The Nurse-Client Alliance Model

The Nurse-Client Alliance Model

Jan Kare Hummelvoll, DrPH, BA, RN

TOPIC. A nursing model for psychiatric nursing.

SOURCE. Author’s clinical work, reuim of literature.

GOAL. To describe this model and its use with psychi-

atric clients.

CONCLUSION. This model complements the biomedical

model by helping clients gain insight and access to

their su bjective experience.

Key words: Existentialism, holistic model, psychi-

atric nursing, nurse-client-relationship, nursing

care plan

12

Jan Kare Hummelvoll, DrPH, BA, RN, is Associate Professor, Hedmark College, Department of Nursing Education, Elverurn, Nomay.

A l t h o u g h the focus of psychiatric treatment has shifted from institution to community, there is within a sociopsychiatric perspective a need for combining group and community strategies with a therapeutic, relational approach. The nurse-client-alhance model (NCA), based on a humanistic- existential view, can stimulate insight and understanding of people with psychiatric sufferings, through a specific nursing care plan.

NCA is necessary for a holistic-existential approach to most clients, though it is not a sufficient frame of refer- ence for every client. NCA is not appropriate when clients are involuntarily hospitalized on an acute unit, when being treated against their will, or when their level of consciousness is reduced.

The nurse-client-relationship has for some decades been considered the cornerstone of psychiatric nursing (Peplau, 1952; Tudor, 1970; Lego, 1980; Lego, 1996; Hummelvoll, 1 984; Hummelvoll, Nordby, & Sundmoen, 1988). In nursing research and practice the nurse-client relationship is a central theme (Kim, 1987). Peplau (1962) argues that the nurse-patient relationship is the crux of psychiatric nursing. She defines the nurse-patient relationship as the specific interpersonal relationship that evolves between a nurse and a patient. This is a relation ”. . . in which recurring difficulties of everyday life arise” (1952, p.xi). The nurse uses knowledge and the nurse- patient relationship as a therapeutic tool, to promote the growth and well-being of the client. Peplau holds that this relationship ”is both educative and therapeutic” (p. 9); and it evolves through a process with interlocking and overlapping phases, including orientation, identification, exploitation, and resolution. Peplau’s theory draws from developmental, interpersonal, and learning theories (Forchuk & Brown, 1989). Peplau’s comprehension of the therapeutic relationship has had a great impact on the development of psychiatric nursing, emphasizing the therapeutic potentialities embedded in

Perspectives in Psychiatric Care Vol. 32, No. 4, October-December, 1996

the systematic relationship work. This is illustrated, for example, by Forchuk & Brown, who have further developed Peplau's theory by applying the theory in cornmu- nity psychiatric nursing. The authors developed an instrument to measure the phases of the client-nurse relationship. By describing client-nurse behaviors within Peplau's phases, it is possible for the nurse to be con- scious of the special challenges occurring in each phase. Forchuk & Brown hold that this awareness can make psychiatric nursing more systematic, because the process of collaboration becomes predictable.

How is the nurse-client relationship used today, 44 years after Peplau presented her model? Two contribu- tions, "emancipatory nursing actions" and "nursing care parfnership," will serve as points of orientation before presenting NCA and will simultaneously indicate some of the breadth in relational thinking.

Two Contemporary Nursing Models

Emancipatory Nursing Actions

Judy Kendall (1992) takes a critical view of contemporary nursing, arguing that traditional nursing is an arm of oppression since its purpose is to maintain the current system of inequality by focusing on adaption and coping. This contention must be understood against the background of the growing poverty and two- tier delivery of health care in the United States. Kendall believes there is a need for a new direction in nursing practice that may help oppressed people fight back against social systems and political groups that keep them down. Consequently, there is a need for emancipatory nursing strategies that differ from the current system of herding clients through an uncaring and dis- connected health and social service system. The aim of the emancipatory model is to improve health through liberation from oppression and to increase empowerment. Kendall's model draws from Marxism, namely the works of Freire (1968), Habermas (1971), and Katz (1984). Kendall's model can be used both on a group and a personal level.

