Name of Patient) (Signature of Patient)
_______________________________ ____________________________
_______________________________ ____________________________
________________________________
(Date)
206
----------------------------------------------------------------------------------------------------
REQUEST FOR SUMMARY OR RESULTS OF THE MBTI:
If you wish to receive a summary of the study when it is finished or the result of the
MBTI questionnaire, please complete the following section:
Summary of study:
Results of MBTI:
Name:
Address:
207
APPENDIX F
Page 1 of 3
CONSENT FORM
(for visitors and staff).
information.
PURPOSE: to observe the effect of nurse-patient interactions on the patient.
PROCEDURE: This will be done by videotaping patients and those they interact with in
hospital. The videotaping will use a system like the surveillance cameras used in stores
and other public places for security purposes. Two cameras record voices and actions.
One camera will focus on the upper part of the patient's body. The other camera will
record the actions between the patient and the nurse.
When a patient agrees to take part in this study, the videotaping will continue for
two days (50 continual hours). Cameras are on a wall in the patient's room. They do not
affect the care or the ability of the patient to move about.
During the project, the researcher will ask patients at certain times to provide
information. The information is about feeling tense or relaxed. Also at certain times of
the day, electrodes will record the reactions of the patient to the care provided. The
electrodes are on the patient's forehead, arm and hand. These electrodes do not hurt.
PARTICIPATION: You will not benefit directly from this study. The study will include
some loss of privacy with the use of videotaping. Results from the study may be helpful
to nurses in improving nursing care.

208
Page 2 of 3
You do not have to be in this study if you do not wish to do so. You may drop
out whenever you wish by telling the researcher. The patient, the visitors or staff may
request that the researcher end the videotaping. You can make a direct request to the
researcher watching the videotaping or indirectly through the cameras. Taking part in
this study or dropping out will not affect you in any way.
During the project, only the researcher, her research assistants, and the
researcher`s committee will view the videotapes. The researcher will store all tapes and
view them in her office. Although it is possible to recognize you on film, we will not use
your name or identifying information.
The researcher will erase your name and any other identifying material from the
notes and the tapes. She will keep all tapes and notes in a locked cabinet separate from
consent forms or the code list. The conservation period is for at least seven years after
the completion of the study. She also will keep consent forms for five years. All
material or data may be used for another study in the future without obtaining further
consent from you. However, each study arising as a result of information obtained in this
study will be submitted for ethics approval.
take part in the project any rights to these videotapes are waived. The information and
findings of this study may be published, presented at conferences, or for educational
purposes. Your name or any material that may identify you will not be used.

I am free to withdraw for the study at any time without jeopardizing myself in any way.
My continued participation will be as informed as my initial consent, so I am free to ask
for clarification or new information throughout my participation.
8771 (CCI switchboard) will answer any

209
questions that I have about the research project:
Tel: (403) 492-6836 (U of A) Tel: (403) 492-2097 (U of A)
(403) 433-5928 (Residence)
in this study beyond my wish to do so, I can contact the Chairman of the Research Ethics
Committee at (403) 482-9366.
reference.
________________________________ ____________________________
(Name of Subject) (Signature of Subject)
_______________________________ ____________________________
_______________________________ ____________________________
________________________________
(Date)
210
APPENDIX G
Client Data Sheet
Client ID Code Age (in years)

Gender 1. Female 2. Male Ethnic/Racial
Identity
1. Caucasian European
2. Caucasian Canadian
3. Caucasian American
4. Caucasian other
First Language
1. English
2. French
3. Other
Education (highest degree)

1. High School
2. Certificate or Diploma
2. Baccalaureate
3. Master Degree
4. Doctorate
5. Other
Medical diagnosis
Other diagnosed disease(s)
Medications
Last menstruation
211
(date of first day)
Regularity of menstruation
1. yes
2. no
Tobacco use
1. yes
2. no
Coffee intake (5 cups or more/day)
1. yes
2. no
Body temperature
1st day
2nd day
MBTI results
212
APPENDIX H
Dinamap Readings
Client ID code:
DATES:
Phases Systolic Diastolic M.A.P. Pulse
1B
2B
1C
2C
3B
4B
3C
4C
213
Note: 1. Three consecutive readings after installation of electrodes at Phase A.
2. Two readings taken by nurse at the beginning and end of each encounter.
214
APPENDIX I
Nonverbal Behaviour Worksheeta
Client ID code: Time begun:

