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Nurse-Patient Relationship

The Nurse-Patient Relationship

Kayla Taylor

English 202, Section 038

Marlen E. Harrison

April 20, 2010

Abstract


When dealing with the nurse-patient relationship, I have came to

realize that there are four main elements that make up this

relationship. The purpose of my paper was to describe these four

elements; which include trust, caring, ethics, and communication. To

ensure these elements were important, I observed a RN working in a

hospital. I took note on how she treated patients in all four of the

elements and I concluded she used them frequently within her shift.

These findings, that I compared with the information given about the

elements were the main focus of my paper.


What effects does the nurse-patient relationship have on the care that

the patient is getting? How does the relationship effect the nurse’s

willingness to treat the patient. These are all questions that, as a

nursing major in college, I am wondering. According to science direct,

“The therapeutic nature of the nurse-patient relationship is grounded

in an ethic of caring.” (Lasala 2009). This all started with the head of

the development of nursing. Her name was Florence Nightingale. She

provided the basis for the nursing habits we see today and she was

founder of the modern nursing profession as a trained profession.

After a little bit of history, what exactly is nursing? According to

The International Council of Nurses (2002),

“Nursing encompasses autonomous and collaborative care

of individuals of all ages, families, groups, and

communities, sick or well and in all settings. Nursing

includes the promotion of health, prevention of illness,

and the care of ill, disabled, and dying people.

Advocacy, promotion of a safe environment, research,

participation in shaping health policy and in patient and health

systems management, and education are also key

roles”

This definition of nursing goes hand-in-hand when talking about the

most important part of nursing: the nurse-patient relationship.


In one study, a hospital asked their patients “What is the most

important thing I can do for you today?" This helps to form the bond

and the connection between the nurse and the patient. It also helps

the patient to trust the nurse. The findings of this study were that

“There were themes major themes that arose in this population of

neurological, orthopedic, and rehabilitation patients” (Cappabianca A.,

Julliard K., Raso R., & Ruggiero J., 2009). The eleven major themes

included activities of daily living, pain management, discharge, eating-

drinking, elimination (bowel movements), care coordination, comfort,

patient education, emotional, family concerns, and "nothing" (meaning

the patient is fine). This study was very successful in the hospital and I

believe that many nurses and doctors should follow it. This study also

concluded that "Nursing envisions a caring place, where patients and

their families feel comforted and safe, staff feels supported, and where

there is a continuous focus on healthy, healing relationships."

(Cappabianca 2009). As a nursing major going for my Bachelor of

Science Degree in Nursing (BSN), this is a very true quote that really

speaks to me. When a patient walks into a hospital, they should be

able to feel welcome and a sensation of well being.

Another element with the nurse-patient relationship is how much

time the nurse actually gets to be with the patient. According to Pat

Rutherford, R.N., vice president for the Institute for Healthcare

Improvement in Cambridge, Mass, “Nurses spend between 20 percent


to 30 percent of their

time in direct patient care. (“The Nurse and Patient Safety,” 2008).

Rutherford then goes on to say that “There's a great deal of waste in

nursing activities. By removing waste, nurses can participate more

meaningfully in the care of their patients.". (“The Nurse and Patient

Safety,” 2008). This I also agree on because if a nurse only gets about

20-30% direct care with the patient, how are they going to form the

sense of rapport, which is successful in a relationship, with them. The

Department of Health and Human Services predicts that the United

States will need 2.8 million nurses by 2020; this is more than 1 million

than they thought. Because of this, improving nursing efficiently is a

top priority. One of the best ways to improve efficiency is to ask nurses

face to face about the problems they meet in their work environments.

According to Beverly Nelson, R.N., director of nursing programs at the

University of Texas M.D. "Nurses know what needs to happen in their

practice… They are the most informed“ (“The Nurse and Patient

Safety,” 2008). By asking the nurses what kinds of problems they face

in their everyday routines at the hospital can actually reduce those

problems.

