How does the nurse establish a therapeutic relationship with their client?
Establishing positive and trusting therapeutic relationships with patients has long been recognised as an essential component of nursing practice and is important for effective care. There are various challenges in clinical practice that make it increasingly difficult to deliver effective care centred on such relationships. Understanding and addressing these challenges is crucial to ensure a positive experience of care for patients, families, carers and nurses. This article outlines how nurses can use a framework to develop therapeutic relationships with patients and use the best available evidence to deliver effective care. It also explores the challenges in developing effective therapeutic relationships with patients at the healthcare system level, and considers how these challenges can be addressed. Show
Nursing Standard. doi: 10.7748/ns.2017.e10735 CorrespondencePeer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software Nursing and Physiotherapy Department, Universitat de les Illes Balears, 07122 Palma, Spain; [email protected] *Correspondence: [email protected] Received 2019 Dec 26; Accepted 2020 Jan 26. Copyright © 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/). AbstractBackground: The patient is observed to acquire a passive role and the nurse an expert role with a maternalistic attitude. This relationship among others determines the capacity for autonomy in the decision making of patients. Objectives: The aim of this study is to analyse the nurse-patient relationship and explore their implications for clinical practice, the impact on quality of care, and the decision-making capacity of patients. Design: A phenomenological qualitative study was conducted. Settings and participants: Thirteen in-depth interviews with nurses and 61,484 nursing records from internal medicine and specialties departments in a general hospital from 2015–2016. Methods: A discourse analysis and triangulation for these sources were conducted. Results: The category elaborated from nursing records was defined according to the following codes: Good Patient, Bad patient, and Social Problem. Analysis of the interviews resulted in a category defined as Patient as a passive object. Discussion: A good nurse-patient relationship reduces the days of hospital stay and improves the quality and satisfaction of both. However, in contrast, the good relationship is conditioned by the patient’s submissive role. Conclusion: An equal distribution of power allows decisions about health and disease processes to be acquired by patients, autonomously, with the advice of professionals. The nurse-patient relationship should not pursue the change in values and customs of the patient, but position the professional as a witness of the experience of the health and illness process in the patient and family. Keywords: nurse-patient relationship, decision making, personal autonomy, quality of health care, nurse’s role 1. IntroductionIn general, most of the literature does not deal with behaviours and communication skills between the nurse-patient relationship and the role of both. There has been a large amount of documentation on self-care strategies, medication adherence, psychological interventions, and patient and nurse satisfaction [1,2,3,4] Studies on the implications of this relationship in the perceived improvement of patient care are also common [5]. Many studies have focused on the exploration of nurse-patient relationships based on empirical studies [6,7,8,9]. Most of the literature refers to the experiences of nurses and are narrated in a personal tone [10]. This research focuses on how the nurse’s relationship with the patient can affect the capacity for autonomy in the latter’s decision making. Although it is a phenomenon that is affected by many other factors such as interprofessional relationships, the health institution, care models, etc. 2. BackgroundThe most concurrent topics in the literature reviewed on nurse-patient relationship are the (a) role of the patient, (b) role of the nurse, and (c) type of nurse-patient relationship. 2.1. Role of the PatientA significant number of authors agree that the patient is usually considered a passive subject [11,12]. Thus, it is understood that, classically, a person who assumes a rigorously passive attitude, who does not ask or protest and who obeys all the mandates is considered a “good patient”. This conception places excessive emphasis on the authority of the professional regarding the patient [13]. Hallet et al. [1] associated the passive role as a form of paternalism, wherein the patient is seen as a subject who must be limited to comply with the therapeutic indications. Kleiman, Frederickson, and Lundy [14] relate the passive role with the belief of professionals that many patients, or most of them, do not have the educational and cultural levels necessary to engage in an equal professional relationship [15]. The reviewed works show that patients focus their relationship with the nurse on trust [16]. The patient trusts the nurse and allows her to make decisions, being treated as a minor. Many authors see the origin of this role in the Oath of Hippocrates that places a large emphasis on the power, knowledge, and virtues of the professional, without mentioning anything about the autonomy of the patient [4,17,18]. Henderson [19] notes that this domination over the patient causes a depersonalization and, consequently, a worsening of the relationship between the nurse and the patient [11,20]. 