Concept of Nurse-Patient Relationship

“Nursing is a dialogue-a human-to-human event”. This is according to Lynette Long on the subject of nursing as a communicative and understanding process that has been for some time now overlooked by many nurses in our major hospitals and health centres (Long 1992). The subject of this essay is a look into the concept and relating the same using a famous theorist- Peplau- in certain acute conditions of patients. No matter what theory of nursing would be espoused, all that nursing involves is the human to human process of relating. The concepts in this case include basis for communicating and ultimately building a relationship by attending, listening, perceiving, caring, disclosure, acceptance, empathy, authenticity and respect. In regard to an acute conditioned patient, relationship with the person from a nurse’s perspective can always go a long way in according some form of comfort and recognition. According to Long, a powerful moment in the dynamics of communication that makes possible a deeper experience of the relational nature of nursing is the moment when there is a simultaneous understanding between the nurse and the patient.

The work of Hildegard Peplau offers a very important contribution to the practice of nursing in many settings. Even though the original context was a psychiatric setting, the work of Peplau has relevance across the clinical spectrum since it focuses on the interpersonal relationship that is to exist between a nurse and a patient (Andrist, Nicholas and Wolf 2006). It is important however, for the understanding of the theory, to first understand Peplau’s definition of nursing and the nursing process. According to Wolf, Nicholas and Andrist, Peplau viewed nursing as a “significant, therapeutic, interpersonal process” that works in the cooperation with the other existing human processes to make health possible (2006). In quoting Peplau, Andrist, Nicholas and Wolf, state that

“In specific situations in which a professional health team offers health services, nurses participate in the organization of conditions that facilitate natural, ongoing tendencies in human organisms. Nursing is an educative instrument, a maturing force that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal, and community living.” (Peplau 1952, p.16)

According to Peplau, a number of roles that would generally be taken by the nurse emerging from the relationship were six. These include:

Stranger: A nurse meeting a patient for the first time offers a basic form of respect since the nurse and the patient do not know each other they are estrangers but must begin to forge the nurse-patient relationship. It is at this stage that many conscious and unconscious feelings are formed that follow and influence the nurse’s ability to support the patient. At the initial stage the nurse determines to form a communication link with the patient and his or her family member(s), developing the initial groundwork for the evolution of the relationship.

Resource: At this point the nurse is expected and generally would be answering many questions and interprets any technical language, plans, or procedures needing clarification. The technical language may be very difficult for the patient to understand; hence the nurse minimizes anxiety in such difficult situations.

Teacher: This role is divided into two categories by Peplau; instructional that includes disseminating literature and providing information, and secondly, experiential role that utilizes the patient’s base of experience to guide the learning (Peplau 1964). During the time when patients share their thoughts, the nurse can assess what is needed and how best to process.

Leadership: This role of the nurse is heavily influenced by the nursing management which may be autocratic, laissez-faire, or democratic. The patients normally look to the nurse for leadership in managing their care the nurse’s ability to lead is dictated partly by the views and management style of the seniors. Peplau believed that a democratic leadership was the best since it allows patients to become active participants in the design of their own nursing plans.

Surrogate: This role involves the nurse having to, more often, remind the patient of someone in their past. The patient often verbalizes these feelings to the nurse hence enabling the nurse explore the relationship with the patient. In so doing, the nurse would be furthering the establishment of trust and thus helping the patient recognize the difference between the nurse and a symbolic figure. The nurse-patient relationship moves forward from its initial stages of dependence to independence, with the goal of the adult interdependence.

Counselor: The nurse’s role of counseling is most challenging since the nurse is to help the patient process how they feel about their current health-related situation and experiences thereby integrating these feelings into their lives rather than disassociate them. Counseling according to Andrist, Nicholas and Wolf is not about giving advice but it entails reflecting, restating, observing and being able to understand a patient’s silence during a conversation (2006).

Virginia Henderson, a famous theorist also in the nursing field, viewed the patient as a person requiring help toward achieving independence. She envisioned the practice of nursing as independent from the practice of most physicians acknowledging her interpretation of nurse’s function as a synthesis of many influences (Tomey and Alligood 2005). Henderson is quoted by Tomey and Alligood, saying that the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery that he would perform unaided if he or she had the necessary strength, will, or knowledge and to do this in such a way as to help him or her gain independence as quickly or rapidly as possible. Henderson identified a number of basic needs upon which nursing care is based on with a three level nurse-patient relationship. The nurse in her understanding needs to act as:

–  A substitute for the patient

–  A helper to the patient

–  A partner with the patient

Henderson supported an empathetic understanding stating that the nurse must “get inside the skin of each of her patients in order to know what he needs” (Tomey and Alligood 2005). Looking at the various four phases that Peplau stipulates including: orientation, identification, exploitation, and resolution. Firstly looking at the initial phase, orientation, the nurse-patient relationship begins with the patient exhibiting a “felt need” for help from a professional. At this point, according to Andrist, Nicholas and Wolf, the nurse first has to assess the situation, taking note of the patient’s physical and psychological needs. In the case of acute conditions, the nurse has to be very careful and requires both objective and subjective assessment. Secondly, the nurse needs to assess the needs of the family then can begin to work with the patient (and family) to establish a relationship. Consequently, the patient becomes an active participant in the process, asking questions either personally or though the help of the family member present; in acute conditions, and by so doing developing a basic comfort level with the nurse (2006).