Observer: Time ended:
CATEGORY NUMBERS OF TOTAL REACTION

TIMES
FACIAL EXPRESSIONS
Smiles or laughs
Relaxes muscles
Nods head up and down "Yes" Positive
Yawns or sighs "inattentive"
Frowns "displeasure"
Moves head side to side "No"
Moans or groans "discomfort" Negative
BODY MOVEMENTS
Touches nurse
Turns toward nurse Positive
Turns away from nurse
Nervous body movements Negative
EYE CONTACT
Looks at nurse Positive
Looks away from nurse Negative
GENERAL RESPONSE
Seems interested Positive
Seems rejecting Negative
a Modified from McCorkle Nonverbal Behavior Worksheet. Instruments for measuring nursing practice and other health variables
(p. 500) by M. J. Ward and C. A. Lindeman, 1979, Hyattsville, MD: U.S. Department of Health, Education and Welfare. No copyright.
215
Eye contact: (to be scored by investigator) yes no

Definitions
FACIAL EXPRESSIONS: any form which the face takes. The face is an affect display
system which is more informative about the nature of an emotion than the body (whether
the stimulated person appears to feel angry, afraid, sad, etc).
Smiles or laughs: a facial expression involving a brightening of the eyes and an

upward curving of the corners of the mouth with or without a sound, that may express
pleasure or amusement.
Relaxes muscles: change in facial muscles in which the client shows a

spontaneous indication of relief or demonstrates expressions of feeling better after a
period of tension.
Nods head up and down: a gesture in which the position of the head is changed
vertically to express or emphasize ideas in conjunction with verbal expression. "Includes
giving specific signs of attention to what the other is saying as he goes along, as a means
of encouraging him to say what he wishes, by nodding the head, saying, 'I see,' 'Yes,' 'M-
hmn.'"
Yawns or sighs: to take a deep breath with or without the jaws widespread, as an
involuntary reaction to fatigue or boredom. Included when behaviour "indicates to the
observer that the actor is inattentive, bored, or psychologically withdrawn from the
problem at hand, such as yawning."
Frowns: to contract the brow or a wrinkling of the brow as in displeasure or as an

indication of intolerance.
Moves head from side to side: a gesture in which the position of the head is
changed horizontally to express or emphasize ideas in conjunction with verbal
.Ekman, P., & Friesen, W. V. (1967). Head and body cries in the judgement of emotion: A
reformulation. Perceptual and Motor Skills, 24, p. 712.
.Bales, R. F. (1951). Interaction process analysis. Cambridge, MA: Addison-Wesley, p. 179.
"Bales, p. 180.
"Bales, p. 192.
.Bales, p. 195.
216
expression.
Moans or groans: to utter a low prolonged sound of grief or pain or a deep
inarticulate and involuntary sound abruptly begun and ended. Included as an indication
of distress, discomfort, fatigue or pain.
BODY MOVEMENTS: any movement or change in position or posture of the body,

except for the head. The body shows the client's adaptive efforts regarding affect, which
is more informative than the face about the intensity of an emotion.
Touches nurse: to come in contact physically with the nurse. Included as an

indication that the actor is attracted to the other.
Turns body toward nurse: changes or moves body in direction of the nurse.
Turns body away from nurse: changes or moves body away from the nurse.
Nervous body movements: rapid, repeated motions with the hands, fingers, feet,
face, shoulders, head, or body, such as tapping of the fingers or squirming.
EYE CONTACT: face-to-face contact between the client and the nurse.
Looks at nurse: focusing one's eyes in the general direction that is facing the
nurse, watching the nurse attentively.
Looks away from nurse: focusing one's eyes in another direction other than facing
the nurse.
GENERAL RESPONSE OF CLIENT: the observer's overall subjective interpretation of