2.2. Role of the NurseThe bibliography refers to two types of roles that are well differentiated from the nurse: The role of an expert nurse, and the role of a maternal nurse. Most authors describe the practice of nursing as empirical [21], wherein cognitive, behavioural, integration of skills, values, and beliefs are relegated to a secondary level. Other authors consider the expert role to be circumscribed by a collection of fragments of information only on biological aspects of the patient [22]. In contrast, Brown [23] considers an expert professional to direct his knowledge, professional experience, and clinical skills to the specific objectives of each patient. Thus, the conceptions of the expert role of the nurse are very heterogeneous. Regarding the maternal role, authors refer to a position of the nurse that is more intimate than desirable [24,25] or is based on the concepts of adherence [26], collaboration [27], concordance [28], and compliance [29]. It is interesting to note how some studies identify the role of nurses as simple informants of treatment regimens based on the assumption that if patients understand, they will be compliant, again highlighting the maternalistic role of the nurse [3,4,17]. 2.3. Types of Nurse-Patient RelationshipsThe studies analysing the type of nurse-patient relationship focus on concepts of compliance, empowerment, quality of the relationship, impotence, and power. Compliance is defined as the will to develop and consent to the wishes of another person [29,30]. Along with the term compliance [31,32], others have been considered, including empowerment [32,33] and association [11,34]. These studies refer to the nurse-patient relationship as an interaction between both based on the patient’s autonomy in making decisions after listening to the advice of professionals. Regarding the quality of the relationship, it appears to be a factor that influences the professional to promote patient-centred care [2]. Luker, Austin, Caress and Hallet [35] argue that this quality of the relationship directly affects the quality of care provided and is crucial for the effectiveness of the nursing practice. Regarding the concept of impotence, the authors analyse the nurse-patient relationship according to the difficulties experienced by the nurse to observe the real needs of the patient without clinical practice guidelines or evidence-based practice support [1]. However, in addition, this impotence is generated when the patient does not receive the expected attention from professionals [36]. Finally, a concept present in the literature is that of power [15,37]. Cameron [31] defined it bilaterally, in which the professional develops a “reference power” in the patient, and for the patient, the professional is considered a “frame of reference”. The patient’s perception of the professional will be configured: An expert who exercises power over the decision-making process during care [24,38]. The health system has developed strategies with the aim of humanizing care and improving the quality of care. However, now the management models have not allowed a real autonomy of the patient in the decision making. The nurse-patient relationship is one of the aspects that affects the patient’s autonomy. Analyzing the types of relationships allow us to establish new ways of understanding the decision-making capacity of patients in a clinical setting. The analysis of nursing records and nurse discourses have shown that our professional practice is not yet totally patient-centred. A good nurse-patient relationship reduces the days of hospital stay and improves the quality and satisfaction of both. However, in contrast, although the patient’s participation in their decisions is greater, the good relationship is conditioned by the patient’s submissive role [39,40,41,42]. A poor or bad nurse-patient relationship decreases the quality of care and diminishes the patient’s autonomy. A bad patient is considered who demands a lot of information, who wishes to make his/her own decisions, sometimes, contrary to those recommended by professionals, who does not maintain a good relationship with professionals [40,41]. The aim of this study is to analyse the factors that condition the nurse-patient relationship and explore the implications for clinical practice, the impact on quality of care, and the decision-making capacity of patients. 3. Materials and Methods3.1. Research DesignA phenomenological qualitative study was conducted. A discourse analysis was conducted for two sources. On the one hand, through in-depth interviews with nurses, and on the other hand, nursing records about the clinical evolution of patients from internal medicine and specialty departments in a general hospital. This study on nurse-patient relationships belongs to a larger one that has also analyzed interprofessional relationships and the relationship of the nurse with management models. This article analyses the patient’s autonomy in decision making and the factors that condition it, based on the criticism of the current ethical model in the clinical setting from the perspective of Foucault [43,44]. Knowing the connection between the patient’s autonomy and power’s exercise in daily practices in a hospital is essential to understand and articulate a Foucauldian ethic. For this reason, the mechanisms and procedures that are present in the exercise of strategies of normalization, homogenization, impositions, restraints, oppressions, and knowledge that determine the patient’s autonomy capacity in making decisions must be analysed [45,46,47]. The perspective of the Foucauldian ethic analyses the autonomy based on the codes that currently configure the behaviors allowed or forbidden as opposed to personal choice that opens a new possibility of understanding ethics. This analysis allows us to establish a new way of understanding the subject as an autonomous being. Foucault’s ethical proposal aims to break with the ethics based on universal principles, giving rise to a greater leadership to the patient’s self-determination [48,49]. 