Building Trust in the Provider-Parent Relationship

by Janice B. Mandernach

Successful practitioners, whether they be physicians, nurses or educators, strive to create an atmosphere in which the parent feels free to share his/her concerns. The provider must know the client's true concern and be assured that whatever follow-up is recommended is followed by the client. In the pediatric well-child practice or a preschool educational setting, although the client is the child, the practitioner must establish a relationship with the parent as well as the child since the parent is crucial in assuring the client's successful development.

Building a relationship of trust yields greater compliance in well-child visits and school participation, increases the attachment between parent and child, and increases the knowledge of the parent. How to build the relationship between practitioner and parent remains the challenge. First, one must accept that relationship building is a long-term endeavor, not something accomplished in a single visit. But steps can be taken with each visit. Analogous to the development of the child (Tronick, Monaco speech), the relationship of trust evolves over time. Three phases of trust building will be discussed: affiliation, probing and affirmation.

Relationship begins with affiliation--common ground between parent and provider. Perhaps it's a comment about the "effort the parent made to get to the appointment," "how pretty you and the baby look today," acknowledgment of "how long you've had to wait because of my schedule," or some other small item which affirms the parent as a human being. Initial eye contact with the parent is especially important.

In subsequent visits, affiliation may also include the reference to an item from a previous visit--the "hook." This may take the form of a note about something of importance to the parent, or perhaps some issue alluded to by the parent which you, as practitioner, want to follow up with during this visit. For example, the parent said in passing during the last visit "My older child is having trouble in school." During the current visit, you will ask "How is your older child doing in school now." These "hooks" are documented at the end of each visit so that you can use them to tell the parent by your reference to them during the current visit that you were really listening to her during the previous visit.

Body language bears a powerful message to parents during an appointment. In order to balance the power in the practitioner-parent relationship, the practitioner may sit at the same level as the parent and, to signal interest, lean slightly forward as the parent is talking. The parent, in turn, gives the practitioner clues as to whether s/he is involved and willing to share in the conversation by also leaning slightly forward and permitting eye contact.

Body language is always understood within the cultural context. In exploring the practitioner-parent relationship, an African-American woman seeing a Caucasian male practitioner will interpret body language differently than a Caucasian parent. Body language signals such as down-turned eyes and backing away are extremely important and give the practitioner cues about how quickly to proceed in this developing relationship. It is the practitioner's responsibility to read these cues and move with them, focused on the goal of building a long-term relationship.
The affiliation phase of this relationship may only be one or two minutes, or with some parents for whom the practitioner has little common base, may take the entire visit. The new parent who comes to the clinic only for shots may not want more of a relationship than checking out this practitioner and facility. The goal is always to keep the door to the relationship open, so that the parent returns, signaling her desire to continue with the relationship. As trust builds, the patient becomes more receptive to practitioner information and teaching.

Once the initial desire for a relationship is established, the practitioner's goal is to reach a level beyond the surface relationship. This goal is reached by the practitioner taking a risk with the relationship by probing more deeply in an area that has been suggested by the parent but which may be uncomfortable for the parent. Parents throw out numerous clues during an interview which can help the practitioner know where to probe. Body language (such as leaning forward, turning away, or rigid posture), facial expression (such as a fallen jaw, raised eyebrow, or frown), intonation in the voice, choice of words, or a look with silence following are all clues to the practitioner that s/he has hit a sensitive area. For example, the mother of a 2 week old comments in passing that "her life is more stable now. Although on the surface, the comment of this mom appears to be unrelated to the care of the child, by taking the risk and asking, "Now? That suggests it may not have been stable in the past," the practitioner is signaling that the feelings and perceptions of the parent are as important to the practitioner as the child's growth.

Numerous techniques are available to the practitioner to accomplish the probe: repeating the parent's statement with a question mark or raised inflection at the end, "More stable now?"; reflecting the parent's statement, "Life has not always been this stable?"; asking "What do you mean by stable?"; or saying "Tell me more about that," then sitting in silence to allow the parent to respond. If the parent does not respond, the practitioner may even say something like, "That may be too difficult to get into right now for you" or simply go back to the baby.

If the parent chooses to respond to the probe, a response of acceptance and affirmation from the practitioner allows the trust in the relationship to deepen. Human beings consider change if they feel supported and accepted. The practitioner's message about change for the parent-child relationship can better be heard if the parent trusts that the practitioner has her interests at heart as well as the child's.

Finally, the practitioner's responsibility in the relationship is to affirm the parent. This affirmation phase provides support and acceptance for the parent wherever s/he is at the moment and conveys care and concern for the parent. Affirmation is accomplished with a nod, a light touch, a furrowed brow, eye contact and actively listening. Above all, listening. This is not a time for the practitioner to share his or her own personal experience in a similar situation. Each parent wants to be valued for his own response to difficulty, not to be told that everyone else has encountered the same frustration. However, each parent also wants to hear that he is not alone and hearing about the universality of his situation is also a message of comfort. This recognition of uniqueness within the universality of parenting is what the affirmation phase of relationship building offers to the practitioner-parent interaction.

Sometimes probes don't work. The practitioner misinterprets a cue. The parent will tell the practitioner if s/he is off track or respond easily with an "It's OK" message. See that as a good--one less area of potential concern. Or, a probe may not work because the parent is not ready to increase the level of intimacy or trust in the relationship yet. This can be checked out by continuing to probe a couple more times and then exuding acceptance of the parent wherever s/he is, knowing that the parent will return, allowing the practitioner to continue to build the relationship on the next visit.
In any provider-parent relationship, either party has the option of declining interaction over any particular issue. Long term the relationship will not be successful if every issue is declined, but the provider cannot insist on interaction on any specific issue s/he probes. When an impasse is reached in the relationship, the practitioner can return to the language of the child. The child is the initial bond between the practitioner and the parent. If the probe brings the practitioner too close to the parent and the parent "shuts down," the child's behavior is still a language understood by both parties.

As with any developmental process, building trust in relationships sometimes regresses. The parent and practitioner experience conflict. Trust decreases some because one party to the relationship places demands of time or commitment that the other party is not ready for. Perhaps the practitioner wants the parent to embrace her value concerning spanking and "directs" the parent to behave in a certain way with the child. This "demand" imbalances the relationship and could lead to disintegration of the relationship. It could also provide an opportunity for the parent to share with the practitioner at a new level if the practitioner can "hear" and accept the parent's place on spanking. Some practitioners have difficulty risking the possibility of growth on an issue such as spanking. However, if there is to be growth toward maturity in the relationship, the practitioner must be open to the parent's instruction.

In a balanced relationship, this possibility of openness also means that the parent will be open to the practitioner's instruction. The child becomes the real beneficiary of trust in the parent-practitioner relationship. The child's optimal development, after all, is the goal for both parent and practitioner. Bringing the best from both parent and practitioner to the child's situation allows the child to grow to his/her fullest potential.