Original Manuscript

Nursing Ethics
2022, Vol. 29(2) 4 62­–484
Defining and characterising ª The Author(s) 2021
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the nurse–patient relationship: sagepub.com/journals-permissions

10.1177/09697330211046651
journals.sagepub.com/home/nej
A concept analysis

Regina Allande-Cussó , Elena Fernández-Garcı́a

and Ana Marı́a Porcel-Gálvez
Universidad de Sevilla, Spain.

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 nurse-
patient 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

Corresponding author: Elena Fernández-Garcı́a, Faculty of Nursing, Physiotherapy, and Podiatry, Universidad de Sevilla,
C/ Avenzoar, 6, 41009 Seville, Spain.
Email: [email protected]
2Allande-Cussó et al. 463
Nursing Ethics XX(X)

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 inter-
personal 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
464
Allande-Cussó et al. Nursing Ethics 29(2)3

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 ethics23 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 char-
acteristics 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 char-
acterising the construct; (c) published in Spanish or English; (d) quantitative or qualitative studies, empiri-
cal 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 conven-
tional 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 confer-
ences 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
4Allande-Cussó et al. 465
Nursing Ethics XX(X)

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).
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 editor-
ial, 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).
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
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
466
Allande-Cussó et al. Nursing Ethics 29(2)5

Number of records iden�fied through 2646 invalid or duplicate records

database searching excluded
Iden�fica�on

PubMed (n = 1520)
Number of addi�onal records iden�fied
SCOPUS (n = 437) through other sources
CINAHL (n = 391)

Records a�er removing duplicates

(n = 149)
Screening

Records excluded:
Records assessed for Databases (n = 96)
eligibility (n = 149) Other sources (n = 9)
Eligibility

Full-text ar�cles excluded for the

following reasons:
Full-text ar�cles assessed for eligibility:
Databases (n = 53) Study popula�on: mental health
Other sources (n = 10) and/or disability

Scale valida�on studies

Studies on the impact of the nurse-

pa�ent rela�onship
Included

Studies included in the Not including the year or author

synthesis
Databases (n = 26)

Other sources (n = 10)

Figure 1. Study flow chart of the sampling process (PRISMA).

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
6Allande-Cussó et al. 467
Nursing Ethics XX(X)

Table 1. Countries of studies’origins (N ¼ 36).

Country Number of studies, n (%)

United States 11 (30.5%)

Spain 5 (13.8%)
Colombia 3 (8.3%)
Canada 3 (8.3%)
México 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%)

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 understanding51,56,65 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 con-
fidentiality, 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 other45,47 and considering the other32 based on one’s own self-awareness57
and motivation and engagement in the caring interaction.60
 468

Table 2. Summary of the studies included.

Elements,
Country Concept of the nurse– conditions, Level of
Author of origin Objectives Design Participants patient relationship attributes evidence

Williams30 United To explore the concept Literature review N ¼ 64 articles An element with intrinsic Therapeutic V-A
Kingdom of intimacy as a feature therapeutic potential intimacy
of the nurse–patient
relationship
Lotzkar and United To describe the Qualitative N ¼ 60 subjects A negotiation process Communication III-A
Bottorff31 Kingdom development of the observational between the nurse and
nurse–patient study–ethology the patient
relationship and
identify its features.
Sumner32 United States To apply Habermas’s Reflective analysis Not applicable Therapeutic intervention Communication V-B
Theory of Moral aiming to improve the ‘Considerateness’
Consciousness and patient’s health
Communicative Action
(1995) to the nurse–
patient relationship,
offering a different
interpretation to the
nurse–patient
relationship
Mok and Chiu33 China To explore aspects of Phenomenological N ¼ 10 nurses The foundation of nursing Trust III-A
nurse–patient study and 10 patients care based on mutual Reciprocity
relationships understanding
between the nurse and
the patient to establish
common goals
Shattell34 United States To describe the nurse– Literature review Not specified A central element of Communication V-B
patient interaction clinical nursing practice
using Goffman’s theory based on a
communicative nurse–
patient interaction

(continued)
Nursing Ethics 29(2)

7
8
Table 2. (continued)

Elements,
Country Concept of the nurse– conditions, Level of
Author of origin Objectives Design Participants patient relationship attributes evidence
Allande-Cussó et al.