3.2. Sample/ParticipantsNursing records were collected throughout the year 2019 and interviews were conducted from March to December 2019. The Department of Internal Medicine and Medical Specialties compared to the other units, has the most types of pathologies attendance and different types of professionals are present. With respect to professionals from both services, we highlight the following characteristics: Nurses (23 regular staff and approximately 70 temps per year) working three shifts, in the morning, afternoon and night, with an average age of 33 years and a minimum experience of five years in service and nine years as a nurse. The reasons for selecting these units are as follows: (a) These are the services with the highest occupancies in the hospital. This allows an analysis of the phenomenon in greater depth because there is greater wealth in the nurse’s relations with the patient and other professionals; (b) since there are different pathologies, this allows different types of care and therefore, greater complexity in the nurse-patient relationships; (c) these services have the highest health care burdens (data obtained from the system of Related Groups for the Diagnosis of the Health Center, which establishes the workload and distribution of necessary health personnel). In this way, the tensions and resistances that arise between the nurse and the patients can be analyzed in greater depth; and (d) these services are associated with a greater number of professionals on staff, but a lower nurse-patient ratio and a greater diversity of the specialties involved in patient care. 3.2.1. Nursing RecordsNursing observation records are documents in which nurses collect the assessments and incidences on the care and clinical evolution of the patients. These documents include all activities that the nurse performs during her work shift and are recorded in the medical histories. In the Spanish health system, the nursing records are annotations that nurses make about the patient’s clinical evolution, as well as the care plan for these patients during a work shift. These records can be accessed by nurses of all shifts assigned to the patient, their doctors, and other professionals as assistants. Only the healthcare professional and not administrative staff. The inclusion criteria were as follows: (a) Computerized records in the care management programme of the Can Misses Hospital in Ibiza and (b) clinical histories of patients who have been admitted to the unit for more than five days, with a minimum time considered to have generated greater discursive significance on the continuity of care. 3.2.2. Interviews with NursesOf a total of 16 nurses in the two selected services, only 13 met the inclusion criteria. Ten semi-structured interviews were conducted, by which the level of theoretical saturation was reached. The inclusion criteria were as follows: (a) Nurses with a minimum experience of five years, which is considered enough time to have some professional expertise in the development of nursing care; (b) nurses with a minimum stay of three years in the services under study, which is considered a sufficient duration to understand the structure and function of this unit and the professionals involved in the team; and (c) nurses who agreed to participate and signed the informed consent. 3.3. Data Collection3.3.1. Nursing RecordsAll records of nursing observations that are reflected in the Patient’s Clinical Record are included in a computer care management tool called Gacela ©. This tool allows nursing observations to be obtained without needing to know the personal data of the same or of the professionals involved, which supposes an absolute anonymization of the data and therefore a guarantee for the participants’ right to confidentiality. Both the nursing records and the clinical unit have been selected through intentional sampling. Initially, all records for the year 2015 were used for their chronological reading from January to December of the internal medicine unit, totaling more than 60,000. This hardly manageable amount for a study of these characteristics raised a series of strategies for definitive selection. These strategies were as follows: (1) Select a series of key words regarding the core concepts of the study and review the literature, which by means of a sweep with the Atlas.ti program provided a first approximation of the saturation of the discourse; (2) select the months that generated the greatest amount of discourse regarding the study phenomenon. For this reason and taking into account the months that met the inclusion and exclusion criteria, the months of January, February, March, and April were selected; and (3) after selection, the data were exported to Atlas.ti and its categorization and codification. The records were stored in a database from which the preliminary analysis has been developed. The first step of the data collection consisted of the literal reading of the records. An encrypted code was assigned to each patient and professional corresponding to the records, and later records were classified by the same registration number to ensure the inclusion and exclusion criteria. 