Nursing Care Partnership

The nursing care partnership model, presented by Schroeder and Maeve (19921, challenges the traditional, professional helping- role characterized by objectivity and neutrality, both of which have dominated psychiatry. They reason that changing social conditions and new health problems require an alternative model of nursing practice. This model is based on Jean Watson's theory of "caring consciousness" as a guide to all nursing interac- tions. Working with people living with HIVIAIDS, Schroeder and Maeve have modified a case management model, which presupposes an authentic caring relationship between clients and nurses. This relationship stimulates mutual empowerment and helps the client pass through the conglomerate of not easily accessible helping systems in the United States. The purpose of this reciprocal and chosen partnership is to increase the client's safety and quality of life. Here too, empowerment is a means to better health, with the nurse acting as the client's advocate, avoiding the kind of "herding" that Kendall rejects.

Comparison of the Models

The two models have ideological similarities, for example, empowerment of clients as a goal to lessen powerlessness, helplessness, subordination, and loss of control (Jones & Meleis, 1993). Empowerment increases clients' access to health care so they can feel in control of their lives (Gibson, 1991). Empowerment refers both to a process of being in charge of one's own life and a goal of gaining authenticity and autonomy. The condition for promoting empowerment is the nurse's attitude toward the client. This attitude is ethically moti- vated in that the nurse feels morally obligated to help clients take responsibility for their choices and gain control of their lives.

Kendall's view expands the nursing perspective of the traditional one-to-one nurse-client relationship. By emphasizing empowerment against social conditions that keep some groups down, the individual's need for

Perspectives in Psychiatric Care Vol. 32, No. 4, October-December, 1996 13


coping and adaption in some situations may be lost; for example, situations requiring coping, adaption, and empowerment. The two outlined models have not been linked to psychiatric nursing. However, people suffering from mental disorders often lack a sufficient social net- work, and often cannot express their own needs. Schroeder and Maeve’s model is primarily relevant to rehabilitation, while Kendall’s is relevant to community or societal intervention. Both models differ from Peplau’s in that they focus on societal conditions, point- ing out the role of the nurse as an advocate for under- privileged and oppressed clients. They do not underhe the nurse-client relationshp as a therapeutic process, but regard it as a mutual interhuman relationship (Schroeder & Maeve, 1992), and as an educative collaboration to lib- erate clients from oppressing forces (Kendall, 1992). Autonomy is a key value in both models.

Nurse-Client-Alliance Model (NCA)

NCA is an alternative and complementary model to those described. NCA has an ideological similarity to the nursing care partnership in that it stresses the intersub- jectivity between the nurse and the client and it empha- sizes humanistic ideals, such as respect for human dig- nity, autonomy, and personal integrity. Both NCA and nursing care partnership models use a hermeneutic- phenomenological approach to understanding and describing the basic qualities of the client’s experiences. In contrast to nursing care partnership, in which partners are mutually chosen, NCA seeks to establish a therapeutic alliance to whom the nurse is assigned.

NCA is the therapeutic alliance that is created as a consequence of a client’s need for help, and the nurse’s response to this need. The alliance is characterized by a spirit of community when working together; it increases the client’s insight and comprehension of the situation, thereby contibuting to the client’s ability to solve health problems, or to cope with them. To make this happen, it is crucial that the nurse move between closeness and keeping distance, giving support and presenting challenges (Hummelvoll, 1984)

The Holistic-Existential Basis of the Nurse-Client Alliance

The holistic-existential approach is based on a non- reductionistic view of Man, which is indeterministic, multidimensional, and existential-humanistic. This view of Man presupposes using a qualitative method to describe the client’s experience of freedom, identity, and suffering (Barbosa da Silva, 1992). From an existential viewpoint, freedom implies that Man is a free subject, who by his free will can make choices and be responsible for these. Laing (1969) holds that “clients’ experiences cannot be grasped entirely through the traditional, biomedical, and reductionistic approach using a quanti- tative method, but rather require an existential-phenomenological method to reveal their true human uniqueness” (p. 18).

Carl Rogers (1958) was one of the first scholars to describe the helping relationship. He defined it broadly as: ”. . . a relationship in which one of the participants intends that there should come about, in one or both parties, more apprehension of more functional use of the latent inner resources of the individual” (p. 413). The characteristics of this particular relation are experiences like trust, empathy, understanding, respect, genuineness, and warm positive regard (Rogers, 1951). A criticism of Roger’s characterizations of the helper’s behavior is that they can be regarded as techniques the helper does instead of a way of being present when meeting the other‘s ”whole being” (Yalom, 1980, p. 409).

