The Nurse–Patient Relationship: Caring, Trust, and Boundaries

Introduction

One of the primary reasons nurses embark upon the profession of nursing is their desire to give care to others. However, caring in the sense of nursing is different from the type of caring a person gives to a friend. Nursing is a specific discipline that dispenses a specific kind of care, and professional boundaries must be preserved in the delivery of that care. Yet although a nurse is not a friend, a nurse must also be a good listener and provide care that shows sensitivity to each patient's individual needs.

Trust and Power in the Nurse–Patient Relationship

Trust is at the heart of caring in nursing. As Bell and Duffy (2009) observe, "The concept of trust is of particular interest to nursing as it has been identified as an important element in the nurse-patient relationship; however, the concept is loosely used in everyday discourse with confusion apparent and the true meaning of the concept of trust unclear. Patients' trust in the nursing profession cannot be taken for granted simply due to a requirement for nursing care" (p. 46). Trust may be compromised because patients perceive a power imbalance in the nursing relationship. The nurse may feel that she knows what is best based upon her framework of professional knowledge, while the patient intuitively feels that he or she knows what is best for his or her own health — an intuition that may differ significantly from the nurse's perception.

Surveys of nurses reveal that one of the most significant impediments to creating a relationship of trust and open communication is nurses' conviction that they know best, regardless of patient input. As Henderson (2003) found, "With the exception of a few, the majority of nurses were unwilling to share their decision-making powers. This created a situation of power imbalance with subsequent little patient input. Factors identified included nurses' beliefs that they 'know best,' the view that patients lacked medical knowledge, and the perceived need for nurses to hold onto their power and maintain control."

Patient Input and the Limits of 'Knowing Best'

One way to shut down communication entirely is for a nurse to react with anger when a patient expresses reservations about a treatment or questions whether a procedure is necessary. The nurse may perceive such questions as an affront to professional competence. However, a truly effective application of the nursing paradigm involves seeing the situation from the patient's perspective and addressing reservations with attention to the patient's experiences, level of education, and personal definition of health. Only then can a genuine bridge be built between the nurse's expertise and the patient's lived experience. Research indexed in PubMed continues to document this dynamic across a range of clinical settings.

Conclusion

A nurse would be well-advised to apply these lessons when dealing with any patient who engages in potentially troubling behavior, such as persisting in smoking. If the patient feels that he or she will be censured or judged, the patient will simply withdraw from the healthcare relationship and continue to practice unhealthy behaviors. The nurse must offer treatment and advice, but the patient must also be willing to accept that offering for true nursing care to take place. Maintaining contact with the patient — even when that patient is resistant — improves the likelihood that, at some point, the patient will be ready to listen and engage.