3.3.2. Interviews with NursesAn in-depth interview technique was used via non-intrusive or direct yet comprehensive interactions within the framework of the participants, observing reality as they experience it and how they view the study phenomenon. For the recruitment of nurses, they were contacted through the hospitalization unit and invited to participate. After accepting, the information sheet and informed consent were given. A day and time was specified with them for the realization and recording of the interview. The entire data collection process was accompanied by the development of a field diary and dual digital recording in the presence of an observer, who collected data on metalanguage, positions, and gestures, among others. The minimum duration of the interview was 34 min, and the maximum was 68 min. After the recording was obtained, it was incorporated into the database for the study for the sole and exclusive use of the research team members. After checking the audio, the recordings were delivered to the transcriber, who had previously signed a confidentiality agreement regarding the data. To ensure data anonymity, each transcript was reviewed, and symbols were substituted for the names of people or places. From then on, every interview was assigned a hermeneutic unit by the qualitative programme ATLAS.ti version 6 (Scientific Software Development GmbH, Berlin, Germany). 3.4. Ethical ConsiderationsThis research involves completely confidential data and sources from the personal data of patients to the professionals who treat them. This study was approved by the Ethics Committee for Clinical Research of the Balearic Islands and was authorized by the hospital. With respect to the recorded interviews, once the digital files were transcribed, the recordings were discarded. In addition, the study participants received information about the research and signed an informed consent document developed for this study. We respected the legislation in Spain and the principles of the Declaration of Helsinki and other international recommendations with regard to data protection. No conflict of interest existed between participants and researchers conducting the study. 3.5. Data AnalysisDiscourse analysis was used to explore the factors that condition nurse-patient relationships and their impact on the quality of care and the patient’s autonomy in decision-making from the nurses’ perspectives. A discursive analysis was used to reconstruct the meaning of the text from the particular to the general. Association and interpretation along with the extraction of conclusions consisted of interpreting the transcripts and their implied significance based on Foucault’s poststructuralist theory. 3.5.1. Validity and Reliability/RigourThe strategy of methodological rigor was carried out through a field diary in which the steps and decisions were assumed during the development of the investigation of two analysed sources, and the nurses’ records and in-depth interviews with nurses were described. 3.5.2. About the Nursing RecordsFrom the documentation technique, the nursing records were selected. This technique has contributed the narrative of the texts in a temporal order, with key arguments used to analyse the nurse-patient relationship. With the electronic anonymized format, the records were selected according to the inclusion and exclusion criteria established in the methodological design. The following table (Table 1) presents the documental process of selection of records from the first screening performed. Table 1Nursing record selection process. N RecordsMonthsNursing Records in Inclusion CriteriaNursing Records in Exclusion CriteriaTotal Selected in Phase IExperience > 3 yearsHospitalization > 5 daysExperience < 3 yearsHospitalization < 5 days9103January 2015910391030091038037February 2015803780370080378820March 2015882088200088208821April 2015882188210088217906May 2015391239123221 *773 **391211744June 20158568567233 *3655 **85613929July 20157747744899 *8256 **77411192August 20153083081006 *9878 **3089962September 2015252125215623 *1235 **252110996October 2015698769873210 *789 **69879379November 2015703670361211 *566 **703611204December 2015430943096253 *321 **4309Subtotal61.48432.65625.473Total61484 Open in a separate window * Due to the vacations of the fixed staff of the internal medicine service, the criterion of minimum of experience in the service of three years was not covered. ** Due to the summer period, patients did not stay in the service for more than five days, when they entered internal medicine due to acute pathologies. In the table, a change in the number of records is highlighted that affects the inclusion and exclusion criteria expected from the month of April. This situation is due to two clearly differentiated factors. On the one hand, the criteria refer to the nurses in the service who, as of the month of April, initiated vacations periods and were replaced by temporary personnel with no minimum experience of three years in the service. In addition, nurses who acted as reinforcements of personnel with very short contracts due to workloads caused by the increase in the population in summer periods were identified as another cause of the aforementioned change. On the other hand, in reference to the criterion of patients admitted for at least five days, from the month of April and especially during the summer months, changes in the pathologies of admission, with more acute episodes and the overload of other services, resulted in differences in internal medicine. Taken together, these findings explain why the records selected in this first phase decreased according to the established criteria and justified the methodological approach. Using very brief and descriptive records, we decided that references to purely clinical values such as vital signs, diagnostic tests, or delegated activities would be omitted. Due to the characteristics of the records, these being very brief, sometimes non-existent, we tried to cover most of the records and use those that presented the greatest discursive load for a deeper discourse analysis. Despite this, the number is so high, considering that certain ways of registering provided a wealth for the analysis. 