Buber (1967) wrote that people are interdependent with each other, and holds that the basic human mode of existence is relational. Consequently, the helper pre- sumes the help-seeking person needs ”to get out” of himself and experience a spirit of community with others. Thus the alliance is built up through a holistic dialogue where both parties meet each other’s totality in an I-TrZou relationship. This relation cannot be quantified or objecti- fied. Objectification is possible in an I-It relationship, where one partner regards the other as an object and not as a subject, that is, as an active agent and a person. The I-Thou relationship involves full closeness, but every

14 Perspectives in Psychiatric Care Vol. 32, No. 4, October-December, 1996

profound relationship requires the difficult task of mov- ing in and out of relations (Frej, 1988). No one can sur- vive in complete closeness or total isolation. Buber wrote that only through distancing can we regain closeness.

We need others to fulfill ourselves. To make the alliance function in an authentic way, we have to recognize we are dependent on one another in a process. The spirit of community implies that the helper is also a part of the life-world of the client. By fife-world is meant the world in which people live their everyday lives, shaped by earlier and present experiences that make it possible to interpret their existence. This world transcends the person, but is simultaneously the person’s “lived world (Bengtsson, 1988, p. 62). Hence, it becomes decisive that the helper appear as a whole person, that helpers reflects on what place and function they hold in the other’s life- world and vice versa. In a real encounter, both persons are influenced and changed. If the helper is not open for change, neither will the client be (May, 1986). Tillich (1952) argues that courage is required for being and affirming one’s self, and it takes courage to encounter another human being openly, because in the authentic encounter one is threatened by losing something of one’s self.

In a dialogue between Buber and Rogers concerning the meaning of affirming another person, Buber main- tained that ”. . . confirming means accepting the whole potentiality of the other. . . I can recognize in him, know in him, the person he has been . . . created to become . . . I confirm him in myself, and then in him, in relation to his potentiality that . . . can now be developed, can evolve” (Rogers, 1958, p. 413). Therefore, it is important to accept that the other is in the process of becoming, and to confirm or contribute to making real his possibilities. This cannot happen if the helper views the other person as something fixed, already diagnosed and classified, and already formed by his history. Confirming the other person positively requires maturity in the helper, whch can stimulate growth of the other as a separate person.

The alliance can stimulate authencity and autonomy. Autonomy implies freedom of will, freedom of choice and freedom of action. However, not everybody is able to use

all these dimensions of freedom. During illness, some of one’s freedom might be curtailed. Kalkas and Sarvimaki (1987) hold that illness often produces a reduction in the right to self-determination (freedom). The fact that one asks for help implies some renunciation of self-control. In this way, illness might have some negative impact upon the person’s freedom of will and freedom of action. Therefore, it is the duty of the helper to realize that this limitation is sometimes perceived by the client as reduced humaneness. It requires empathy to understand this, and to help the client improve the situation.

The relation between autonomy and paternalism. Paternalism is often associated with the traditional role of the therapist or the nurse as an expert, with the client seen as dependent and in need of help. This kind of paternalism is called unsolicited paternalism, that is, acting paternalistic toward an autonomous person who has not asked for such conduct. A kind of paternalism that is ethically justified, is genuine paternalism, which is used toward children or people who are unable to exercize their autonomy because they are unconscious, delirious, or have a serious mental handicap. A third kind of pater- nahsm is solicited paternalism, an ethically acceptable type of paternalism, in which an autonomous person has given his explicit or implicit consent for being treated paternalistically (Wullf, Pedersen, & Rosenberg, 1990). In modern consumer-oriented health service, paternalism in the traditional sense, that is, unsolicited paternalism, is rejected as a valid ethical principle. Autonomy is preferred and is regarded today as a universally valid moral principle in medical ethics (Trarwy, 1991).

NCA differs from Kendall’s and Schroeder and Maeve’s models in regard to the comprehension of autonomy, beneficence, and Paternalism. NCA does not reject genuine and solicited paternalism. There are clients who need beneficence and guidance in periods when they cannot function autonomously. Even when clients do not have the power to exercize their right to autonomy owing to various intellectual, emotional, and physical impedi- ments and consequently, have to entrust it to another person they cannot hand over their integriq. Integrity is not dependent on certain abilities. The question then, is, how


The Nurse-Client Alliance Mode1

nursing shall be developed so that it should not m a d y be marked by theoretical and technical knowledge, but also by practical knowledge concerning autonomy and beneficence that grows out of experience. However, if autonomy is entirely absorbed by beneficence, then traditional, authoritarian paternalism emerges. Thus, the helper will need both wisdom and love to flexibly use the continuum of autonomy to paternalism.

