A questionnaire determine the progress of building nurse-client relationship in the community setting.

1. NURSE-CLIENT RELATIONSHIP RATING
(Adapted from McNaughton, 2005)
Age:_______ Gender:___________
Instruction:
1. Please be honest in rating in every item. Your honesty will depict the reliability of the data
gathered.
2. Write the number of home visitation to your client/family assigned.
3. Put a check (√) marks on the specific scores to indicate the quality of achievement that
describes as follows:
Score 1 2 3 4
Description not effective or Mild effectiveness Moderate Very effective
barely effective effectiveness
Interpretation This means that This means that This means that This means that
building nurse- building nurse- building nurse- building nurse-
client relationship client relationship client client
has been stressful is still mutually relationship is in relationship is
and disorganized coping and its mutual productive base
or not successful. adjusting functioning on their contract
level. or agreement.
Quality of
ORIENTATION PHASE achievement
1 2 3 4
1. Nurse introduces his/herself to the patient and client shows
accommodation.
2. Initiating a therapeutic contract by establishing a time, place and
duration of each meeting as well as the length of time the relationship
will be in effect
3. Demographic data of Client had been identified and collected
completely.
4. Determines their client’s health condition accurately.
5. Determines client’s health need and prioritized according to client’s
open and honest discussion.
6. Client shows interest in the topic openly discussed.
7. Rapport established by demonstrating acceptance with each other.
8. Built open communication by establishing trust with each other.

2. WORKING PHASE Quality of
achievement
1. Continuity in assessing the clients/family’s need, coping strategies,
1 2 3 4
strategies, strengths and weaknesses.
2. The consistency and continuity of home visitation achieved as
stipulated on specific date
3. Find means and solutions by discussing and sharing each other
with ease and understanding.
4. Enhance or broaden a client’s/family’s information and knowledge
base on health and related matters
5. Deepened your awareness in understanding your attitudes and
values, sense of social awareness; genuine concern and desire to
help and serve your client/family as home visitation progresses
6. There is a presence of signs of improvement on specific skills and
abilities related to health and health care of your client/family as a
whole.
7. There are changes in personal habits, behavior patterns or lifestyle
of your client/family in order to promote letter health.
8. There is optimum mutual active participation and collaboration in
the implementation of the solutions specifically in the preventive
and control practices of illness.