Therapeutic Relationships in Nursing

NTRODUCTION

A therapeutic relationship in nursing is a professional association between the

nurse and the patient, working hand in hand for a defined period of time in
order to accomplish specific health-related goals (Dossey and Keegan, 2013).
It is a relationship that may occur even if a patient is in the end stages of life,
is generally uncooperative, or in health and wellness initiative. Further,
therapeutic relationships differ from social relationship in such a way that it is
patient-centred with a focus on goal achievement, and the relationship ends
when the goals are achieved hence time limited (Timby, 2009). Through a
concerted and participatory healing process that distinguishes the wholeness
of human being and the uniqueness and autonomy of each individual, trust is
brought forth and intentional therapeutic outcome is realised (Basford and
Slevin, 2003).

This paper critically appraises the nurse-patient relationship within the

author’s area of expertise, identifies various barriers in therapeutic
relationships, as well as recognises aspects for future development.

Professional Background

This author entered the nursing profession in the country of Saudi Arabia.
There was a continuous shortage of nurses during those times mainly due to
the negative image of the profession within the society. In 2007, this author
completed a diploma course in nursing from the most reputable institution for
nursing in the country, the Faculty of Health Sciences in Saudi Arabia. The
main motivation for pursuing the profession was the opportunity to help
people in distressed conditions.
The author had the privilege of working as an intensive care nurse for five
years. This was in an acute hospital in Saudi Arabia. Patients were generally
intubated and some were also ventilated. It was standard practice to admit
patients to surgical intensive care after major surgery, perhaps for just twenty-
four hours before they are transferred to a general ward for routine post-
operative care. Within the five-year employment at the intensive care unit, this
author was promoted twice; first to the position of team leader and then, to the
position of assistant nursing service. By the end of the fifth year employment,
this author progressed from Level 4 to Level 7 in the career ladder. As she
worked her way up, she had less involvement in direct patient care and more
responsibility for staffing issues, supervision of more junior nurses and the
arrangement of professional development activities for the team.

However, the need for continuous education and career improvement came
after five years of serving critically ill patients. This author felt the need for
higher education and therefore, applied for a Bachelor’s degree in nursing
programme at the University of Wolverhampton in 2012, and completed the
said degree in 2014. Currently, this author is taking a Master’s programme at
the University of Salford .

Therapeutic Nurse-Patient Relationship: Background

The relationship between patient and nurses has changed over the years. In
the past, the role of a sick person was passive, paving the way for others to
make decisions and patients submit to treatment and management without
question (Williams and Davis, 2005). Today, nurses promote and anticipate
individuals for whom they care to become actively involved, to query, to
communicate, to aid in the planning of care, and to maintain as much
independence as possible (Timby, 2009). As nurses engage in therapeutic
relationship, there is genuine and compassionate regard for the deeply
individual and personal life of the patient, respecting the uniqueness and
inherent capacity of their life (Wright, 2010). In the ideal situation, the patient’s
stories are heard, their beliefs about what is happening to them, and the
nurses listen with care in an attempt to understand and grasp the meaning of
what is being conveyed (Basford and Slevin, 2003). In doing so is
acknowledging that the individual is the expert on their own life, on how they
experience what they are going through.

There are five components of nurse-patient relationship as stated in the

practice standards of the College of Nurses of Ontario (2013). These
components include trust, professional intimacy, respect, power, and empathy.
These elements are always present in the relationship in spite of the context,
whether the nurse is the primary or secondary care provider, as well as the
length of interaction. As stated by Forchuk et al. (2000) in their study about
nurses’ perspectives in developing nurse-patient relationship, trust is very
significant in a nurse-patient relationship due to the fact that the patient, at this
stage, is susceptible. Early in the relationship, trust is easily broken; therefore,
it is vital for the nurse to keep promises to his/her patient. If trust is broken at
this early stage, it becomes difficult to re-establish (Hupcey et al., 2001).
Furthermore, professional intimacy is innate in the kind of care and services
offered by nurses. It may encompass physical activities such as bathing the
patient that create closeness with the individual (Forchuk, 1995). Professional
intimacy may also involve social, psychological, and spiritual components that
are acknowledged in the plan of care as recognised by the American Nurses
Association (2001). Professional intimacy may also entail access to the
patient’s personal information within the boundaries set forth by the Nursing
and Midwifery Council (2015) and the Data Protection Act (1998).

