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What effects does the nurse-patient relationship have on the care that the patient is getting? How does the relationship effect the nurses willingness to treat the patient. These are all questions that, maybe I as a nursing major in college, 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, 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 (International Council of Nurses, 2002). This definition of nursing going 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

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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 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

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going to form the sense of rapport, which is successful 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 nurse 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.

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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 patien ts 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,

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caring, ethics, and communication. I will be talking 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 Its the nurses core responsibili ty 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

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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 Carter (2009) about trust, she also stressed that The nurses 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 LaSalas (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 society. More and more today our society 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

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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 patients needs. Instead, using your own perceptions will lead to appropriate responses to patients and also will help to form ones moral motives. Moral imagination is self reflecting from the nurse. They act 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 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 nurses personal experiences and the emotional responses to clinical situations affect the way they communicate. This often backfires for

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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 that 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 most times 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 cares for her patient, how well she follows her ethics and morals, and last but not least more importantly how she interacts and communicates with her patients. For my primary research, I conducted a interview and also an observation of one female participant. She is an RN working at Latrobe Hospital in Latrobe, PA. Basically, I asked her a series of questions in the beginning of the day about how she communicates with her patients, how she treats them, and also how she handles difficult situations. Then, I shadowed her for a day. I looked for the things that she told me in the interview and also the four elements of the nurse patient relationship previously stated in my paper. I believe this was the perfect method for my topic because it put me in a real

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life situation and allowed me to see up front how a nurse operates. After interviewing and shadowing the RN for a day, I analyzed my data and see how the answers she gave me versus what she actually did during the day and made connections. Also, I will 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 nurse because I wanted to make it seem like I was not even there. I know, however, that since I have known this nurse my whole life 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.

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Works Cited: Armstrong, A.E. Towards a strong virtue ethics for nursing practice. Nursing Philosophy. 7(3),110-124. Retrieved from http://web.ebscohost.com/. Belcher, M, & Jones, L.K. (2009). Graduate nurses experiences of developing trust in the nurse-patient relationship. Division of Nursing and Midwifery. 31 (2), 142-52. Retrieved from http://web.ebscohost.com. Bell, L, & Duffy, A. (2009). A concept analysis of nurse-patient trust. British Journal Of Nursing. 18 (1), 46-51. Retrieved from http://web.ebscohost.com. Cappabianca A; Julliard K; Raso R; Ruggiero J. (2009). Strengthening the nurse patient relationship: "what is the most important thing I can do for you today?". Creative Nursing. 15 (3), 151-6. Retrieved from http://web.ebscohost.com/. Carter M.A. (2009). Trust, power, and vulnerability: a discourse on helping in nursing. The Nursing Clinics Of North America. 44 (4), 393-405. Retrieved from http://web.ebscohost.com/

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Halldorsdottir S. (2008). The dynamics of the nurse-patient relationship: introduction of a synthesized theory from the patient's perspective. Scandinavian Journal Of Caring Sciences. 22 (4), 643-52. Retrieved from http://web.ebscohost.com/ Hodkinson, K. (2008). How should a nurse approach truth-telling? A virtue ethics perspective. Nursing philosophy: an international journal for healthcare professionals. 9 (4), 248-56. Retrieved from http://web.ebscohost.com/. LaSala C.A. (2009). Moral accountability and integrity in nursing practice. The Nursing Clinics Of North America. 44 (4), pp. 423-34. Retrieved from http://www.sciencedirect.com/

McGuigan D. (2009). Communicating bad news to patients: a reflective approach. Nursing Standard (Royal College Of Nursing). 23 (31), 51-6. Retrieved from http://web.ebscohost.com/. Taylor, C, Lillis, C, LeMone, P, & Lynn, Pamela. (2008) Fundamentals of Nursing. Philadelphia, Pa: Lippincott Williams & Wilkins. The Nurse and Patient Safety. H&HN: Hospitals & Health Networks. 82(11), 43 46. Retrieved from http://web.ebscohost.com.