3.5.3. About Interviews with NursesInterviews with nurses are included to both expand the information of the records and compare a written discourse of them with that obtained through an in-depth interview of the nurses about the phenomenon under study. The interview script was elaborated based on the objectives of the study and the thematic categories that emerged during the literature review. Two interviews with nurses were scheduled in January 2019 for similar services from another hospital centre to pilot this script. From this piloting, some questions were modified due to difficulties in compression and response. In this way, the final script of the interview was established, taking into account the semi-structured interview technique in depth. At the beginning of each interview, the sociodemographic data were collected for the participants (Table 2). Table 2Sociodemographic characteristics of the interviewees. NurseAgeUnitProfessional Experience in YearsYears in UnitsLabour SituationE137EME *115Permanent staffE229EME96Eventual staffE334MIR **135Eventual staffE450EME2819Permanent staffE554EME1724Permanent staffE639EME186Permanent staffE735MIR123Eventual staffE837MIR103Eventual staffE945MIR127Eventual staffE1031MIR95Eventual staffE1137MIR95Eventual staffE1228EME73Eventual staffE1331MIR95Eventual staff Open in a separate window * Medical specialties unit. ** Internal medicine unit. The use of various tactics such as facilitation-animation, reaffirming and repeating questions, clarification of the concepts asked, and recapitulation was required. The transcription included a series of common elements for the representation of silence and other aspects of the discourse (Table 3). Table 3Transcription techniques used. ElementTranscriptionSilence > 3 s(Silence)Silence < 3 sLaugh(Laugh)Laughter interviewer, interviewee, and observer(All laugh)TailsLiteral transcriptionDoubtful attitude(doubt) Open in a separate window The triangulation consisted of the delivery of four interviews transcribed to each member of the research team and three meetings for sharing the transcriptions. It began with an initial inductive analysis without pre-established categories or codes, although the topics described in the literature review and the objectives established in the study were considered as references. We then proceeded to the elaboration of certain categories that encompassed these discourses, and an approximation of the codes of each category was made according to the different discursive positions. The comments collected increased the methodological rigor of the research and provided key elements for its subsequent categorization. Next, the refined and sensitive discourse analysis phase began. This process allowed the division of each code in different discursive positions before the phenomenon of study, as well as the configuration of a series of relationships (association, causal, and transitive) between the different codes based on the factors determined by the studies carried out in this regard according to the literature review. All these aspects established the criteria used to assess the methodological rigor of the study. These were credibility, auditability, and transferability, in accordance with Morse [27]. 3.6. Research LimitationsIn relation to the particular limitations of the technique of collecting data from nursing records, it should be noted that since it is a very extensive documented source, with concise and unstructured texts, we have established a selection strategy to ensure the analysis of contextualized discourse in the clinical setting. This selection is meant to circumscribe certain months of the year and the discrimination of those registries that did not contribute, due to their grammatical structure, information relevant to the phenomenon under study. 4. Results4.1. Nursing Records in Clinical HistoriesSingular characteristics of the construction of nurses’ discourse on the clinical evolution of a patient are observed. The set of nursing registers are, for the most part, brief, unstructured, centred on clinical plots of the patient, and without connection to each other. Depending on the narrative style of the nurse, more or less punctuation marks, separations and use of capital letters appear. The structure of the discourse also demonstrates the ease or difficulty to express certain situations and the greater or lesser interest of the nurse in preparing such discourses. The category elaborated from the discourse analysis of the registries has defined the Be Patient with the following codes: Good Patient, Bad patient, and Social Problem from the Nurse Perspective (Table 4). Table 4Category, codes, and definitions of nursing records about clinical evolutions of patients. Category: Be PatientCodeDefinitionNursing RecordsGood patient from nurse’s perspectiveIn an impersonal way, clinical states, vital signs and pathologies are recorded, wherein the identity of the patient disappears. Open in a separate window * people who do not have a supportive social support or live in a situation of risk of poverty. It is evident that the nurse prefers a submissive and passive patient. Hence, two types of patients are fundamentally conceptualized. The first is a patient as an object of care, who is described as collaborative and participatory and with a limited ability to make decisions. The other patient, the one that generates discomfort because of his attempts to make decisions about his