Moreover, respect being one of the components of therapeutic nurse-patient

relationship, refers to the acknowledgment of the intrinsic dignity, value, and
individuality of every person; not withstanding any personal attributes,
socioeconomic status, and the nature of their health problem (Milton, 2005).
Empathy, alternatively, is the expression of understanding, certifying, and
reverberating with the meaning that the healthcare experience holds for the
patient. In the context of nursing, according to Kunyk and Olson (2001),
empathy comprises suitable emotional distance from the patient to make sure
objectivity and a proper professional reaction is made. Lastly, therapeutic
nurse-patient relationship is one of uneven power. It may not be apparent at
first, but the nurse has more authority and influence in the healthcare system,
specialised knowledge, access to privileged information, and has the capacity
to advocate for the patient and the patient’s relatives (Newman, 2005).

The therapeutic relationship between a nurse and his/her patient is different

from a friendship or the relationship between intimate (that is, life/sexual)
partners. In the therapeutic relationship, the nurse seeks to optimise
communication, heighten understanding of the way the patient behaves, and
develop personal strengths and characteristics to facilitate the patient’s
healing (Varcarolis, 2014). However, there are circumstances where it
becomes impossible for nurses to develop a positive relationship with every
patient. There are barriers to achieving the optimal therapeutic nurse-patient
relationship. Barriers to this relationship include lack of respect, lack of caring,
barriers to effective communication, barriers to empowerment, mistrust,
cultural and spiritual differences, and lack of empathy, and time (Arnold and
Boggs, 2015). Other barriers that affect the development of a therapeutic
nurse-patient relationship may include anxiety, stereotyping, and lack of
personal space. Each of these barriers will be discussed in detail in the
following section.

Place of Work and Care Provided

As mentioned above, this author worked as a nurse in the intensive care unit
for a period of five years. Medical and surgical intensive care units in this
hospital segregated the most critically ill patients where they were cared for by
nurses with specialised knowledge in those areas of care. Patients in these
units were cared for by multidisciplinary team of healthcare professionals who
had in-depth education in the specialty field of critical care. The
multidisciplinary team was composed of physician intensivists, specialty
physicians, nurses, advanced practical nurses, and other specialty nurse
clinicians, pharmacists, respiratory therapy practitioners, and other
specialised therapists. Patients in the intensive care unit were at high risk for
actual or potential life-threatening health problems. The ones who were more
critically ill required more intensive and vigilant nursing care.

Relatives of patients taken to the intensive care unit can, understandably,

become very anxious (Al Mutair et al., 2013) and it is part of the intensive care
nursing role to involve families as part of the team and in care planning (Brilli
et al., 2001). According to Al Mutair et al. (2013), critical care nurses in Saudi
Arabia are willing to engage with family members when care is more routine
(relatively speaking), but less so when the situation is more life threatening
and/or invasive care needed. Both patients and nurses can experience a
sense of “regret” if this is not handled judiciously (McAdam et al., 2014).

As a nurse in the intensive care unit, this author provided and contributed to
the care of these critically ill patients in a variety of roles. The most prevalent
role performed was that of a direct care provider. Aside from providing direct
nursing care, as an ICU nurse, this author performed independent
assessments, planned and implemented patient care, made clinical
observations and executed interventions, administered medications and
treatments, as well as promoted activities of daily living. However, as
mentioned above, progression through the hierarchy actually took the author
away from more direct patient care.