Garcı́a and Spain To describe the personal Literature review N ¼ 13 articles Intersubjective interplay Intersubjectivity V-B
Rodrı́guez35 components of the between two social
nurse–patient agents, each of whom
relationship and their contributes their own
relationships values, qualities and
personal life story, all
within the framework
of a given social and
cultural context
Coffey36 Canada To explore the concept Concept analysis N ¼ 167 articles þ A model of relationship Commitment III-B
of the nurse–patient 12 nurses þ that warrants careful Covenant
covenant in cancer 8 patients inspection
care
Naranjo and Colombia To highlight the Reflective article Not applicable A trusting, helping Communication V-B
Ricaurte37 importance of proper based on a case relationship Trust
communication with study Empathy
the patient as a Active listening
fundamental part of Privacy
nursing care
Berg and Sweden To report on experiences Phenomenological N ¼ 13 interviews A meaningful Vulnerability, III-A
Danielson38 of the caring study interrelationship based Dignity,
relationship on reciprocal interest Compassion
established between
nurses and patients
with long-term illness
Kirk39 United States To apply the Reflective article Not applicable The establishment of Clinical intimacy, V-B
interpersonal process patterns of behaviour Shared meaning,
model of intimacy to than can give rise to a Empathy
the nurse–patient shared interpretive
relationship schema

(continued)
469
 Table 2. (continued)
470

Elements,
Country Concept of the nurse– conditions, Level of
Author of origin Objectives Design Participants patient relationship attributes evidence

Bell and Duffy40 Ireland To provide a greater Concept analysis N ¼ 20 articles A relationship of goodwill Trust V-B
understanding of the characterised by a
term ‘trust’ in relation power differential
to the nurse–patient
relationship
Tejero41 Philippines To determine the degree Descriptive study N ¼ 420 nurses and An engaged patient who Bonding III-A
of bonding between patients feels bonded to the
nurse and patient nurse in a similar way
based on their to family or friends
openness to each other
and their engagement
in patient care.
Pullen and United States To describe the concept Editorial Not applicable A helping relationship Trust V-B
Mathias42 of the nurse–patient Respect
relationship and its Gratification of
main attributes. patients’
physical,
emotional, and
spiritual needs
Active listening
Eye contact
Dinç and Turkey To study trust within the Literature review N ¼ 34 articles The cornerstone of Trust V-A
Gastmans43 nurse–patient nursing work, and trust Vulnerability
relationship. is critical in this Time
relationship because
without trust, it is not
possible to effectively
meet the needs of
patients and to
improve their
satisfaction with
nursing care

(continued)
Nursing Ethics 29(2)

9
10
Table 2. (continued)

Elements,
Country Concept of the nurse– conditions, Level of
Author of origin Objectives Design Participants patient relationship attributes evidence
Allande-Cussó et al.

Green44 United States To examine the meaning Reflective article Not applicable Interaction that plunges Contact V-B
of physical touch as it the nurse into the Presence
occurs in the nurse– patient situation in a
patient interaction. direct and immediate
way
Zolnierek45 United States To characterise the Integrative review N ¼ 21 articles A positive relationship The process of V-B
concept of knowing the with patients knowing the
patient and to consider patient
implications for nursing
practice.
Kennedy46 United States Book chapter on the Book chapter Not applicable A health-focused, patient- Respect V-A
establishment of the centred therapeutic Communication
nurse–patient relationship agreed Authenticity
relationship between the nurse and Empathy
the patient Active listening
Trust
Confidentiality
Unconditional
acceptance
Errasti et al.47 Spain To understand how the Meta-ethnography N ¼ 9 articles A trusting, standardised Respect V-B
nurse–patient relationship with a Reciprocity
relationship is focus on mutual Familiarity with
interpreted by nurses understanding one another
and patients with involving feelings of
advanced and terminal affection, concern, and
cancer and which commitment
aspects of this
relationship are
perceived to be the
most valuable for
patients.