care, leads to denial in the face of certain interventions or nonconformity for perceived attention. A small number of records describes other patients who can be characterized by their clinical and socio-familial situation and are classified as agitated or with social problems. The definition of a “good patient” is one who collaborates and participates in what the professionals indicate, who moderately expresses their feelings and concerns, who is autonomous in basic activities such as hygiene, food and elimination, and who ultimately does not make decisions about his care, clearly providing a more comfortable role for the nurse. A “demanding” patient, one who is difficult or uncomfortable, who denies professional imperatives and is agitated neurologically, is perceived by the nurse as a “bad patient” due to the increase in workload and tensions that arise in the relationship between both. Hence, the preference of the nurse for a patient with a passive role in care with little or no role in decision making is reinforced. Finally, another conceptualization of a patient classified according to their degree of physical autonomy and socio-familial assessment appears, which does not provoke a negative or positive perception in the nurse but rather a maternalistic attitude in this regard. 4.2. Nurses InterviewedThe profile of the interviewed nurses was mostly women, aged from 29 to 54 years, with professional experience between nine to 28 years and who have developed their professional practice in internal medicine and medical specialties services for at least three years, although some have been working for up to 24 years. The employment situation of the interviewees was permanent staff of the health service, interim personnel, or on commission of services. This indicates stability in both groups, although some of them were only for a few months. Although segmentation variables were not considered, the sociodemographic characteristics were described according to the homogeneity in the distribution of the groups, allowing the distinction of two stripes in each characteristic to analyse the differences that appear in the discourses. Analysis of the interviews has generated a category in the patient-nurse relationship, confirming what was found in the registers and what has been defined as Patient as a passive object of care. The codes that have appeared in this category are Protective paternalism with the patient, Tensions in the relationship with the patient, Power of decision of the patient, Strategies of power of the nurse, Good patient for the nurse, and Impact of the nurse relationship-patient in care (Table 5). Table 5Category, codes, and definitions in interviews about patient-nurse relationship. Category: Patient as a Passive Object of CareCodeDefinitionInterviewsProtective paternalism with the patientIt is noted that the nurse acts as a consultant to the patient, taking the doctor as a reference. The nurse bases her relationship with patients on trust and friendship to calm their anxieties and worries during the hospital stay. Open in a separate window It was found that for the nurse to support, empathize, advise and care for a patient, and ultimately, to develop a good relationship with him, the degree of participation in the care and attitude acquired by the patient in this relationship are decisive. In this sense, the majority of nurses interviewed asserted that the patient must accept his illness, collaborate, and carry out all indications imposed on him by the professionals. Otherwise, there are conflicts that cause changes in the attitude of the nurse and configures the concept of the “good” or “bad” patient. The type of nurse-patient relationship determines the making-decision of patients. Nurses with fewer years of professional experience believe that physicians should make the last decision about care. The nurse only makes decisions about basic care and, in some cases, after consulting the doctor. However, nurses with more experience recognize their influence on the decisions of the doctor. Likewise, a preference for an obedient patient appears in the discourse of younger nurses and those with fewer years of professional experience. Having more experience is related to assuming that patient decision-making depends on the degree of participation allowed by the nurse. They recognize that the guidelines are established by the professional or the institution and must be enforced. The nurse controls the relationship in terms of empathy and direct treatment with a paternalistic attitude, and the patient accepts this control, in these terms. This relationship is efficient, stable, and predictable if each one acquires the established role. Thus, the patient’s decision-making capacity is limited to assuming the passive role that is the object of care. In addition, certain differences are observed in nursing discourses according to their age and professional experience. Although in both groups the relationship with the patient is based on trust, in nurses with a younger age and less experience, this trust is given when the patient values and respects the work of the nurse. In the older and more experienced nurses, the interpersonal relationship with the patient is prioritized to generate this trust. In all the described roles, the capacity for the decision-making of the patient is limited, demonstrating a greater presence in young nurses and those with little experience. In older and more experienced nurses, there is a greater recognition that this autonomy is limited by the professional. 