IDENTIFICATION OF BARRIERS TO THERAPEUTIC RELATIONSHIPS

1. Lack of Respect

Expressing authentic respect for patients assists in building a professional

relationship as the mutual objective is to maximise the patient’s health status,
especially in an intensive care unit setting. Respect may be attained by
regarding a patient’s values and opinions (Arnold and Boggs, 2015). An initial
step is asking patients what they prefer to be called and address them as
such.
In a study by Williams and Irurita (2004) wherein interviews were conducted
amongst 40 patients who were or who recently had been hospitalised
revealed that emotional comfort was recognised as a therapeutic state that
patients distinguished as promoting their recovery. On the other hand,
patients felt devalued when they perceived that nurses were avoiding talking
with them or were unfriendly. These patients felt comforted with short
conversations. The lack of respect amongst the team members was also cited
as a cause of poor communication leading to adverse patient outcomes. In a
true collaborative model, each team member conveys respect and assumes
responsibility for initiating clear communication (Williams and Irurita, 2004).

2. Mistrust

The establishment of trust is the foundation in all relationships. The

development of a sense of interpersonal trust, a sense of feeling safe, is the
centrepiece in nurse-patient relationship (Rushton et al., 2007). Trust offers a
nonthreatening interpersonal climate in which patients feel secure revealing
their needs. The nurse is viewed as dependable. The creation of this trust is
significant towards making accurate assessments of a patient’s needs. For
the patient, trust involves a willingness to place oneself in a situation of
vulnerability, relying on healthcare professionals to perform as expected.
Trust is built incrementally and earned behaviourally (Reina and Reina, 2006).
An individual’s ability for trust increases or decreases that is depended on
experiences either positive or negative and relying on observations of reality
in a particular situation (Thorne, 1988). For trust to increase, participants in a
relationship interact with each other with unguarded sincerity, genuineness,
and openness. An expression of their capacity for trust, trustworthy
behaviours are an outgrowth of conscious or unconscious choices that rely on
an individual’s level of willingness, readiness, and awareness (Butler, 1991).

Mistrust affects the communication between healthcare professional and

patient, as well as affects the healing process (Arnold and Boggs, 2015).
Trust can be easily replaced with mistrust between nurse and patient
(McAllister et al., 2004). Just as some employers treat their employees as
though they are not trustworthy, some nurses treat some clients as though
they are misbehaving children. An example for this is when a patient failed to
follow a treatment regimen and is labelled with the nursing diagnosis of
noncompliant. Another example is when a paediatric nurse indicates falsely
that an injection will not hurt is jeopardising a patient’s trust. It is difficult to
uphold trust when one person cannot depend on another. Having confidence
in the nurse’s skills, caring, and commitment enable the patient to place full
attention on the situation requiring resolution. In some cases, patients also
endanger the trust a nurse has in them (Arnold and Boggs, 2015). From time
to time, patients test a nurse’s trustworthiness by compelling the nurse to
undertake extraneous tasks or pontificating incessantly on inane subjects.
Trust between professionals and patients can be cultivated providing nurses
identify such conduct, however, subtle, and set clear boundaries for
interaction (Arnold and Boggs, 2015).

In a case study reported by Rushton et al. (2007) involving a critically ill

patient admitted to the intensive care unit with repeated health crises and
irreversible organ dysfunctions following coronary artery bypass surgery and
mitral valve replacement demonstrated the challenges critical care
professionals encounter in caring for patients and their families. The authors
in this case illustrated that trust is especially fragile and coexisted with its
counterpart of betrayal. In this case study, the Reina Trust and Betrayal Model
(Reina and Reina, 2006) defined three types of transactional trust:
competence trust, requiring healthcare professionals to practise humility,
express compassion, and honour the patient’s choices; contractual trust or the
trust of character by which healthcare professionals are required to keep
agreements, establish boundaries, and manage expectations; and lastly the
communication trust or trust of disclosure, by which founded through respect
and telling the truth. When critical care professionals acknowledge the
countless methods by which trust can be built, these critical care
professionals become proficient in altering their communication, decision
making, and behaviours in trustworthy ways. This recognition paves the way
for the development of intentional approaches that may be incorporated into
each critical care encounter, resulting in nurses in the intensive care unit to
accomplish their promises to patients and families (Lynn-McHale and Deatrick,
2000).