(continued)
471
 Table 2. (continued)
472

Elements,
Country Concept of the nurse– conditions, Level of
Author of origin Objectives Design Participants patient relationship attributes evidence

Kesselring48 Switzerland To reflect on the nurse– Reflective article Not applicable A helping relationship Trust V-B
patient relationship foundational to nursing Respect
and its key practice Empathy
components Professional
intimacy
Communication
Confidentiality
Ramı́rez and Mexico To reflect on Literature review N ¼ 58 articles An interpersonal process Verbal and V-A
Müggenburg49 interpersonal between a sick person non-verbal
relationships and the and a healthy one communication
importance of
communication in care
practice.
Beltrán Salazar50 Colombia To understand the Phenomenological N ¼ 16 nurses A way of providing care Compassion III-B
meaning of humanised study and the means to make Affection
nursing care in the its attributes visible Closeness
experiences of Empathy
participants, nurses,
patients, and their
families.
Garcı́a et al.51 Spain To explore and Literature review N ¼ 10 articles The basis for becoming Communication V-B
understand the and concept acquainted with the Trust
meaning of the nurse– analysis sick person, supporting Understanding
patient relationship in and caring for them Presence
advanced and terminal according to their Empathy
illness. needs while taking Compassion
their individual
characteristics into
consideration
Angel and Vatne52 Denmark To examine the mutual Reflective article An encounter between Mutual vulnerability V-B
vulnerability of patients the patient and the
and nurses. nurse to which the two
must be open

(continued)
Nursing Ethics 29(2)

11
12
Table 2. (continued)

Elements,
Country Concept of the nurse– conditions, Level of
Author of origin Objectives Design Participants patient relationship attributes evidence
Allande-Cussó et al.

Bentley et al.53 Australia To review the key Integrative review N ¼ 10 articles A patient-centred Respect V-A
features of the nurse engagement based on Trust
practitioner-client therapeutic
interaction in the encounters
therapeutic encounter.
Du Plessis54 South Africa To describe enacting Reflective article Not applicable A compassionate, Presence V-B
presence as a form of committed caring
spiritual care. relationship manifested
through the nurse’s
presence
College of Licenced Canada To provide direction and Summary and Not applicable A professional, Trust IV-A
Practical Nurses promote clarity in interpretive interpersonal alliance Respect
of Newfoundland relation to the document in which the nurse and Ethical,
and Labrador55 Canadian Standards of the patient join compassionate
Practice and Code of together to achieve care
Ethics. health-related
treatment goals
Adams56 United States To explore the attitudinal Reflective article N ¼ 36 articles A helping relationship Empathy, V-B
and behavioural based on empathy and Understanding,
aspects of empathy understanding others Compassionate
within the nurse– care,
patient relationship. Ethical values
Rasheed et al.57 Canada To describe self- Scoping review N ¼ 76 articles Self-awareness enables Self-awareness V-B
awareness in nursing nurses to develop an
effective interpersonal
relationship and engage
in therapeutic
communication with
patients

(continued)
473
 Table 2. (continued)
474

Elements,
Country Concept of the nurse– conditions, Level of
Author of origin Objectives Design Participants patient relationship attributes evidence

Fernández et al.58 Mexico To analyse the concept of Concept analysis Not specified An interpersonal Contact V-B
effective nurse–patient relationship Expressing feelings
relationships with fundamental to the Active listening
patients undergoing care of healthy or sick Communication
renal replacement individuals that
therapy in facilitates therapeutic
haemodialysis. interactions
Cuchetti and United States To explore the concept Reflective article N ¼ 35 articles Nurses’ ability to Intentional V-A
Grace59 of intentional conceptualise and authenticity
authenticity within the implement care that
nurse–patient meets patients’ needs
relationship. and focuses on nursing
goals and perspectives

Riviere et al.60 Belgium To explore and Systematic mixed- N ¼ 24 articles A helping relationship Communication III-A
synthesise research methods review based on person- Patient
findings regarding the centred care, participation
elements of the communication, and
interpersonal care participation
relationship concept
from the perspectives
of older patients.
Fernández et al.61 Spain To gain a deeper Literature review N ¼ 6 articles A helping relationship Active listening V-A
understanding of the Acceptance
nurse–patient
relationship for
application in the
nursing and/or
midwifery professions.
Carlson62 United States To reflect on the nurse– Dissemination Not applicable A therapeutic Contact V-B
patient relationship article published relationship leading to Communication
and its implications. in a specialised positive health Trust
online journal outcomes Compassion

(continued)
Nursing Ethics 29(2)

13
14
Table 2. (continued)

Elements,
Allande-Cussó et al.