the mood of the interaction.
Seems interested: to share, participate, or to become involved with the

interaction.
Seems rejecting: to be unwilling to share, participate, or to become involved with
.Bales, p. 192.
.Ekman & Friesen, p. 172.
.Bales, p. 177.
.Bales, p. 180
217
the interaction, a refusal. "Includes any behaviour in which the actor appears to be
provoked in which he shows annoyance, irritation, heat, anger, rage or has a temper
tantrum."
EYE CONTACT: direct visual contact between the nurse and client in which there is
eye-to-eye contact with each other during at least half the interaction.
N.B. do not score borderline behaviour.
"Bales, p. 195.
218
APPENDIX J
Summary: Physiology of Blood Pressure and Heart Rate
Physiological "blood pressure is the force exerted by the blood against the inner
walls of the blood vessels. Although such a force occurs throughout the vascular system,
the term blood pressure most commonly refers to systemic arterial pressure. The arterial
blood pressure rises and falls in a pattern corresponding to the phases of the cardiac
cycle. That is, when the ventricles contract (ventricular systole), their walls squeeze the
blood inside their chambers and force it into the pulmonary trunk and aorta. As a result,
the pressure in these arteries rises sharply. The maximum pressure achieved during
ventricular contraction is called the systolic pressure. When the ventricles relax
(ventricular diastole), the arterial pressure drops, and the lowest pressure that remains in
the arteries before the next ventricular contraction is termed diastolic pressure" (Hole,
1990, p. 693). The difference between the systolic and diastolic pressures is known as
the pulse pressure. The pulse pressure is needed in order to calculate the mean arterial
pressure. The mean arterial pressure represents the force that is effective throughout the
cardiac cycle for driving the blood through the tissues. "This force, called the mean
arterial pressure, is approximated by adding the diastolic pressure and one-third of the
pulse pressure (DP+1/3PP)" (Hole, 1990, p. 697). Another important measure is the
pulse. "The surge of blood entering the arterial system during a ventricular contraction
causes the elastic walls of the arteries to swell, the pressure drops almost immediately as
the contraction is completed, and the arterial walls recoil. This alternate expanding and
recoiling of an arterial wall can be felt as a pulse in an artery that runs close to the
surface... The radial artery pulse rate is equal to the rate at which the left ventricle is
contracting, and for this reason, it can be used to determine the heart rate" (Hole, 1990, p.
693, 695).
The arterial pressure is not regulated by a single pressure controlling system but
instead, by several interrelated systems each of which performs a specific function.
Guyton (1991) has described the systems in these words: "arterial pressure control begins
219
with the life saving measures of the nervous pressure controls, then continues with the
sustaining characteristics of the intermediate pressure controls, and finally, is stabilized at
the long-term pressure level by the renal-body fluid mechanism. This long-term
mechanism, in turn, has multiple interactions with the renin-angio-tensin-aldosterone
system, the nervous system, and several other factors that provide special control
capabilities for special purposes" (p. 219).
References
Guyton, A.C. (1991). Textbook of medical physiology (8th ed.). Philadelphia, PA: W.B.
Saunders.
Hope, J. W. (1990). Human anatomy and physiology (5th ed.). Dubuque, IA: Wm. C.
Brown.
220
APPENDIX K
"Z" Interaction Observation Grid
Client ID code: Time begun:

Observer: Time ended:
OBSERVATIONS CODE
Nurse looks in the direction of client as she enters the client's 1

visual field
Nurse establishes eye contact 2
Nurse touches client 3
Nurse expresses interest in the client's situation 4
Nurse expresses interest in the client's external 5
environment
Client relaxes muscles of legs or arms or face 6
Client has an open facial expression such as smile or interest 7
Client changes body posture to follow nurse's movement 8
Client cooperates with request from the nurse 9
OVERALL: the nurse-client interaction seems to be a harmonious Y or N
give and take between them
As you observe one of these behaviour for the first time (only) you sequentially note
the corresponding code.
221
APPENDIX L
Client Two Results:

Physiological and Psychological Measures
222
Figure L1. Client 2 skin temperature period averages
223
Figure L2. Client 2 electrodermal (EDG) measurements period averages
224
Figure L3. Client 2 electromyography (EMG) measurements period averages
225
Table L1
Client 2 - Blood Pressure (systolic, diastolic), Mean Arterial Pressure (MAP) and Pulse
Readings Taken at the Beginning and the End of each Interaction
Interaction Systolic Diastolic MAP Pulse
Baseline 98 59 72 64
1 Pre 98 61 72 63
1 Post 95 58 72 64
2 Pre 108 70 83 58
2 Post 100 72 71 54
3 Pre 107 64 80 57
3 Post 106 65 76 57
4 Pre 96 61 77 68
4 Post 95 60 74 72
5 Pre 90 60 71 64
5 Post 94 58 70 61
6 Pre 99 66 75 62
6 Post 94 69 83 60
7 Pre 88 57 61 64
7 Post 94 58 76 66
8 Pre 95 66 78 64
8 Post 94 58 68 66
Note. Baseline measures were taken by the investigator early in the morning before the
first interaction, three times at 10 minute intervals; pre = at the beginning of the
interaction; post = at the end of the interaction.
226
Table L2
Client 2 - Subjective Units of Disturbance (SUD) and State Anxiety Inventory (STAI)
Measures Taken Before and After each Interaction
Interaction SUD STAI
1 Pre 3 39
1 Post 1 32
2 Pre 2 36
2 Post 2 42
3 Pre 5 60
3 Post 4 45
4 Pre 6.5 59
4 Post 3 44
5 Pre 1 35
5 Post 2 33
6 Pre 4 39
6 Post 3 51
7 Pre 9 67
7 Post 4 59
8 Pre 2 35
8 Post 2 24
Note. pre = before the interaction; post = after the interaction; measurements in integral
number.
227
Table L3 Frequencies of Nonverbal Behaviours Reported by Two Observers during "Z"
and "Non-Z" Interactions
228
229
APPENDIX M
Client Three Results:

230
Figure M1. Client 3 skin temperature period averages
231
Figure M2. Client 3 electrodermal (EDG) measurements period averages
232
Figure M1. Client 3 electromyography (EMG) measurements period averages
233
Table M1
Client 3 - Blood pressure (systolic, diastolic), Mean Arterial Pressure (MAP) and Pulse
Baseline 102 63 81 98
Baseline 105 68 85 91
Baseline 106 65 82 90
1 Pre 110 64 80 97
1 Post 105 61 80 97
2 Pre 99 61 74 101
2 Post 106 61 80 98
3 Pre 98 66 77 102
3 Post 106 61 80 98
4 Pre 104 59 75 100
4 Post 103 60 73 98
Baseline 101 64 90 92
Baseline 107 66 82 93
5 Pre 103 72 83 91
5 Post 106 66 82 91
6 Pre 105 64 77 98
6 Post 105 65 78 97
7 Pre 103 63 85 101
7 Post 101 65 80 97
8 Pre 108 67 84 98
8 Post 115 65 84 98
234
Table M2
1 Pre 5 32
1 Post 3 29
2 Pre 1 25
2 Post 1 23
3 Pre 2 24
3 Post 0 20
4 Pre 5 34
4 Post 2.5 28
5 Pre 1 27
5 Post 1 28
6 Pre 5 30
6 Post 4 28
7 Pre 1 25
7 Post 1 22
8 Pre 4 26
8 Post 2 32
number.
235
Table M3 Client 3 Frequencies of Nonverbal Behaviours Reported by Two Observers
during "Z" and "Non-Z" Interactions
236
237
APPENDIX N
Client Four Results:

238
Figure N1. Client 4 skin temperature period averages

239
Figure N2. Client 4 electrodermal (EDG) measurements period averages
240
Figure N3. Client 4 electromyography (EMG) measurements period averages
241
Table N1
Baseline 104 65 77 93
1 Pre 100 63 74 91
1 Post 99 60 72 90
2 Pre 102 67 78 101
2 Post 100 66 78 96
3 Pre 112 64 86 111
3 Post 97 63 73 101
4 Pre 106 70 80 100
4 Post 104 65 82 96
Baseline 99 66 77 111
Baseline 108 63 75 98
Baseline 99 62 73 108
5 Pre 106 69 78 111
5 Post 102 60 73 102
6 Pre 110 70 85 91
6 Post 99 69 78 111
7 Pre 113 75 88 111
7 Post 110 69 83 117
8 Pre 102 63 74 102
8 Post 97 59 71 105
242
Table N2
1 Pre 7 59
1 Post 8 69
2 Pre 6 55
2 Post 6 34
3 Pre 8.5 51
3 Post 10 67
4 Pre 9 63
4 Post 8 61
5 Pre 5 67
5 Post 2 54
6 Pre 10 67
6 Post 10 65
7 Pre 10 70
7 Post 8 71
8 Pre 10 80
8 Post 8 60
number.
243
Table N3 Client 4 Frequencies of Nonverbal Behaviours Reported by Two Observers
during "Z" and "Non-Z" Interactions
244
245
APPENDIX O
Client Five Results:

246
Figure O1. Client 5 skin temperature period averages

247
Figure O2. Client 5 electrodermal (EDG) measurements period averages
248
Figure O3. Client 5 electromyography (EMG) measurements period averages
249
Table O1
Baseline 143 81 99 82
Baseline 128 78 94 89
Baseline 139 86 104 85
1 Pre 143 86 104 86
1 Post 143 81 102 81
2 Pre 139 84 102 86
2 Post 146 89 107 81
3 Pre 139 86 105 78
3 Post 154 86 107 78
4 Pre 142 88 105 78
4 Post 159 91 112 79
Baseline 158 89 111 81
Baseline 154 88 108 80
Baseline 147 86 105 83
5 Pre 138 88 104 82
5 Post 145 91 108 88
6 Pre 144 87 104 84
6 Post 148 93 114 86
7 Pre 156 95 116 72
7 Post 152 98 117 79
8 Pre 163 104 125 82
8 Post 164 100 127 81
250
Table O2
1 Pre 6 60
1 Post 6 60
2 Pre 7 62
2 Post 6.5 55
3 Pre 7 58
3 Post 7 61
4 Pre 6 60
4 Post 5.5 57
5 Pre 6 56
5 Post 6 59
6 Pre 6 55
6 Post 6 60
7 Pre 9 70
7 Post 8.5 66
8 Pre 8.5 63
8 Post 9 61
number.
251
Table O3 Client 5 Frequencies of Nonverbal Behaviours by Two Observers during "Z"
and "Non-Z" Interactions
252
253
APPENDIX P
Aggregate of Clients' Results by Interaction and Variable:

Reduction or Non-Reduction of Stress
254
Table P1 Skin Temperature

255
Table P2 Electrodermal Measurements
256
Table P3 Electromyography Activity
257
Table P4 Systolic Blood Pressure
258
Table P5 Diastolic Blood Pressure
259
Table P6 Mean Arterial Pressure
260
Table P7 Pulse
261
Table P8 Nonverbal Behaviours
262
Table P9 State-Trait Anxiety Inventory
263
Table P10 Subjective Units of Disturbance
264
APPENDIX Q
MBTI Preferences and Scores Results
Nurse Ex/In S/N T/F J/P
1 test E(09) S(21) T(11) P(05)

retest I(01) S(21) T(09) J(01)
2* test I(01) S(13) T(25) J(01)
retest I(13) S(15) T(13) J(01)
3* test I(09) S(05) F(01) J(03)
retest E(05) S(05) T(09) P(01)
4 test E(01) S(13) T(09) P(01)
5 test E(03) N(01) T(11) J(17)
retest I(05) S(25) F(05) J(09)
6* test E(45) S(11) F(31) J(13)
retest I(01) N(05) F(07) J(03)
7 test I(09) S(05) T(11) J(11)
8 test E(01) S(15) T(19) J(09)
9 test I(09) S(13) T(17) P(11)
retest E(01) S(15) T(17) P(09)
10 test I(05) S(17) T(01) P(05)
retest I(19) S(11) T(11) P(01)
11* test I(23) S(03) T(21) P(01)
retest I(29) N(01) T(11) J(05)
12 test I(17) S(09) T(03) J(09
(Table continues)
Note. Ex/In = extraversion/introversion; S/N = Sensing/Intuition; T/F =
Thinking/Feeling; J/P = Judgement/Perception; * = "X" nurses; where there are two sets
of scores for one nurse the second line represents the retest scores.
265
Table (continued)
Nurse Ex/In S/N T/F J/P