3. Lack of Empathy

Empathy is the capability to be receptive and communicate understanding of

a patient’s feelings. It is the ability to put oneself into another individual’s
position. According to McMillan and Shannon (2011), empathy and empathic
communication are vital to the practice of nursing. Empathy is a significant
component of a therapeutic relationship. The capacity to communicate
efficiently empathy to patients is associated with improved patient satisfaction
and patient adherence to treatment (Morse et al., 1992). In fact, American
Academy of Paediatrics in a policy statement extends this communication
component to the patient’s family members as well (Levetown, 2008). It is
especially important for nurses to form therapeutic relationships with families
of critically ill patients. This makes them partners in care (Kryworuchko and
Heyland, 2009), engendering trust and imparting of information.

An empathic nurse understands and views a patient’s emotion correctly.

Other experts regard this as compassion (Basford and Slevin, 2003), which
has been identified by staff nurses as being vital to the nurse-patient
relationship. Communication skills are being utilised to express respect and
empathy. Even though expert nurses acknowledge the emotions felt by
patients, they hold on to the objectivity, maintaining their own separate
identities (Mercer and Reynolds, 2002).

Failure in understanding the requirements of patients may result in failure to

providing important education and/or the needed emotional support. Literature
points toward the existence of barriers to empathy in the clinical environment,
including the lack of time, lack of trust, lack of privacy, and lack of support
(Kelly, 2007). In this study, findings indicate that lack of empathy affected the
quality of care, result in less favourable health outcomes, and decreased
patient satisfaction.
4. Lack of Effective Communication

Furthermore, effective communication is regarded as a basic nursing role.

Good communication is at the centre of the therapeutic relationship that
nurses endeavour to achieve with patients in their care (McCabe and Timmins,
2013). Keating et al. (2002) in their study argued that insufficient utilisation of
communication skills presented a barrier to the development of therapeutic
relationship. Furthermore, Costa (2001) recommended that nurses develop
specific therapeutic communication skills in order to address patient needs
more fully. This included being truly present to the patient, manifested as
being able to listen, being perceptive to the environment, and being able to
anticipate patient needs. Communication skills believed to be essential to the
therapeutic nurse-patient relationship include being able to recognise
individual informational needs, empowering patients, and being present to
patients (Lauder et al., 2002). Yet, barriers exist to the operation of these
skills in practice. This can occur within the nurse, within the patient, or within
the environment (McCabe and Timmins, 2013).

Several studies have demonstrated the effects of lack of effective

communication towards therapeutic nurse-patient relationship. A literature
review conducted by Kennedy et al. (2014) found mixed results, with one
suggestion being that nurses who showed “openness” were less likely to
become stressed. As “openness” would imply honest communication with
patients and relatives, it can be extrapolated that stressed nurses are less
open. These commentators identified that working in intensive care could be
particularly stressful because of the nature of the one to one nurse-patient
relationship and sudden acute changes in patient condition. Moreover, a cross
sectional study conducted in Iran in 2014 evaluated barriers contributing to
the demonstration of an effective nurse-patient communication (Jahromi and
Ramezanli, 2014). In this study, a total of 200 nurses and patients were
interviewed from two hospitals and results showed that the greatest barrier to
nurse-patient communication was the characteristic of the nursing job. From
the patients’ perspectives, barriers to effective communication included heavy
workload for nurses, language difference, and nurse values.