5. DiscussionThis study reveals that the patient is not autonomous in making decisions about their care due to the characteristics of the nurse’s relationships with the patient, as an important factor among others. It is these elements that describe the current situation in a hospital setting and the ability of the patient to make decisions regarding the kind of care they want from the perspective of the nurse. There continues to be a crossroads between a model of protective paternalism and an informed choice model [2,17,50,51,52,53,54]. In this study, both models are intermingled, but the dominance of the first one is observed. It is noted in the results that the professionals are those who make decisions on the patient’s care. The records provide the clinical characteristics of the patient, but there is no consistency in terms of their identity or their decision. When reviewing the records, the reference to psychological aspects or decision making, are practically absent. Most refer to hemodynamic or purely clinical aspects: “hemodynamically stable patient” “has no fever”. While in the interviews, the decisions are based on the confidence about how the technical aspects are relegated to the background. In both sources, the records and interviews, the silence of the patient in the decision making is evidenced. The nurse constantly justifies any decision about care, for the benefit of the patient, without leaving a space for their autonomy. Faced with a clinical situation, the professionals decide based on scientific evidence. On some occasions, but not always, they take into account the opinion of patients as revealed by Epstein and Peters [55], Nelson, Han, Fagerlin, Stefanek and Ubel [56], Sevdalis and Harvey [57] and Dowie [58]. This study dominates a restrictive conception about the decision-making of patients in our clinical setting. Despite the dominance of the restrictive model, certain discourses emerge in nurses, which emphasize the need to involve the patient, advising on the different possible care alternatives. The nurse-patient relationships, although characterized by trust, remain fixed and marked by the roles assumed by each in that relationship, as defined by Enmanuel [59]. Therefore, the limitations of practical operationalization of a more open model in the decision making of the patients proposed by Cribb and Entwistle [50] are manifested. 5.1. Autonomy in the Decision-Making of the Patient According to the Relationship with the NurseBoth records and interviews confirm that the nurse prefers a submissive and passive patient who complies with the therapeutic indications (Figure 1), which would explain why the nurse focuses on patient clinical records in an impersonal way, in which the patient’s voice only refers to situations of pain or subjective perceptions. Open in a separate window Figure 1 Autonomy in the decision-making of the patient according to the relationship with the nurse. This idea is reinforced in interview discourses, in which the nurse assumes that the patient must trust the professional fully and let go. Thus, when the patient enters a hospitalization unit, figuratively, he/she becomes the property of the professionals and is therefore dominated by them, as indicated by Arrollo Arellano [13]. The “good patient” is conditioned by the degree of submission that the patient acquires in the relationship with the nurse. The results of the present study also reveal that to be considered a “good patient”, characteristics such as accepting the disease and not continuing denial, not requiring a lot of information, and not requiring attention, must be present assuming the rules and norms of the institution, that the work of the nurse must be valued and that a collaborative and participatory role is observed in the imposed care. 5.2. Perception about the PatientThe results show that the nurse is immersed in a dialectical duality to define a good or bad relationship with the patient. This definition inevitably passes by cataloguing the patient as “good” or “bad”. While the profile of a “good patient” is not clear. In general, a “good patient” from the nurse’s perspective is defined by a patient without identity, trusting, without information, and grateful, i.e., a submissive patient, passive object of care, and without decision power. Important difficulties are observed to refer to the characteristics of a “bad patient” depending on the role and attitude acquired by the nurse in the relationship. The common denomination in both records and interviews is that of the “demanding” or “very demanding” patient, which curiously appears in records as a sign of alarm among professionals to initiate a series of preventive strategies in the relationship with the patient. Demanding patients are those who, in general, increase the workload of the nurse, with respect to what she considers should be dedicated to each patient according to their pathology. Such patients do not obey the orders of professionals, refuse treatment and care, and demand a lot of information. A good relationship with the patient, in contrast, is accompanied by mutual trust, cordiality, closeness, resolution of doubts, counselling, empathy and even friendship, as widely contextualized in other studies [4,7,21]. The bad relationship poses a positioning of the nurse as an expert in care, accompanied by a distancing towards the patient, with continuous conflicts, scarce communication, a decrease in time dedicated to the patient and their concerns, and a relationship centred purely on technical aspects. 