1. Killam, Patricia RN, MS, ARNP

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Maintain Relationships with Challenging Families

Maintaining long-term relationships with families troubled by poverty and other social difficulties requires a special set of skills and the willingness to embrace small, incremental changes.


Motivating parents to pursue care for their children despite barriers is crucial, and a relationship with health care providers can help. Most of us have more volatile reactions under stress. When families are stressed, we must consider our words and responses even more carefully than we do with stable families.


The following are communication ideas that may help NPs maintain positive and therapeutic relationships with challenging families.


Positive Reinforcement

Let families know how glad you are to see them. At home, immediate needs for food and shelter may take a higher priority than clinic visits. Pediatric patients have no control over their own schedules.


Instead of commenting on previously missed appointments, give families positive reinforcement for making it in today. Take the opportunity to explore barriers to care; is there anything you can do to make the next visit easier?


Look for opportunities to praise and you will find them. It takes constant self-coaching to give positive reinforcement; remember that praise is much more powerful if it is labeled 1, or describes specific behavior.


Help families leave each visit feeling better than when they came in. 2 For problems that cannot be solved readily, this may simply mean praise for identifying the concerns.


This approach models an important parenting tool as well. If parents were not raised in a nurturing and supportive environment, they can still learn positive reinforcement skills as adults. One of our goals can be to help parents give more as parents than they received as children.


Use Everyday Words

Avoid intimidating medical jargon. Think of medical terminology as a foreign language; some families are "bilingual" and some are not. "Translating" health issues into everyday words is a learned skill and gets easier with practice.


Try to weave questions into the flow of conversation rather than using the "report card" approach. Encourage parents to brag about their children. Seek "teaching moments"3 to offer care suggestions. Notice and expand upon parental comments that have even the slightest connection to the health care agenda.



Empathy promotes a sense of partnership and helps to diffuse and illuminate anger or distress.


Acknowledging emotions without accusations or shame is tremendously supportive. It's also another powerful parenting tool; helping children "name" their emotions may help families at home as well. 2


Four shoulders are better than two. NPs can present themselves as members of a health care team. Encourage families to form relationships with other staff members who have individual fields of expertise.



If a family's problems begin to suggest the need for a child protection referral, use "transparency".


Frankly and gently share with parents the perceived risks to the children. Attempt to form a collaborative plan to meet these concerns. Remember that nurses and families have the same goals for children: health and safety. Keep this thought at the forefront of the interaction.


If collaboration is unsuccessful, use transparency again to describe your legal responsibilities (briefly) and focus on possible sources of assistance.


Very few people have the rich work life nurses do. If stories are the fabric of human life, this is living!


Take joy in the knowledge that we have an opportunity every day to make a difference in the lives of others.




1. Hembree-Kigin T, Bodiford-McNeil C: Parent-child interaction therapy. New York, NY, Plenum Press, 1995. [Context Link]


2. Green M: Coping with the "helpless" parent. Contemporary pediatrics 1997; 14:75-88. [Context Link]


3. Brazelton TB: Touchpoints: the essential reference, New York, Ny. Addison-Wesley Publishing Company. 1992. [Context Link]