Furthermore, language difference in the delivery of care by nurses leads to

miscommunication and compromise nurse-patient relationship. A study
conducted in Saudi Arabia investigated patient perceptions of nursing care
delivered by non-Arabic speaking nurses (Al-Khathami et al., 2010). This
study was a cross sectional survey of patients selected randomly in King
Abdul-Aziz Medical City in Riyadh, Saudi Arabia in 2009. A total of 116
patients were interviewed in the study and results showed that most patients
believed that Arabic language was important in providing high quality of care.
About 75 per cent of patients reported difficulties in understanding nursing
instructions and felt that non-Arabic speaking nurses could not understand
their concerns as well. About half, 50 per cent of respondents, believed the
non-Arabic speaking nurses were prone to errors. Additionally, patients
believed that these nurses avoid or end conversations due to the language
barrier. This study was able to demonstrate that therapeutic relationship can
also be affected by ineffective communication, specifically language barrier. It
showed less trust on the part of the patients, less comfort, and some
uncertainty towards nursing care delivered. As shown, the duration and
quality of the interaction between nurses and patients were compromised as a
result of this barrier. Baker et al. (1998) proposed the utilisation of interpreters
in order to address and bridge the gap in communication between healthcare
professionals and patients.

5. Cultural and Spiritual Differences

Being a multifaith society, healthcare professionals in the United Kingdom

must take the cultural and spiritual needs of patients into consideration so as
to allow the NHS to maintain and provide culturally harmonious care of the
highest standards to patients (Hinchliff and Rogers, 2008). As described by
McSherry (2000), spirituality is usually utilised and pertain to an individual’s
personal beliefs, principles, and experiences. This may be since the meaning
of spirituality is inextricably associated with religion (Davidhizar and Bechtel,
2000). Addressing the spiritual needs of patients is a basic component of
holistic care and may be the most neglected area of care. Yet, there had been
changes in the manner by which individuals express their spirituality or
religion. In a population census by the Office of the National Statistics (2004),
more than 75 per cent of the United Kingdom populace answered positively
regarding religion.

The National Institute of Clinical Excellence (2004) guidelines for palliative

care argued that spiritual care concerns all healthcare professionals that are
caring for patients. Failure to respond to such need or if it is inappropriate for
them to do so, other members of the multidisciplinary team should be made
aware of these needs. Narayansamy (2001) suggested that nursing care must
explore the language of spirituality to guarantee that an aspect of holistic care
is not dismissed as this may be critical to the well-being of patients and the
integrity of nursing.

Unfortunately, barriers exist in achieving cultural, linguistic, and religious

competence. These barriers persist due to the fact that most organisations
are not designed to facilitate cultural diversity (Hinchliff and Rogers, 2008).
There may be absence of facilities that accommodate certain cultural and
religious needs. Shortages of staff limit the time spent in attending to patient
specific cultural and religious needs. There may be communication barriers
between nurses and patients. There may also be concerns about projecting
own beliefs and attitudes to patients, or uncertainties and concerns over
managing some issues relating to death (Wright, 1998). These reasons affect
therapeutic nurse-patient relationship.

Every interaction encounters a basic challenge of communication when the

culture of the patient is different from that of the nurse (Arnold and Boggs,
2015). Barriers may also include high literacy problems or cultural definitions
of the sick role. An example of this is that in some cultures, the sick role is no
longer valid after the symptoms disappear. Specifically, if a patient’s diabetes
is already under control, members of the family may no longer feel the need
for a special diet or medication. However, as society moves towards a
multicultural society, all healthcare professionals providing care need to
become culturally competent communicators (Arnold and Boggs, 2015).
Cultural competence necessitates nurses to be sensitive of the arbitrary
nature of their own cultural beliefs. Culturally competent communication is
characterised by the willingness understand and respond to the patient’s own
beliefs (Stickley and Freshwater, 2002). Knowledge of the patient’s cultural
preferences aids in avoiding stereotyping and enables nurses to adapt their
communication.

Furthermore, in order to achieve culturally and spiritually appropriate care,

nurses need to acknowledge and understand how health behaviours are
influenced by culture and religion. It is vital to note that perception of illness,
health, diseases, and their causes differ culturally. Therefore, nurses must
possess the ability and knowledge to communicate and understand patient
religious and cultural needs. It is important to show respect for individuals
from various cultures and their religious and cultural beliefs, and being able to
listen and communicate with patients from diverse cultural background is
important.