Lutzen (1993) describes ethical conflicts between autonomy and paternalism and between autonomy and benevolence as psychiatric nurses experience them in their daily practice. Beauchamp and Childress (1989) hold that the principle of beneficence includes any form of action to benefit another, and consists of two principles: provision of benefits and a balancing of benefits and harms. Benevolence, on the other hand, is a wish to do good. Thus, beneficence presupposes benevolence. Lutzen proposes the concept of moral sensing to guide nurses in their solutions of moral confhcts, especially in situations when the client has reduced capacity for self- choice. The principles of expressed benevolence and modify- iizg autonomy are then preferred. The latter concept is defined as adjusting the meaning of self- choice to suit the perceived needs of the client.

The general question is how to balance beneficence and autonomy to avoid unsolicited paternalism. One- sided emphasis on autonomy can result in failing to be involved in the client, becoming detached from the suffering, and thus not using beneficence to help the client make choices. Consequently, one does not fulfill one’s duty as caregiver. There will always remain a certain tension between the principle of autonomy and the helper‘s duty to care about the client’s well-being (Tran~y, 1991).

Phases of the NCA

A basic part of NCA is the process of collaboration through partly overlapping phases, as shown in Table 1.

In the pre-interaction phase, the nurse and the client have not yet met, but they prepare for the first meeting emotionally, cognitively, and practically. The orientation

Table 1. Phases of the Nurse-Client Alliance

phase phase phase phase

Preliminary First meeting Last meeting

phase is triggered by the first meeting, a decisive contact in the development of the collaboration. The aim is to establish mutual trust as the basis for the alliance, to make a collaborative contract, and to assess how the clients experience their life situations by identifying the problems, resources, and previous problem-solving and coping strateges. Finally, the nurse and the client agree upon which desired goals they will try to achieve, depending on the client’s values. In the working phase the nurse supports the client in the search for meaning in the suffering and life situation, while working together to reach the agreed-upon goals. Patterns of thoughts, feelings and experiences are investigated, so the client’s insight and understanding of the situation increases, as in the Peplau model. Together, they elucidate what con- sequences different choices may bring. The work is oriented to the here-and-now and the nurse stimulates the client to apply this increased insight to concrete actions to strengthen self-empowerment and authenticity. The family is invited to participate in the work according to the client’s needs and wishes,.

During the termination phase the nurse and the client sum up their experiences together and what these have meant to them both personally and practically. Reactions to termination are also discussed. The alliance is loos- ened by focusing on the client‘s ability to function inde- pendently and by the nurse motivating and sustaining the client‘s connections to social networks and vice versa. Follow-up is discussed and clarified.

Use in Clinical Practice

NCA has emerged from cooperation with clients and nursing personnel over many years, and has been docu-


mented through three evaluation studies (Hummelvoll, 1984, 1990; Hummelvoll et al., 1988). NCA includes a holistic comprehension of the client and the client‘s life- world, including the social context. Clients enter the encounter wholly, and must be met according to their apprehension of their life-world. The nurse cannot totally eliminate the client’s feelings of loneliness and isolation, as these feelings are a part of existence itself that every person must face and find a way to take into oneself (Yalom, 1980). However, the nurse-client alliance can lessen the burden connected to this challenge. The alliance gives greater courage to self-affirmation and to looking at oneself and one’s life situation openly. Through the examination the client becomes curious about possibilities to improve health and to function in everyday life (Hummelvoll & Barbosa da Silva, 1994).

In her doctoral dissertation, Lindstrom (1992) investigated the professional paradigm of psychiatric nurses. She found that many nurses believe clients should participate in planning their own nursing care. NCA presupposes this cooperation. Together, the client and the nurse try to clarify and increase the client’s level of functioning.

The nurse acts as a companion who alternatively provides support, challenges, information, and practical help as the collaboration moves ahead. Cody and Mitchell (1992) illustrate the companion-function and hold that the nurse moves with the rhythms of the person or family as they explore and clanfy the meaning of the life situation, choose direction, and move beyond the now moment. This way of being present helps increase the client’s autonomy and empowerment. To succeed in this close spirit of community, supervision is essential to help the nurse maintain emotional distance and gain perspective in working with the client. This requires the ability to develop ”internal supervision,” namely, to establish emotional distance both to oneself and the client (Casement, 1985, p. 32). This can be accomplished through ”trial identification,” which consists of t M n g or feeling into the experience being described by the client, or reflecting upon one’s own comments as they probably are understood by the client (Wifstad, 1991, p. 68).

