Defining and characterising the nurse-patient relationship: a concept analysis

Depósito de investigación de la Universidad de Sevilla https://idus.us.es/ “This is an Accepted Manuscript of an article published by Sage in Nursing ethics on MAR 2022, available at: https://doi.org/10.1177/09697330211046651 DEFINING AND CHARACTERISING THE NURSE–PATIENT RELATIONSHIP: A CONCEPT ANALYSIS Abstract The nurse-patient relationship involves complex attitudes and behaviours with ethical and deontological implications. It has been linked to improvements in patient health outcomes, although there is still no consensus in the scientific literature as to the definition and characterisation of the concept. This article aim to define the concept of the nurse-patient relationship. A concept analysis was conducted using the Walker and Avant method to identify the attributes defining the nurse-patient relationship. An integrative review of the literature was conducted using the PubMed, Web of Science, Scopus, and Cumulative Index to Nursing & Allied Health Literature databases. A review of the grey literature and other minor non-indexed publications on the topic was also conducted. A total of 36 articles were included in the review. A model case, a contrary case, a related case, and empirical references were produced to clarify the concept and identify its essential attributes. The concept is defined as a helping relationship involving interaction between different players. It is the basis of nursing care and is intended to meet the healthcare needs of the individual receiving this care. It is also viewed as an intervention in itself, requiring a specific training process just like any other nursing skill. The essential attributes of the relationship are empathy, presence, contact, authenticity, trust, and reciprocity. In conclusion, the nursepatient relationship is a helping relationship established with the patient and/or their family based on interaction, communication, respect for ethical values, acceptance, and empathy in order to encourage introspection and behavioural change. Key components include communication, active listening, and respect. Bioethical values and confidentiality must also be present to ensure that the relationship is built on equality and intimacy. Keywords: Attitude of health personnel, concept analysis, helping behaviour, interpersonal relation, nurse–patient relation, nurse–patient relationship Introduction Defining the concept of the nurse–patient relationship has been a constant concern throughout the history of nursing because of its implications for health outcomes. The concept has been associated with improved levels of health and feelings of empowerment, safety, and trust among patients (1–3). The nurse–patient relationship is also key to the advancement of the nursing profession because the ultimate goal of the discipline – to provide care – would be difficult to achieve without it (4,5). However, there is a high level of variability surrounding the concept of the nurse–patient relationship. Attempts to measure the construct are challenging, as they must be based on a characterisation of the concept (6,7). Furthermore, definitions and characterisations of the concept in terms of identifying elements, attributes, and situations also vary (8). Background The nurse–patient relationship has tended to be conceptualised as a helping relationship aiming to enable individuals in a particular health-related situation to identify that situation and, if possible, to select the best strategy to address it (9). This relationship involves the establishment of human relations between the nurse and the patient or their family that foster attitudes encouraging interaction. This situation involves an exchange based on interpersonal communication and mutual influence. The concept of the nurse–patient relationship has thus been reconceptualised as a ‘caring interaction’, because it is based on the interaction between the nurse and the patient or the patient’s family and because the patient’s responses and behaviours have an impact on nurses and vice versa. The individual or their family need care and it is the nurse who provides that care. Therefore, the ultimate goal of these interactions in nursing is caring in and of itself (10). Given the historical, methodological, clinical, and deontological background to the concept, the nurse– patient relationship may be considered essential for the provision of care. The historical evolution of the nursing discipline is underpinned by a concern for the relationship with the patient as the starting point for care and has been influenced by a variety of perspectives, (11,12) including the interactive-integrative paradigm of nursing, according to which the individual should be considered as a holistic being requiring interaction with the nurse. The ‘school of interaction’ was created as part of this paradigm, comprising authors of nursing theories focusing on studying nurse–patient interaction. Peplau, Travelbee, King, and their contemporaries, as well as Eriksson and Jean Watson, developed theories focusing on the nurse–patient interaction and relationship (11,13,14) Other schools of thought agree on the difficulty of fully implementing nursing care without patient interaction, which is why it constitutes a core nursing intervention (15). From a methodological perspective, the nurse–patient relationship is included in the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) (10,15–17). Of particular note is the NIC intervention Complex relationship