6. Other barriers to therapeutic nurse-patient relationship

Other barriers that hinder the development of a positive therapeutic nurse-

patient relationship include anxiety (Behice et al., 2008), stereotyping, lack of
personal space, and lack of time (Arnold and Boggs, 2015). Barriers inherent
in the healthcare system are also present. Under managed care, barriers
often reflect cost-containment measures. Such barrier includes lack of
consistent assignment of nurse to patient and increased utilisation of
temporary staff such as agency nurses or floats. Also, the lack of time may
result from low nurse to client ratio or early discharge. Other system barriers
include communication conflicts with other healthcare professionals,
conflicting values, poor physical arrangements, and lack of valued placed on
caring by for-profit agencies. These system barriers limit the nurse’s capacity
to develop considerable rapport with patients. Sufficient time is important in
order to achieve therapeutic communication and achieve effective care
responsive to patient needs.
Stereotyping and bias may also be considered as barriers to therapeutic
nurse-patient relationship. Stereotyping is when certain characteristics are
attributed to a group of people as though all individuals in the identified group
possess these characteristics (Fleischer et al., 2009). Stereotyping may
include ethnic origin, religion, culture, social class, occupation, et cetera. Even
health issues may be an object of stereotyping. These include mental illness,
alcoholism, or sexually transmitted diseases. Stereotypes negate empathy
and erode the nurse-patient relationship (Arnold and Boggs, 2015). As nurses,
insight must be developed into own expectations and prejudgements about
people. Moreover, if nurses convey biases into the clinical situation,
perceptions will be distorted, prevent patient change, and disrupt the nurse-
patient relationship (Elder et al., 2009). Nurses need to make it a goal to
reduce bias. This is done by recognising a patient as a unique individual, both
different from and similar to self. Acceptance of the other person needs to be
total. This unconditional acceptance, as described by Rogers (1961), is a vital
component in helping the relationship. It does not entail approval or
agreement, but acceptance occurs without judgement.

Another barrier to therapeutic nurse-patient relationship in the intensive care

unit is time. Time has become an increasing challenge in this relationship. At
the moment, nurses care for large numbers of patients with complex medical
conditions (American Nurses Association, 2001). In caring for critically ill
patients with increasingly complex health problems and heavier workloads,
nurses think there is shortage of time for care and lack the time
communicating with each patient (Hemsley et al., 2012). In circumstances
where a nurse failed to offer ample time with a patient, the patient may feel
that he/she is not important and his/her needs may not be met (Brody, 2003).
By offering enough time for patients, the nurse offers the client the feeling of
being cared for, valued, and understood. Yet, it is still a challenge for nurses,
especially in a critical care setting such as in the intensive care unit, to offer a
sufficient amount of time per patient so as to avoid appearing rushed, educate
patients, gather vital diagnostic information, and establish a positive
therapeutic relationship.
REDUCTION OF BARRIERS IN THERAPEUTIC NURSE-PATIENT
RELATIONSHIP: SUGGESTIONS FOR THE FUTURE

The recognition of these barriers in various clinical settings, and in this case in
the intensive care unit, is the first step in eliminating these challenges. This
will result in the enhancement of the therapeutic nurse-patient relationship
(Moyle, 2003). Findings from various studies and opinions by different experts
in the field emphasise the importance of honesty, cultural sensitivity, and
caring especially in recognising actively to complaints and suggestions from
the patients and their families. In order to reduce therapeutic relationship
barriers, trust must be established. Empathy and caring are demonstrated as
well as empower the patient (Arnold and Boggs, 2015). Patients in the
intensive care unit are sometimes anxious; this must be recognised and
addressed (Choi et al., 2004). Nurses in this setting may also be sensitive to
cultural differences. The time barrier may be addressed by developing quality
communication and utilising team rounds (Arnold and Boggs, 2015). This
method of reporting at the bedside includes the patient as a team partner.
However, Rehder et al. (2012) found that this strategy becomes a barrier to
communication if the nurse tried to multitask.