13 test I(15) N(01) T(17) J(11)
14 test I(13) S(05) T(15) J(21)
15 test I(09) N(07) T(09) J(17)
16 test E(01) S(15) T(07) P(01)
17 test I(07) S(03) T(21) P(17)
Note. Ex/In = extraversion/introversion; S/N = Sensing/Intuition; T/F =

Thinking/Feeling; J/P = Judgement/Perception; * = "X" nurses; where there are
two sets of scores for one nurse the second line represents the retest scores.

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University of Alberta

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Name of Author: Ginette Lemire Rodger

Degree: Doctor of Philosophy

Year this Degree Granted: 1995

Permission is hereby granted to the University of Alberta Library to reproduce single

research purposes only.

whatever without the author's prior written permission.

9938 - 86th Avenue

Date: _______________________ 1995

and erratic manner, can learn about it."

Stephen Jay Gould

The mismeasure of man

A "Z" Nurse-Client Interaction

its Effects on Stress Level of Clients

Ginette Lemire Rodger

of the requirements for the degree of Doctor of Philosophy.

Faculty of Graduate Studies and Research

Date: ____________________ 1995

clients. A single subject quasi-experimental design with withdrawal and repeated

measures, was used.

Four cancer patients participated in these interactions. A reduction of stress was

measured by changes in one of four physiological and one of three psychological

skin conductance (EDG), skin temperature and cardiovascular activities. The

(STAI), the Subjective Units of Disturbance (SUD) and an observation schema of

nonverbal behaviour using a Nonverbal Behaviour Worksheet.

interaction was significantly longer than other interactions as measured by a t-test. A

were significantly different for the "Z" interactions on all clients.

value, and can be documented. Further testing of the theory is recommended.

It has been my privilege to have been surrounded by scholars who created a

challenging and wonderful environment for my doctoral studies. I am grateful to all of

them. I would also like to acknowledge a few people in particular.

their interest in my work and their helpful suggestions.

significantly to facilitating the project. I acknowledge the nurses who volunteered to

also essential in moving the project along to completion.

It is hard to find appropriate words to acknowledge the contribution of my

This research was supported in part by a Dissertation Fellowship from the

the Faculty of Nursing of the University of Alberta.

Theory "Z": A Nurse-Client Interaction................................................................ 2

Origin of the Theory.................................................................................. 2

The "X" Nurse............................................................................................ 3

The "Y" Client........................................................................................... 7

The "Z" Interaction................................................................................... 13

Nurse-Client Interaction Theories........................................................................ 25

Nurse-Client Interaction Theory Testing.............................................................. 33

Stress: Nature and Measurement......................................................................... 40

Stressors: Illness, Hospitalization and Cancer.......................................... 42

Mediator: Nurse-Client Interaction........................................................... 44

Psychological and Physiological Reactions.............................................. 47

Purpose of the Study............................................................................................. 52

Operational Definition of Terms.......................................................................... 53

The Research Design............................................................................................ 53

Population and Sample......................................................................................... 57

Identification of "X" Nurses and "Y" Clients........................................... 58

Protection of Human Subjects.................................................................. 60

Relationship of Physiological and Psychological Data............................ 65

Blood pressure and heart rate measurement................................. 76

Subjective anxiety scale................................................................ 80

Spielberger's State Anxiety Inventory.......................................... 81

Nonverbal Behaviour Worksheet.................................................. 83

Additional Psychological Instrument........................................................ 85

Myers-Briggs Type Indicator........................................................ 85

Effectiveness of the Tools....................................................................................129