So how will I bring the online research to my own personal

experience? In my lit review, I will be providing primary research,

methods and findings. The primary research is going to be shadowing a

RN that I know. I will first ask her a series of questions about her


relationship with her patients. Then while shadowing her, I will see her

relationship with the patients and how she interacts with them. I will

link the connection between what she told me about her relationship

with her patients to how she actually treats them in her every day life.

I believe that this approach will be the best approach because it puts

the nurse-patient relationship into life perspective and it provide some

details as to what actually goes on in a hospital.

Before talking about the essential elements that make up the

nurse-patient relationship, some basic principals about it must be

covered. According to S. Halldorsdottir (2008), there are prerequisites

for a nurse-patient relationship to develop. The nurse should be looked

at by the patient as showing care for the patient as a person, having

professional wisdom, and being competent-Which is having the skills in

the specific area of nursing that the patient is being seen in. Another

principal is that the nurse-patient relationship involves two inter-

related processes; which include the development of connection while

having a sense of respect and compassion. Along with this, there are

five phases to the relationship. They include: Reaching out, removing

the mask of anonymity, acknowledgement of a connection, reaching a

level of trust, and also having a sense of solidarity (Halldorsdottir,

2008, p. 4).

“When we care as nurses, we escape our own boundaries

and egos as we completely and openly focus on our patients.


At the same time, our patients’ personal boundaries

are fraying, often because they have such a great

need for physical or emotional relief. Surprisingly, this

permeability ends up making each patient and nurse able to

form a new connection in that space that usually separates

two people” (Askinazi, p. 23).

This was a quote from Askinazi, who was a lady explaining what

happens in a nurse patient relationship from her perspective as a nurse

(Halldorsdottir, 2008, p. 7). This information from Askinazi goes hand-in

hand with the elements of a nurse patient relationship. Now that I have

mentioned about some of the principals in the above paragraph, I will

now discuss the essential elements I think that are the most important

in the nurse-patient relationship. They consist of trust, caring, ethics,

and communication. I will be discussing about each one in depth.

Trust is an important consideration in the nurse-patient

relationship. It can be easily established as well as easily broken. Once

the patient walks into the hospital, they depend on the nurse for trust

and for the nurse to have morals. If the expectations of the patient are

not met by the nurse, trust along with the relationship will be lost.

According to Carter (2009), Florence Nightingale once said “It’s the

nurses core responsibility to use the tools of science as they further the

healing mission” (p. 2). Carter believes that trust is a feature of

everyday life and that it has many different perspectives. Along


side of this belief is another from Talcott Parsons, who was an American

sociologist who served on the faculty of Harvard University. His theory

states that

“The patient is expected to have confidence in his

physician, and if this confidence breaks down, to seek

another physician. This may be interpreted to mean that

the relationship is expected to be one of mutual

“trust,” of the belief that the physician is trying his best to

help the patient and that, conversely, the patient is

cooperating with him to the best of his ability. The nurse-patient

relationship has to be one involving an element of

authority” (Parsons 1951).

Still discussing trust, Bell and Duffy (2009) both believe that trust

is an essential part to living in a complex world, and an essential

component of the nursing practice (Luhmann, 1979 & Pask, 1995).

Following this idea, trust has four characteristics. They are expectation

of competence, the goodwill of others, vulnerability, and elements of

risk. All of these theories provide evidence that one of the most

important elements in the nurse-patient relationship is in fact trust.

The second element of the relationship is caring. In comparison

to what Florence Nightingale said in the journal article Trust, power,

and vulnerability: a discourse on helping in nursing (2009) about trust,

she also stressed that “The nurse’s ability to form therapeutic


relationships is based on caring, healing, and clarity of purse” (LaSala,

2009, p. 1). If the nurse does not care

about the patient when they walk into a room, it is clearly noticeable.

The

body language and also the tone of voice of the nurse can tell the

patient weather they care or not. To master trust, the nurse should first

master putting care into the patient. Within LaSala’s (2009) article,

Jean Watson believes that “A caring attitude is not something generally

passed on from one generation to the next but rather through “the

culture of society” (Watson, 2008, p. 77-79). I believe that this

statement is true because the caring element of nurses changes over

time along with the growth of civilization. More and more today our

civilization is seeing the baby boomers reach their old age and the

nurses have to improve their quality of care and their skills when

dealing with the elderly more often.