building (5000), defined as ‘establishing a therapeutic relationship with a patient to promote insight and behavioural change’ (15). There are no other NIC interventions defining or addressing the establishment of a nurse– patient relationship. However, the following NOC criteria are related to the establishment of the nurse–patient relationship: Communication (0902), Acceptance: Health status (1300), Coping (1302), and Hope (1201). These are preliminary outcomes that can be of help in advancing and consolidating the nurse–patient relationship (17). The nurse–patient relationship also has intrinsic therapeutic effects and its implementation can be justified as absolutely necessary for the achievement of health outcomes, (18,19) as it reduces anxiety levels among inpatients, improves their sense of safety and physical and spiritual comfort, and improves adherence to treatment (19–22). The establishment of the nurse–patient relationship may therefore be viewed as the foundation of nursing care and the nursing profession has now adopted a code of ethics (23) listing nurses’ ethical obligations within the exercise of their profession (24). If the purpose of nursing is to provide care and care is based on the nurse– patient relationship, this relationship itself is an ethical obligation of the profession (25,26). Methods Concept analysis is a method proposed by Walker and Avant consisting of the thorough study of the descriptions of a concept and its meanings. Concept analysis is a process of explicating a phenomenon to achieve a better understanding and maximum optimisation. According to Walker and Avant, the process of analysing concepts involves eight stages: (1) selecting a concept; (2) determining the aim and purpose of the analysis; (3) identifying the uses (definitions) of the concept; (4) defining attributes, identifying characteristics that appear repeatedly when it is defined in different sources; (5) identifying a model case, which presents all the identified attributes; (6) identifying related, borderline, and contrary cases, in which the concept is not clearly represented or situations totally contrary to the model case; (7) identifying the antecedents, or starting situations, and consequences of the concept, understood as effects or outcomes of the concept; and (8) defining the empirical referents that demonstrate the possibility of the phenomenon in real contexts and how to study it (27). Literature search The questions underpinning the integrative review were: What is the nurse–patient relationship? and What elements or attributes characterise the nurse–patient relationship? The following criteria were used to select studies: (a) documents providing a definition of the concept of the nurse–patient relationship; (b) describing one or more of the features, conditions, or attributes characterising the construct; (c) published in Spanish or English; (d) quantitative or qualitative studies, empirical research reports, and grey literature. Studies involving populations with mental health problems or mental disabilities were excluded on the understanding that the nurse–patient relationship in these cases has specific characteristics and attributes that should be identified in a separate integrative review. The search strategy employed aimed to identify articles published between 2000 and 2020 in major health databases (SCOPUS, PubMed, CINAHL, and Web of Science-WOS). The keywords used were selected from the Medical Subject Headings (MeSH) thesaurus, and the search equations were as follows: (‘nurse patient relation’ OR ‘nurse patient relations’ OR ‘nurse patient relationship’ OR ‘interpersonal relationship’) AND (nursing OR nursing care). A search of grey literature and research projects, that is, any scientific material not included in conventional databases, such as doctoral theses and scientific presentations, was also carried out using OpenGrey (the System for Information on Grey Literature in Europe) and the TESEO database by the Spanish Ministry of Education, Culture, and Sport. We also consulted the proceedings of national and international conferences held by scientific societies over the past 10 years and used the GoogleAcademic© search engine for minor, non-indexed publications. To ensure the reliability of the review, two researchers (R.A.C. and E.F.G.) conducted the searches following the same strategies between December 2020 and January 2021 and assessed the eligibility of publications on the basis of their titles and abstracts. The researchers retrieved the full texts of publications that met the eligibility criteria based on the opinion of at least one of the researchers on the basis of their abstracts. However, if the abstract did not provide sufficient information, each researcher read the full article independently. Subsequently, R.A.C., E.F.G, and A.M.P.G. resolved any disagreements and reached a consensus through joint discussions. The PRISMA Statement was used to select the final sample of studies and report the results of the integrative review (28). A narrative synthesis of the results of the selected studies and an Excel spreadsheet were prepared including author(s) and year, country of origin, objectives, design, participants, concept of the nurse–patient relationship, and elements/conditions/attributes of the relationship. The level of evidence of the studies included in the integrative review was also assessed according to the recommendations of the Johns Hopkins Institute of Medicine (29). Results This section presents the results obtained