Country Concept of the nurse– conditions, Level of

Author of origin Objectives Design Participants patient relationship attributes evidence

Allande et al.16 Spain To present a new Reflective article Not applicable An interpersonal, Caring interaction V-A
conceptualisation of therapeutic
the construct of the relationship that is not
nurse–patient based on power, but
relationship as a caring involves reciprocal
interaction. power between nurse
and patient. It is an
interaction because
both react to it, and it is
caring because it serves
the goal of the nursing
discipline, that is,
providing care
Duque and Arias63 Colombia To identify the way in Integrative review N ¼ 63 articles A process of interaction Communication V-B
which the nurse–family and communication Empathy
relationship is taking place in any
established in the adult therapeutic setting
ICU, as well as the without overlooking
conditions, elements, the quality of
and factors that favour humanised care
or hinder it.
Culin64 United States To reflect on the nurse– Reflective article. Not applicable The core of nursing care. Mutuality and V-C
patient relationship Conference It elicits a sense of reciprocity,
and its implications. proceedings: attunement, security, Equality,
oral autonomy, and Patient autonomy
presentation engagement among
patients
475
476
Allande-Cussó et al. Nursing Ethics 29(2)
15

Figure 2. Elements and attributes of the nurse–patient relationship. *Centre circle: concept definition

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.

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.
Allande-Cussó et al.
16 477
Nursing Ethics XX(X)

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 .’.. The nurse is aware of this, and despite her sadness and helplessness, she
replies: ‘Maria, what can I do to help you?’ Maria sobs and says: ‘I need to hug my daughter’. In response to
this request, the nurse replies that she will immediately speak to her superiors and try to arrange a visit. The
nurse says that she will be right back with more information.
That same day, Maria was visited by her daughter, who entered the room with all the necessary
protection and safety measures in place. She hugged her daughter, they talked, and said goodbye. Maria’s
daughter was very grateful to the nurse for the opportunity, as she felt it was necessary to allow her to cope
with her mother’s imminent death.
This case represents the very essence and definition of the nurse–patient relationship and encompasses
all the defining attributes identified in this concept analysis. It is a perfect example of the evidence identified
in this study, which is embodied in a very plausible scenario that could become a paradigmatic model of the
concept under study.

Borderline case. José is a 60-year-old man attending the nurses’ office at his local healthcare facility to have
his blood pressure and blood glucose values checked. He has been diagnosed with diabetes mellitus and
hypertension. He is warmly greeted by his nurse, who welcomes him and asks him how he is doing. José
tells her that he is doing relatively well, but that he has not been able to follow all the dietary instructions that
the nurse had recommended at the previous consultation. As the conversation continues, the nurse checks
his blood pressure and glucose levels, which are found to be 150/90 mm Hg and 296 mg/dL, respectively.
The nurse realises that Javier is not following her recommendations, which bothers her, but she knows
she needs to find out why. She sits back down at the table, gives him a sympathetic, attentive look, and asks
him: ‘José, what difficulties have you had in following the dietary recommendations we discussed? I think
the two of us can find a way to address them’. José replies,

‘I’ve tried, but I lost my job two months ago, and as you know, I have no family left. The state subsidy pays my
rent, but I can’t buy the food you recommended . . . and I don’t know what else to do to improve my health’.

Hearing this, the nurse feels guilty for thinking badly of José and understands the reasons behind his blood
pressure and blood glucose levels. After noting these issues in José’s record, she replies:

‘Oh José, I didn’t know! In that case, don’t worry, maybe you’ll be able to improve your diet and include the
foods we agreed on for your next visit. I’ll note it all here and give you an appointment for two months from now.
Is that okay?’

José agrees and puts the appointment slip in his wallet.

This case covers many of the attributes of the nurse–patient relationship, but lacks empathy and need
fulfilment. It is, therefore, a suboptimal approach to the concept under study and its characteristic attributes.