Along with caring, the element of ethics and moral decision

making comes into play with the nurse-patient relationship. Unlike the

other elements, the ethics focuses on the caring aspect instead of

exploring the relationship between the nurse and the patient. Also,

when talking about ethics, the term morality is also associated with

nursing. The morals in nursing are a set of rules for nurses and

physicians to follow when practicing their profession and to say what is

right or wrong. Moral wisdom goes hand-in hand with this. According to


Armstrong (2006), moral wisdom is defined as “a complex

phenomenon that includes (at least) three components: moral

perception, moral sensitivity, and moral imagination” (Armstrong,

2006, p. 10). He believed that to be a morally

sensitive nurse, it is insufficient to merely perceive patient’s needs.

Instead,

using your own perceptions will lead to appropriate responses to

patients and also will help to form one’s moral motives. Moral

imagination is self reflecting from the nurse. They ask themselves

“How would I feel if the nurse lied to me?” or “How would I feel if the

nurse spoke to me in such harsh ways?”. This technique is used to help

reflect on what it might be like to be a patient in a specific situation.

Armstrong (2006) also discussed the element of helping in his

research. He views the helping relationship between the nurse and the

patient as one based on moral virtues. Some examples of moral virtues

include compassion, courage, respectfulness, honesty, and

trustworthiness.

The last element that I am going to discuss is the communication

between the nurse and the patient. McGuigan (1987) states that

communication in nurse-patient relationships is an integral part of

nursing practice. Effective communication is important to provide two

things: accurate information and to prevent misunderstandings.

Effective communication also minimizes the development of a


therapeutic relationship between nurses and patients and their families

(p. 2). A study that was done by Sheldon et al (2006) looked at difficult

conversations from the nurses’ perspective. The findings were that the

nurse’s personal experiences and the emotional responses to clinical

situations effect the way they communicate. This often backfires for

the nurse and makes interactions between the patient more

difficult for the nurse to get their message across. Another thing that

McGuigan

(2006) looked at was self awareness. This means to understand others

needs, a nurse needs to be aware of her own. In other words,

becoming more self aware enables a nurse to observe how they react

to particular situations and what effect they will have on others. This is

mostly learned through experience.

All in all, the four elements of the nurse-patient relationship

(which include trust, caring, ethics, and communication) are all

essential parts of nursing. Further down in my paper, which is going to

be my results section from my primary research, I will be explaining

how these four elements play an important role in the everyday real

life of an RN working in a hospital. I will explain my results of

shadowing her every move for a day and relate her actions to how well

her patients trust her, how well she care’s for her patient, how well she

follows her ethics and morals, and last but not least how she interacts

and communicates with her patients.


For my primary research, I observed one female participant. She

is an RN working at Latrobe Hospital in Latrobe, PA. My plan was to

shadow her for a shift. I believe this was the perfect method for my

topic because it put me in a real life situation and allowed me to see up

front how a nurse operates.

After shadowing the RN for a day, I will now analyze my data and

I plan to compare these results with the four elements in the nurse-

patient

relationship and see how they relate with the everyday life of an RN in

my

conclusion. I tried to be as discrete as possible while I observed the RN

because I wanted to make it seem like I was not even there. I know,

however, that since I have known this nurse for a few years it would be

hard for her not to give me the results that I want to hear. I want it to

be as natural as possible. Finally, in my conclusion, I will give some

scholarly input about my topic. I have been researching within some

nursing journals on case studies done concerning the relationship

between the nurse and the patient. I plan on incorporating these

finding done by professionals to enhance my research and also give

some quotes from books along with quotes directly from the RN

participant I interviewed and observed.

On April 11, 2010 from 7-11, I conducted my observation of my

participant. However, due to time constraints, I was not able to sit


down and have an interview with her. She works on the 5th floor in the

PCU, which stands for progressive care unit. This type of unit deals with

cardiac patients that need to be on monitors. The RN would have

roughly five or six patients for a twelve hour shift. When I did

conducted my shadowing, I took notes on how her and her patients

practiced the four elements that I have elaborated on above: Trust,

caring, ethics, and communication.