following the Walker and Avant method (27). Selecting a concept The identity and presence of the nurse–patient relationship in nursing care is undeniable from a foundational perspective.13,14 Despite its relevance for the nursing profession and care provision and its many clinical and ethical implications, there is currently no consensus definition of the concept in the scientific literature. Determining the aim and purpose of the analysis Therefore, we believe it necessary to conduct an analysis of the concept through an integrative review, as its definition varies between authors8 and its characteristics have not yet been defined in an integrated manner. Definition and use of the concept Study characteristics. The search in digital databases yielded a total of 2795 articles. The grey literature search yielded 19 documents. A total of 149 documents were selected and reviewed after eliminating duplicates and invalid records. The final sample consisted of 26 articles, which were selected after thorough reading and application of the inclusion and exclusion criteria. Ten of the 19 records obtained from the grey literature search were selected. As a result, the final study sample was made up of 36 documents (Figure 1). [Insert Figure 1] A total of 36 documents were included: 11 reflective articles (one of them on a case study), 6 literature reviews, 4 concept analysis studies, 3 integrative reviews, 3 phenomenological studies, 1 scoping review, 1 systematic review, 1 meta-ethnography, 1 descriptive study, 1 ethological study, 1 book chapter, 1 editorial, 1 interpretative paper, and 1 dissemination article published in a specialised online journal. All studies were written in English with the exception of 10 articles written in Spanish. The studies were published in a variety of countries (Table 1). [Insert Table 1] Table 2 summarises the studies included in the final sample in terms of their objectives, designs, definitions and characteristics of the concept, and methodological quality (29). Most of the articles describe the nurse–patient relationship as a helping relationship, which means that a union or bond is established between the individual requiring care and the individual providing it, so that the latter takes steps to improve the health status of the former (36,37,40,42,45,47,48,51,54,56,58,60). [Insert Table 2] The nurse and patient interact and interrelate in a two-way, reciprocal relationship. Therefore, their actions and attitudes have an impact on one another (10,34,38,44,49,57,58,63). This process is known as interaction and involves the creation of a meeting space between two or more individuals who connect with one another and work to mutually plan decisions about healthcare outcomes (35,52,53,55,59). A two-way, explicit or implicit communication process begins, encouraging alliance and engagement on both sides, that is, the nurse and the patient commit to being proactive and accountable in the care process. The nurse–patient relationship is also described as key to nursing care, as the care process would be difficult to implement without it. There is interaction from the very first contact between the nurse and the patient, and the nursing assessment, which is the first phase of the nursing process, can begin only as a result of that interaction (10,34,33,43,64). In addition, a number of authors describe the nurse–patient relationship as a nursing intervention in itself. When the relationship is positive and therapeutic, it becomes a powerful tool to enhance adherence, promote change, and achieve the objectives of the care plan agreed upon by the two individuals involved (10,30,32,46,62). Other studies describe the nurse–patient relationship as a specific nursing skill, knowledge, or attitude that can be acquired during university education like any other clinical skill (31,39,65). Consequently, it is neither innate nor voluntary in nature, as it has its own identity within nursing science (31). Defining its attributes The nurse–patient relationship has been extensively characterised in the literature, with authors agreeing on a number of similar traits, including verbal and non-verbal communication (31,32,34,37,46,48,58,60,62,63), active listening (37,42,46,58,61) mutual respect and acceptance (46,48,51,53,55,58,61), contact (42,44,58,61,62) presence (50,51,54) trust (33,37,42,46,53,55,62) and reciprocity (40,43,47,64). Other authors also identify empathy (37,46,48,51,56,63,65), compassion (55,56), mutual vulnerability (38,43,52,62) and understanding (51,56,65) as characteristic traits of the nurse–patient relationship. Authenticity, or authentic intention, understood as a value possessed by nurses who take responsibility for their behaviour and are consistent with themselves and others, has also been viewed as a component of the nurse–patient relationship by several authors (46,59). Ethical values are also viewed as essential components of the nurse–patient relationship, including confidentiality, beneficence, justice, autonomy, (46,48,55,56) and equality (64). Intimacy, closely linked to confidentiality, has also been identified as an attribute of the nurse–patient relationship. Intimacy refers to the creation of an intimate, interpersonal, therapeutic space to protect the individual and their actions from others (30,37,39,48). There is also an intersubjectivity mediated by the bond, a reciprocal process in which awareness and knowledge of the other is shared (10,41), The nurse– patient relationship is interpreted by the players in their own way (35), making it a