The Nursing Care Plan

Nursing care plans are a guide to nursing practice. These are either specific to nursing or integrated in mul- tidisciplinary treatment plans (Nathenson & Johnson, 1992). One purpose of nursing care plans is to ensure interprofessional communication. Some authors stress the importance of active client participation in writing the plan, usually by validating what the nurse has sum- marized (Murray & Huelskoetter, 1991; Brooking, Ritter & Thomas, 1992).

In the NCA model the nursing care plan (see Table 2) is a concrete expression of the holistic-existential approach to the client’s life-world and experiences. It has the following content:

Problems. In this column the nurse tries to approach the client’s experience of suffering. Accordingly, the starting point for the collaboration will be the concerns and problems the client finds most pressing. The nurse also can bring up conditions for joint assessment that are expected to create problems for the client. The nurse strives to increase the client’s understanding of the present life situation, how problems arise, and how they influence self-comprehension and daily life.

Resources. Because it is the client as a person the nurse wishes to know, it is natural to emphasize resources and successful life patterns by focusing on the client’s positive attributes. The possibilities for help and support in the client’s social networks must be addressed as well. These can be used to improve self- comprehension and to strengthen the ability to function. By mobilizing resources and simultaneously curtailing stressors, the client can increase energy to improve health potential (Jones & Meleis, 1993). When problems are solved or managed, the nurse and client write these in the resource column to underscore the client‘s success and thereby strengthen self-esteem.

Earlier problem-solving strategies. Here, the focus is on the client‘s history, clanfylng how earlier and present ways of solving or coping with problems have func- tioned to maintain or solve them.


I

Table 2. Nursing Care Plan

Problems Resources Earlier Problem- Desired Goals New Problem-Solving Solving Strategies Strategies

What bothers you most right now?

What are you satis- In what way have you tried to solve your difficulties

fied with in your life?

Why did you seek What qualities do earlier?

self? help? you like about your-

What interests do you have?

Do you have some one to talk to about the things that con- cern you?

What would make your life situation more satisfactory? your problems? (Try to be specific in regard to family life, housing, work and leisure time )

Can you think of other ways to solve

- How do you think the staff best can help you?

What advantages and disadvantages will the new solutions involve for you?

Which of the new possibilities will you

(When will you start?)

try?

Note. The questions on this nursing care plan are inspired by William Glasser (1965): Reality therapy: A new approach to psychiatry New York Harper & Row.

Desired goals. In this column the nurse and client decide how the client wishes and hopes to experience more satisfaction in life. The answer to this question gives access to the client’s value system. Initially, the answers are often vague, therefore, the wishes must be gradually concretized serving as guidelines for the collaboration. Every wish cannot be fulfilled. Kalkas and Sarvimaki (1987) write that the helper’s duty is, to the best of one’s ability, consider the client’s real caring needs according to the role and function the nurse plays in society. To make the relationship genuine and human, the nurse and client strive to make joint decisions, respecting one another’s values and autonomy.

New problem-solving strategies. The new problem- solving suggestions must be based on the client’s desired goals. The client and the nurse search together for new coping and problem- solving strategies. It is essential that

the nurse not press forward premature solutions, but dwell on and work with the first four columns, so the client’s insight is increased. It is important that the nurse follow the client’s tempo, though at times acting as “pace- maker.” Together they discuss various options, what con- sequences the different choices might have, and what personal efforts and courage are needed to pursue them. Client’s are responsible for their choices, depending on a sufficient level of functioning. New problem-solving strategies are given target dates to increase commitment in the collaboration. This also provides concrete data to compare to later outcomes. At the end of the collaboration, clients are given a copy of the nursing care plan as tangible proof they now have the responsibility for their own lives.

The plan is a way of documenting the work, structuring the collaboration, and thereby giving clients an overview and insight that can challenge them to take


action in a broad sense, thus representing themselves in an active and self-empowered way.