5.3. Nurse-Patient RelationshipThere is a direct impact on the quality of care depending on the type of relationship with the patient. The nurse recognizes that a good relationship improves the quality and healing results in the patient, as previously described in the study by Ramos [60]. Each of these patient conceptions carries with it an associated role and attitude of the nurse. It is evident in the results of records that before a patient refuses, the nurse acquires an expert role that entails persuasion and coercion to achieve the indicated healing objectives [15,61]. In the interviews, the nurse appears as an expert in the delegated activities from physicians, in association with technical skills and clinical knowledge about the pathologies. An interesting dichotomy between records and interviews emerges in this sense. While the texts of the interviews are more valued communication skills and relegates to the background techniques, the records show that most of them only refer to purely technical aspects. Nurses in verbal discourse, bet more on aspects of empathy, understanding, and emotional approach to the patient. However, the records, for the most part, express clinical values, hemodynamic stability, etc. Additionally, although this role can be confused with empathy, it ceases to be so when a continuous manifestation of care that annuls the patient’s autonomy for their benefit and survival appears in the interviews. The patient perceives the nurse as one who makes decisions about his/her care, becoming a reference of imposed power, as indicated in the study by Buchmann [29]. In this dominating-dominated binomial, the patient acts as dominated, and the nurse manipulates the power, alleging a protectionist attitude towards the weakest part using strategies of power such as manipulation, persuasion, and coercion and therefore exercising a role, paternalistic or as an expert, of domination. This situation causes a homogenization of the patient that threatens their identity and hinders the individuality and uniqueness of the people. The present data indicate that the free and autonomous behaviour of the patient in the clinical setting is, insofar as the health institution and professionals are involved, especially the nurse, inclusive of the patient’s capacity for decision-making competencies. The factors analysed in this work show that the patient’s decision-making power over their care must be explained through the nurse-patient relationship. 6. ConclusionsThe passive role of the patient acquires its maximum expression in hospitalization units, in which the context is assumed to lack autonomy to participate in their care and decisions regarding treatment. A quasi-parental role of the patient’s professional and quasi-infant provides a mixture of beneficence and power. The nurse aims to benefit the patient, justifying their paternalistic role, and nullifying the decision-making capacity of the patient. An equal distribution of power allows decisions about health and disease processes to be acquired by patients, autonomously, with the advice of professionals. The nurse-patient relationship should not pursue the change in values and customs of the patient, but position the professional as a witness of the experience of the health and illness process in the patient and family. The results of this research show the use of language as a tool of power, exercised through orders to patients. These orders are based on persuasion before those who resist the impositions of professionals. The language used is based on a sealed communication and the use of terms of affectionate content. This research allows the following: (1) Guiding health organization managers to establish strategies that increase the autonomy of patients in decision-making, (2) modifying those aspects that limit the decision-making power of patients, and (3) implementing new ways to understand the management of health organizations that favour the relationship between members of the healthcare team and the interaction of professionals with the patient, focusing these strategies on the decision-making capacity of the patient in the clinical setting.
Author ContributionsConceptualization, J.M.-M. and J.G.-E.; methodology, J.M.-M.; software, J.M.-M.; validation, J.M.-M., J.G.-E.; formal analysis, J.M.-M..; investigation, J.M.-M.; resources, J.M.-M.; data curation, J.M.-M.; writing—original draft preparation, J.M.-M.; writing—review and editing, J.M.-M.; visualization, J.M.-M.; supervision, J.G.-E.; project administration, J.M.-M.; funding acquisition, J.M.-M. All authors have read and agreed to the published version of the manuscript. FundingResearch funded by the Advanced Research Chair in the College of Nurses of the Balearic Islands (349/11). What is the most important in establishing therapeutic nurseIt can be stated that empathy is not only a moral and philosophical issue but one of the most important competencies of a modern nurse. Without empathy there is no trust, without trust, there is no sincere and good therapeutic nurse‐patient relationship, which is helpful in the treatment process.
What is the therapeutic nurseThe five key components of the therapeutic nurse-client relationship are professional intimacy, power, empathy, respect and trust. Regardless of the context, length of interaction and whether the nurse is the primary or secondary care provider, these components are always present.
How does a nurse establish a therapeutic relationship quizlet?By developing self-awareness and beginning to understand his or her attitudes, the nurse can begin to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients. This is called therapeutic use of self.
What are the 4 phases of therapeutic nurseHildegarde Peplau describes four sequential phases of a nurse-client relationship, each characterized by specific tasks and interpersonal skills: preinteraction; orientation; working; and termination.
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