When talking about trust, there were many things she did to

demonstrate this that are an important part of working in a hospital.

The first

thing that I observed that she did was when she walked into the room

of a

patient, she introduced herself and also her position as a nurse. This

allows the patient to identify the person coming into their room and to

build up the trust and rapport with them. One other observation that

represents trust is when she was giving the patient meds or doing a

simple procedure. She would tell the patient what she was performing

before she would do it. This also is a very good way to build trust up

with the patient.

The second element of the nurse-patient relationship is caring.

The RN I was shadowing was especially caring and respectful of the

patients she took care of. Some things she did that demonstrate this is

when she would go into the patients room, she would put up on the dry


erase board her name as the patients nurse. She would do this so that

if the patient would need anything, they would know her name.

Another thing I observed is that when she would be done giving the

patients their meds, she would move and arrange chairs, stools, etc.

out of the way so neither her or her patient would trip. She looked at

me and added “Not many nurses do this when they come in. It

wouldn’t look very professional if I was tripping over everything”. We

both laughed. When we were ready to leave the room of a patient, she

would ask them “Can I get you anything else?”. I believe that this is

one of the best things to do when leaving a room because it sounds

very polite and caring on the nurses part.

Ethics is a big part of a nurse’s career and part of their routine

shift. A

nurse never forgets her morals and what the difference is between

wrong and

right. The first thing a nurse does, even before making rounds and

seeing the patients, is patient sheets. These sheets are an overview of

each patient laid out so when the nurse does do rounds they have a so

called “guide” to look over. This helps prevent ethical screw ups and

mistakes. Also, instead of the RN giving out verbal patient reports, they

do them over the phone. This helps to protect HIPPA rights. Another

ethic she practiced was honesty. For example, when she had to come

back to a patients room, instead of saying “I’ll be back in 5 minutes”


she said “I’ll be back in a little bit”. This ensures that the RN won’t lie

to the patient if they get distracted and can’t be there in 5 minutes.

One of the patients she took care of while I observed had one arm very

swollen. This was a new sign that she didn’t know about. Instead of just

overlooking this swelling, she investigated. She looked at the patient

chart to see if there was any record of her having this sign. The chart

said that they did an X-ray and everything was fine. She explained to

me that if there was not anything on the sign that she would of

documented it and told the doctor. This type of ethic of nursing is very

important for when I go into the field after I graduate.

The last element is communication. To a nurse, communication is

everything. If the skills to hold a conversation with a patient or

communicate bad news is not there, then the nurse shouldn’t be

working with patients. The

communication I saw the RN I shadowed do was when she walked into

the room

and introduced herself, she did it with a caring, calm voice. I was really

impressed by the way she handled her patients conversation wise. She

would laugh, joke around, and make small talk with them. For example,

one of her patients liked to Polka and they were carrying on a

professional, yet friendly conversation on about it. When I get out and

start working in a hospital, I would love to have the communication

skills the RN I shadowed has. She was very polite and professional to


the patients and, I believe, this is very important and will get a nurse

far in their career.

All in all, nursing started with Florence Nightingale. She set a

wonderful example for future generations of nurses. Many of them

have followed her lead and done much to improve nursing, patient

care, and the lives of individuals (Ulrich, 2008, p. 1). Thus, I believe the

four elements of the nurse-patient relationship are essential in nursing.

The elements include trust, caring, ethics, and communication. To be a

professional and well rounded nurse, I believe that all four of these

elements are a must. To be trusted by the patient, to be cared by the

families, to have morals and ethics while saving peoples lives, and the

communication on an everyday basis. These are the many wonders of

nursing that I would love to become a part of when I graduate and

work in a hospital. Florence Nightingale once said:

“Nursing is an art: and if it is to be made an art, it requires

an exclusive devotion as hard a preparation, as any

painter's or

sculptor's work; for what is the having to do with dead

canvas or

dead marble, compared with having to do with the living

body,

the temple of God's spirit? It is one of the Fine Arts: I had

almost


said, the finest of Fine Arts.”

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Midwifery.

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for you

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