Contrary case. Laura is an 80-year-old woman living in her own home with her son, who is her primary
caregiver. She has severe heart failure and bilateral malleolar oedema, so she cannot move around easily and
does not leave the house very often. Two weeks ago, she was discharged from hospital after a peripheral
venous thrombosis and is now recovering at home. She was prescribed 60 mg enoxaparin administered
subcutaneously every 24 h for 15 days, among other medication. Her son contacted her nurse at the
healthcare facility to have her come and administer the prescribed treatment to his mother, as he did not
know how to do it.
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17

The nurse welcomed the son into the nurses’ office while she was typing on her computer. She urged him
to tell her the reason for the consultation and only looked away from her screen to check that the son was
sitting in the chair. He explained his mother’s hospital admission, discharge, and the treatment she had been
prescribed. The nurse, still typing on her computer, replied: ‘Yes, I’m looking at your mother’s discharge
report on the screen. But what do you need?’ Laura’s son explained that he did not know how to give
injections and that he felt he was unable to do it because he was afraid of needles.
The nurse looked at him and replied:

‘I’m going to send you to the office next door where our student nurses are so they can show you how to do it,
okay? You’ll see they’re very patient and willing. It’s just that we can’t do home visits to administer heparin with
all the work we have to do. If you or your mother want or need anything else, please make another appointment
and we’ll talk about it, okay?’

The son left the office and the nurse continued typing on her computer.
The contrary case described does not portray the concept of the nurse–patient relationship at all and lacks
all of the attributes identified above. It is a prime example of a non-existent nurse–patient relationship.

Antecedents and consequences

The antecedent of the nurse–patient relationship is the contact between the individual and the nurse that
represents the starting point of the relationship. Without that relationship, nursing care, which is the
cornerstone of the nursing process, cannot take place. This relationship is thus essential for professional
nursing practice right from the very first phase of the care process.46,49
From a clinical perspective, the effects of the nurse–patient relationship on the achievement of nursing
care goals have been studied by several authors.47,49,51 In this regard, early studies show that the level of
empathy exhibited by the nurse was indirectly related to the patient’s stress levels, while it was directly
related to the patient’s satisfaction with the care received.56
In addition, providing more interactive nursing care and additional information and education
throughout the care process was also associated with lower anxiety levels among patients and a greater
sense of control and confidence regarding their health status.53,63 Similarly, a good nurse–patient
relationship, conceived as an interpersonal therapeutic interaction, was found to promote emotional
comfort among patients in a hospital setting, increasing their feelings of control over their health
status.38,48 This therapeutic relationship also contributes to increasing individuals’ levels of confidence,
knowledge, and self-esteem, and helps to achieve the objectives of the nursing care plan.47,51 It has also
been found that behaviours such as closeness, reassurance, and communication increase patients’ trust
in the nursing care received.43
Proper nurse–patient interaction significantly decreases anxiety levels among patients. In addition,
comfort measures (lighting, sound, temperature, physical comfort, etc.) and aspects of communication
(such as presence, active listening, etc.) reduced blood pressure, sleep disorders, and stress levels
among hospitalised patients.66 nurse–patient interaction also shortened hospital stays and increased user
satisfaction with the care received.37

Empirical referents
There are numerous tools available for measuring different features or attributes of the nurse–patient
relationship, including tools based on Jean Watson’s model, such as Nyberg’s Caring Assessment (NCA),
the Caring Behaviours Assessment Tool (CBA), the Caring Behaviours Inventory (CBI), and Nursing
Interactions in Caring–Competence Assessment (NIC_CA);67 as well as the Caring Efficacy Scale (CES),
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Nursing Ethics XX(X)

based on Bandura’s social learning theory; the Caring Ability Inventory (CAI), based on Mayeroff’s care
ethics; and the Caring Dimensions Inventory (CDI), based on Leininger’s transcultural nursing theory.7