shared experience (39). The nurse–patient relationship takes time to develop. It is not something that emerges immediately or spontaneously (43). It is also shaped by an agreement or alliance between the individuals involved (36), whereby they are willing to trust one another and take responsibility for their actions. It involves a process of becoming acquainted with the other (45,47) and considering the other (32) based on one’s own self-awareness (57) and motivation and engagement in the caring interaction (60). Given that the objective of the nurse–patient relationship underpins its inception and evolution, need fulfilment may be identified as the origin of this interaction. Individuals or families requiring care to meet their health-related needs contact and seek care from nurses, who are available and motivated to provide that care (42) Figure 2 provides a summary of the different elements and attributes that are characteristic to the nurse– patient relationship, as described above. [Insert Figure 2] Case studies Model case. Maria is a 59-year-old woman who is receiving palliative care in hospital for her terminal cancer. She is unable to receive visitors due to COVID-19 restrictions, although she has her own mobile phone to talk to her family whenever she wants. As she does every morning, her nurse enters the room, which she shares with another patient, to take her vital signs and administer the treatment she has been prescribed. The nurse notices her sad face and although she tries to engage her in conversation as she stands next to her, Maria starts to cry silently. The nurse realises that something is wrong with Maria and draws the curtain separating the two beds in the room. The nurse approaches Maria, calls her by her name, and holds her hand. Then, slowly, in a pleasant tone of voice, the nurse asks her why she is crying. Maria grabs her hand, and says to the nurse: ‘You know I’m dying, don’t you .’.. 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Nurses’ emotions on care relationship: a qualitative study. J Nurs Manag 2020; 28(8): 2247–2256. 80. Barrio I and Simo´n P. Ethical criteria for health decisions at the end of life of incapable people. Rev Esp Salud Publica 2006; 80(4): 303–315. 81. Abuhammad S, Alzoubi KH, Al-Azzam SI, et al. Knowledge and practice of patients’ data sharing and confidentiality among nurses in Jordan. J Multidiscip Healthc 2020; 13: 935–942. 82. McParland J, Scott P, Arndt M, et al. Autonomy and clinical practice 2: patient privacy and nursing practice. Br J Nurs 2013; 9(9): 566–569. Table 1. Countries of studies’origins (N = 36). Country Number of studies, n (%) United States 11 (30.5%) Spain 5 (13.8%) Colombia 3 (8.3%) Canada 3 (8.3%) Mexico 2 (5.5%) United Kingdom 2 (5.5%) Belgium 1 (2.7%) Sweden 1 (2.7%) Denmark 1 (2.7%) Australia 1 (2.7%) South Africa 1 (2.7%) China 1 (2.7%) Ireland 1 (2.7%) Philippines 1 (2.7%) Turkey 1 (2.7%) Switzerland 1 (2.7%) Table 2. Summary of the studies included Author (year ) Countr y of origin Objectives Design Participants Concept of the nurse-patient relationship Elements, conditions, attributes Level of evidence Williams, A. (2001) United Kingdo m To explore the concept of intimacy as a feature of the nurse-patient relationship Literature review N = 64 articles An element with intrinsic therapeutic potential Therapeutic intimacy V-A Lotzkar, M. & Bottorff, J. (2001) United Kingdo m To describe the development of the nurse-patient relationship and identify its features. Qualitative observational study - ethology N = 60 subjects A negotiation process between the nurse and the patient Communication III-A Sumner, J. (2001) United States To apply Habermas’s Theory of Moral Consciousness and Communicative Action (1995) to the nursepatient relationship, offering a different interpretation to the nurse-patient relationship Reflective analysis Not applicable Therapeutic intervention aiming to improve the patient’s health Communication ‘Considerateness’ V-B Mok, E. & Chiu, P. (2004) China To explore aspects of nurse-patient relationships Phenomenolog ical study N = 10 nurses and 10 patients The foundation of nursing care based on mutual understanding between the nurse and the patient to establish common goals Trust Reciprocity III-A Shattell, M. (2004) United States To describe the nursepatient interaction using Goffman’s theory Literature review Not specified A central element of clinical nursing practice based on a communicative nurse-patient interaction Communication V-B Figure 1. Study flow chart of the sampling process (PRISMA). Number of records identified through database searching PubMed (n = 1520) SCOPUS (n = 437) CINAHL (n = 391) Web of Science (n = 447) (n = 2795) Screening Included Eligibility Identification Number of additional records identified through other sources (n = 19) Records after removing duplicates (n = 149) Records assessed for eligibility (n = 149) Records excluded: Databases (n = 96) Other sources (n = 9) Full-text articles assessed for eligibility: Databases (n = 53) Other sources (n = 10) Full-text articles excluded for the following reasons: Study population: mental health and/or disability Scale validation studies Studies on the impact of the nursepatient relationship Not including the year or author Databases (n = 26) Other sources (n = 0) Studies included in the synthesis Databases (n = 26) Other sources (n = 10) TOTAL: 36 documents 2646 invalid or duplicate records excluded Figure 2. Elements and attributes of the nurse-patient relationship *Centre circle: concept definition