The American Nurses Association (2001) statement on cultural diversity in

nursing practice underscores the value of recognising intracultural differences
and assessing each patient as an individual. Becoming culturally sensitive
includes avoiding barriers to communication that occur when generalising
about a patient’s belief based on their membership, rather than taking the time
to discover individual inclinations. Identifying the patient’s health values,
health practices, beliefs, or family factors that may affect the relationship is
crucial.

Involving patients and relatives in “codesign” of services, including in the

critical care setting, can be very effective in making them feel empowered and
safe (Robert et al., 2015). These authors (including a patient representative)
found it was a valuable tool for implementing patient-centred improvements.
CONCLUSION

Nursing is an experience that takes place between two individuals. It is a deep

experience that cannot always be effectively communicated to another person.
Ironically, there is no doubt that the practice of nursing happens within an
interpersonal communication and in the absence of which, nursing becomes
an empty routine. Therapeutic nursing endeavours to capture the environment
of nurse-patient relationship, exploring not only the interpersonal but also the
intrapersonal. Today, more than any other time in history, nursing is being
constructed around the centrality of the nurse-patient relationship, which is
considered as an equal partnership. It is through the promotion of a
therapeutic healing association that nurses are believed to uphold healing.

However, there are barriers to the promotion of a positive therapeutic nurse-

patient relationship in various clinical settings. In the case of this author, the
intensive care unit. One of the barriers demonstrated is the lack of respect
amongst intensive care nurses. Patients felt devalued when they perceive that
nurses are avoiding talking with them or were unfriendly. These patients, on
the other hand, felt comforted whenever nurses engage in ‘chitchats’ with
them. The lack of respect amongst the team members delays healing and
result in adverse patient outcomes. Another barrier is mistrust. It is
challenging to maintain trust when patients cannot depend on nurses, and
vice versa. Having confidence in the skill sets of the nurse, as well as
commitment enables the patient to place full attention on situations
necessitating resolutions. Mistrust in this relationship affects communication
between nurses and patients. In order for trust to prosper, both patient and
nurse interact with each other with unguarded sincerity, openness, and
authenticity. Also, in intensive care settings, there is also the barrier of lack of
empathy. Lack of empathy may result in failure to provide the needed
emotional support. Literature demonstrated lack of empathy may be due to
lack of trust, lack of time, lack of privacy, and lack of support. Moreover, there
is also the barrier of ineffective communication.

In an intensive care unit, nurses communicate poorly with patients regardless

of their high level of skills and knowledge with respect to communication.
Patient care in this setting may be stressful and difficult. In some cases, there
is an issue in language difference in the delivery of care leading to
miscommunication and compromise the nurse-patient relationship.

Furthermore, there is the barrier in achieving cultural and spiritual

competence. These barriers exist if organisations are not designed to facilitate
cultural diversity and if staff projects their own beliefs and attitudes to patients.
These reasons all affect therapeutic nurse-patient relationship. Other barriers
identified affect therapeutic nurse-patient relationship in an intensive care unit
setting include anxiety, stereotyping, lack of personal space, and lack of time.

Being an intensive care unit nurse, it is vital for this author to recognise and
understand these barriers in my care setting. In doing so is upholding the
therapeutic nurse-patient relationship. My experiences led me to understand
that it is important to achieve a positive therapeutic relationship with patients
and as such, would promote the best quality of care and service for the
patient. It is important to develop trust, empathy, and professional intimacy in
the development of a nurse-patient relationship. It is important, in a busy and
rushed environment as the intensive care unit, to give time or at least the
perception of time for the patient. Rather than appearing busy or action-
oriented, I would utilise my attending skills so as to increase the likelihood of
reducing the barriers that may exist.