The second and third phases – identification and exploitation- are forming a working phase  whose focus is on the patient’s efforts to acquire and employ knowledge about the illness, available resources, and personal strengths, and secondly the nurse’s enactment of the roles of the resource person, counselor, surrogate, and teacher in the effort to facilitate the patient’s development toward well-being. In the case of the acute conditions, the nurse has to be flexible enough to gauge the patient’s developmental capacity, level of anxiety, self-awareness, and needs. A clear relationship exists between the phase Peplau terms exploitation and the implementation phase of the nursing process. In both, the individualized plan of care already has been formed, thus the goal is to move to completion of the identified goals, the patient is the one seeking and after beneficial assistance. The final step in the nursing process is evaluation or termination and even through resolution is the last phase, it is not synonymous to evaluation, the nurse in Peplau’s model must make the evaluation that the patient’s goal s have been met and the relationship is ready for termination (Andrist, Nicholas and Wolf 2006).

In a case of acute condition as Sheldon explains of one Susan R, 38 year old woman coming into an outpatient surgery for a biopsy and is approached by a preoperative nurse to prepare her for the surgery. A therapeutic relationship between the patient and the nurse forms the foundation of the nursing care with underlying principles: respect, genuineness, empathy, active listening, trust, and confidentiality. Sheldon states that the purpose of the relationship is to support the patient, to promote healing, and enhance functioning with a reference to Peplau of all nurses’ need to forge a “professional closeness” (Sheldon 2008, pg.53). She asserts that communication is the foundation of the nurse-patient relationship to harness the patient’s needs taking into consideration multiple factors including the acute patient’s physical condition as the case of Susan above, emotional state, cultural background, readiness to communicate, and ways of relating to others. For example, teaching about a low cholesterol diet and aerobics is not appropriate during acute phase of a myocardial infarction since the patient is not in the correct physical or state (emotional) to absorb this kind of information regardless of its importance for the cardiovascular health (Sheldon 2008). This is a case of an acute condition, after the greetings, the nurse clarifies the purpose and nature of the relationship. This according to Sheldon includes information regarding the appointment or interview, describing the nurse’s role, to help the patient provide pertinent information and describing the goal of the relationship (Sheldon 2008).

It is very obvious to have each nurse use different styles of delivering information. It is however important not to overlook the initial part of the relationship as a superficial aspect of the actual work. The establishment of the relationship’s purpose and goal is fundamental not only to deliver care but also to evaluate the relationship and outcome during the termination stage. During the orientation stage, anxiety levels are to be decreased especially when the patient knows what to expect and participates in the establishment of the relationship by the nurse also seeking to promote trust and reduce the anxiety in her genuineness, respect, and informative approach. The data collection stage according to Sheldon is very important to understand the patient’s perception of the problem(s) and their need for medication. For example, the nurse could begin by asking general questions and also take time to listen to the patient’s needs and expectations. This prevents disappointment during and after the termination of the relationship (Sheldon 2008).

At identification phase for an acute patient, it important to work together with the patient since it involves identifying problems and setting specific problem-oriented goals. The nurse can help patients explore feelings of their situation, including fear, anxiety, and helplessness while directing their energies toward actions. In this case of Susan going in for biopsy, the patient has the nurse say about feeling of discomfort while the procedure in underway and would probably develop fear. At the exploitation stages, the nurse assists the patient to use health services with the active work of the relationship happening during exploitation. Sheldon asserts that emotions are part of ending relationships, caring attitudes and shared experiences, especially in long-term relationships, may result into sadness and ambivalence at the end of the nurse-patient relationship. In the acute cases, the patient may feel as though all is getting lost at the termination phase but the nurse must be able to utilize the moment professionally since at this point, the unmet goals are identified  by the nurse and the patient ma y require referral and follow-up care (Sheldon 2008).

Lastly, the ending a therapeutic relationship, requires a period that Peplau aptly refers to as the resolution phase. Every nurse is satisfied after a care relationship with the patient (Andrist, Nicholas and Wolf 2006). Often, very meaningful sharing has been carried out during this process encompassed with some challenging time for instance an acute patient being told of feelings of discomfort during a procedure. Sheldon states that preoperative nurses at an outpatient centre with a patient undergoing arthroscopy often has a short time frame unlike those oncology nurses having a long-term relationship with the patient recurrent colon cancer that might end up with the patient’s death. When the end is approaching, the patient might regress, become anxious, act more superficially or even better become dependent. It is important at this stage to spend less time with the patient in preparation for the termination stage of the relationship and should also spend some time to reminisce about the goals accomplished, moments shared.

In conclusion, objectivity is an important attribute when assessing the patient’s needs and providing competent and professional care and therefore being compassionate implies using empathetic approach; but not so emotionally close to a patient thereby impairing objectivity and judgment compromise patient care. The nurse-patient relationship theory as put forward by Peplau is a foundation stone for nursing care throughout the spectrum of health, illness, and recovery and the establishment of which is facilitated by the nurse and must be patient centered and goal-oriented.