Discussion
This study has comprehensively analysed the concept of the nurse–patient relationship and identified its
characteristic elements and attributes.
The nurse–patient relationship is a concept that has traditionally been understood as the relationship
between two individuals in which all ethical principles are fulfilled. Ethically challenging situations occur
in a wide variety of settings, from neonatal care to elderly care.68 There are thus moral dilemmas related to
nursing care, primarily caused by end-of-life situations, power struggles or other conflicts with physicians, and
organisational constraintsy.69 Most of these moral dilemmas are often analysed using the principle-based
approach which applies the four moral principles of justice, autonomy, beneficence, and non malificence.70 As
this study describes, the development of the nurse–patient relationship is itself an intervention, which is
disciplinary and based on bioethical principles. In moral distress situations, the decision making about moral
issues in healthcare demands that nurses exercise rational control over emotions.70
The concept of nurse–patient relationship is now primarily understood as a helping relationship, in line
with Muñoz-Devesa, who defines it as a helping relationship without which no support can be offered to
patients at any life stage.71 However, there is a new approach that argues that there are no such things as
concepts.72 If concepts are abstract objects, mental images, boundaries and structures then there really are
no such things. In this sense, a concept analysis could not be carried out as nursing understands it. The new
approach poses that a use of expressions that are important to nursing should be studied, examining its
functions in various grammatical constructions.72 Thus, this study describes a concept analysis of the nurse–
patient relationship, although perhaps it would be more appropriate to say that presents a number of uses of
the concept in nursing. Regarding to the uses in different cultures, the current situation of the phenomenon
of international migration, due to labour issues or poverty and social exclusion, has caused all international
health systems to care for culturally and linguistically different users.73 The use of this concept should
therefore be studied considering the cultural elements and characteristics of the people, which may imply
some change in the attributes presented in this study.
The nurse–patient relationship also appears as an intervention in its own right in our findings. This is in
line with the NIC, which includes only one specific intervention related to the nurse–patient relationship:
NIC 5000 – Complex relationship building, defined as ‘establishing a therapeutic relationship with a patient
to promote insight and behavioural change’.15 Based on the description and analysis of the scientific
evidence identified, the NIC 5000 could be redefined as follows: ‘establishing a helping relationship with
the individual or his or her family based on interaction, communication, respect for ethical values, accep-
tance, and empathy in order to promote insight and behavioural change’. This approach aims to better define
the concept and specify its key components or attributes to make the term easier to understand and use. The
nurse–patient relationship constitutes a nursing intervention and underpins the care process. Therefore, its
definition should be as clear and complete as possible in light of the available scientific evidence.
The nurse–patient relationship forms a bond between the individual in need of care and the individual
providing it and is an essential tool for supporting patients and improving adherence to treatment. All
necessary resources should be leveraged to teach students how to manage this relationship at university, as it
is a fundamental tool for the advancement of the nursing profession in all of its fields.74
Another notable finding of this review is that the process of introducing oneself to patients is an essential
interaction because it forms the basis of the therapeutic nurse–patient relationship.75 We also found
evidence of improved patient health, which is consistent with a study by Starndas and Bondas suggesting
improvements to patients’ physical, emotional, mental, and social lives. In short, the relationship
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19

strengthens the patient’s own resources to maintain health.76 From a nursing perspective, organisational and
working environments and conditions also influence therapeutic relationships.77–79
Another important feature of the patient-nurse relationship found in the literature is patient intimacy and
confidentiality. Barrio-Cantalejo acknowledges that health-related relationships are based on the recogni-
tion of the right of patients to participate in health-related decisions.80 When these results were compared
with other studies, confidentiality in hospital settings was found to be one of the best practices used by
nurses to secure patient data.81 Despite the importance of ethical considerations regarding autonomy,
intimacy, and informed consent in nurse/patient interactions, the topic has received little attention in the
literature.82
This study has a number of limitations including the quality of the articles included in the final sample
due to the method employed. Although the level of quality identified is good according to the Johns Hopkins
nursing evidence-based practice guidelines,29 overall, the levels of evidence were IV and V. We failed to
find studies with higher levels of evidence addressing the scoping question. Future studies should increase
the level of scientific evidence if they are to form the foundations of a middle-range theory on the nurse–
patient relationship.

Conclusion
The nurse–patient relationship may be defined as a helping relationship with the individual or his or her
family based on interaction, communication, respect for ethical values, acceptance, and empathy in order to
promote insight and behavioural change. It is both the foundation of nursing care and a nursing skill and
intervention in its own right.
The characteristic components of the nurse–patient relationship include communication, active listen-
ing, mutual respect and acceptance, contact, presence, trust, and reciprocity, as well as a number of ethical
values such as confidentiality, beneficence, justice, autonomy, equality, and intimacy.

Implications for nursing practice

Nursing care is delivered through the nurse–patient relationship. This interaction is understood as a helping
relationship between the nurse and the patient or his or her family, which means that nurses with knowledge
of this skill are needed to meet the practical and ethical demands of the profession. This concept analysis
paves the way for the expansion of this helping relationship based on ethical principles.

Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Ethical approvals
The study was approved by the Research Ethics Committee for the Andalusian Public Health System
(reference number: 1967).

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs
Regina Allande-Cussó https://orcid.org/0000-0001-8325-0838
Elena Fernández-Garcı́a https://orcid.org/0000-0002-7922-2663
Allande-Cussó et al.
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