The client’s vocabulary and thinking are positively valued by using their own words in the plan, unlike the technical language commonly used in traditional treatment and nursing care plans. Traditionally, while personnel may believe the explanations and conclusions of the client‘s condition are valid, there is a lack of equality between the parties (Skau, 1992). The NCA nursing care plan, however, presupposes an authentic dialogue, where the client and the nurse negotiate what shall be written on it. By using the vocabulary of the client and of the alliance, some of the alienation and powerlessness that follows extensive use of technical terms will be reduced (Wifstad, 1991). Designing the nursing care plan like all work in the NCA is characterized by constant searching for new understanding. This is done by con- cretizing the content in each column. In this manner, the client’s insight, and the nurse’s knowledge of the client, are increased.

The Advantages and Disadvantages of the NCA

Former clients in a psychiatric day hospital, where the NCA model was implemented, were asked what qualities and attitudes by the personnel they appreciated, and whch were not helpful (Hummelvoll, 1990). The positive attitudes of the personnel were ranked by the clients as follows: personal caring, power of empathy, openness, appearing as a person, hope and optimism, equality, flex- ibility and ability to rethink, being secure and giving sup port, and finally, having a sense of humor. The negative attitudes were: Lack of empathy, moralizing and ”besser- wissen,” being busy, passivity and not being able to separate their own problems from the client‘s. The latter negative quality is, of course, easy to avoid when taking the traditional, professional attitude, marked by objectivity and neutrality. The danger of this professional attitude is that one simultaneously loses the positive attitudes and qualities of empathy and openness.

The clients’ negative experiences are probably increased and intensified in today’s hospital treatment,

marked by very short admissions. This may lead to superficial human contacts, that make it difficult to establish significant, personal relationships (Murray & Huelskoetter, 1991). Such a situation is common in purely biomedical thinking and practice, in contrast to the holistic-existential approach. The biomedical, reductionistic view of Man, which ontologically reduces Man to his body, produces fragmentary treatment and care. The result is often readmission.

A possible disadvantage of NCA is that a narrow two-person relationship might hinder the client’s inde- pendence and the opportunities for being engaged in other relations. However, by practising NCA properly, the alliance can serve as a place of refuge for hylng out new coping and problem-solving strategies, where clients can think freely about their actual life-situations and can gain courage to change for the better.

NCA presupposes the mutual trust necessary for all positive relations. A client who is unable to trust some- body cannot enter an alliance. This marks both the scope and a limitation of NCA.

Several reports deal with the possibilities and limita- tions of the nursing care plan (Rosenberg, 1988; Persson & Stenqvist, 1990, Sunnqvist, 1990). It is difficult to decide whether it is working with the plan, or the relationship itself that is the most effective factor (Anderaa, 1991). Nursing personnel believe working with the plan has had the following advantages: It contributes to the clients’ insight and stimulates hope for improvement. The clients get opportunities to participate in their own treatment and nursing care in a well-arranged and responsible manner. The plan is a suitable tool for assessing the client‘s situation and is helpful for the evaluation of the nursing care.

As for the disadvantages, the personnel point out that writing the plan can be time-consuming. Some clients are reluctant to fill out the plan because it is difficult, and some believe their situation and problems cannot be placed in columns. Finally, one can be too involved in writing the plan and, therefore, miss giving the client full attention. The clients’ evaluations of the disadvantages paralleled the nurses’ assessment of the problems (Hummelvoll, 1990).



There are some indications that a few clients experience the prewritten questions on the plan as too self-dis- closing (Hummelvoll et al., 1988), and too difficult and challenging to answer (Persson & Stenqvist, 1990). In these cases the plan is used as a technique, instead of as a means of systematically entering the life-world of the client. NCA will probably serve as a functional model in the rehabilitation of psychiatric clients, in intermediary wards, day hospitals, and community-based psychiatric nursing. In acute wards, it might counteract the ten- dency toward reductionism, when coupled with a pri- mary nursing system, where a particular nurse follows the client throughout the hospitalization.

Future Research

Further research about the possibilities and limita- tions of the NCA model is needed, both in institutional and community psychiatric nursing. Some important questions are: Does this model presuppose such a lengthy contact that it is impractical in brief hospitalization? Is it possible to use this model when working with clients who are treated against their will?

Conclusion

The nurse-client-alliance model (NCA) rests on a holistic- existential basis, grounded on a view of Man that uses a holistic approach to the client’s situation. NCA is not primarily preoccupied with explaining why things happen, but instead focuses on exploring and understanding the client’s subjective experience and stimulating insight in a broad sense.

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