The Nurse-Patient Relationship Reconsidered: An Expanded Research Agenda
Lowenberg, June S. Rn, PhD, Scholarly Inquiry for Nursing Practice
This article examines gaps in the available research on the nurse-patient relationship and proposes an expanded research agenda. The author's previous research comparing the physician-patient relationship in holistic health to traditional medical practice is reviewed and then contrasted with the literature describing the nurse-patient relationship. Five dimensions of the relationship are examined: affectivity, specificity, status differential, placebo salience, and trust. Most of the existing research in nursing focuses on the dimension of affectivity. Further empirical data on how each of these components is enacted in concrete clinical encounters is needed. Beyond expanding our understanding of each dimension, comparing them to equivalent attributes in other prominent models of provider-client relationships can provide further insight into those complex processes.
Nursing literature is replete with both theoretical articles and research attempts to describe the nurse-patient relationship; however, most attempts focus on the composite elements of "caring." Some more recent literature incorporates elements of consumerism and patient advocacy into descriptions of those relationships, representing the value placed on egalitarianism within the interaction. Most studies, however, fail to go beyond idealized conceptualizations to generate theory based on empirical research.
Learning more about the actual interactions that take place between nurses and patients continues to have important implications for both patient outcomes and patient satisfaction, as well as for future health care delivery. Nursing theory conceptualization would also benefit from a more incisive understanding of these processes. To move beyond the level of ideology and rhetoric-what we believe or say happens when the two parties interact-we need to develop additional studies that describe and critically analyze what actually occurs across the wide range of concrete clinical encounters. Although a number of recent studies begin to explore and document aspects of the relationship (Beaton, 1990; May, 1991; Morse, 1991; Ramos, 1992), further research is essential, and it should incorporate an expanded view of the relationship components.
In this article I will present a theoretical template of five key dimensions of the nurse-patient relationship within the context of related provider-patient relationships. Drawn from my previous research on the provider-patient relationship in holistic health (Lowenberg, 1989) and grounded in broader social science theory and research on provider-patient relationships, each of these dimensions will first be described in relationship to available data contrasting the holistic-health and traditional medical models. Next, those dimensions will be compared and contrasted with the corresponding interactions that are postulated to take place in consumer-oriented medical interactions and between nurses and patients. This juxtaposition can help further our understanding of the complexities of such interactions, as well as highlight the distinguishing characteristics of nurse-patient encounters. It also emphasizes the gaps in the interactional data currently available on the nurse-patient relationship, thus suggesting an expanded research agenda.
Many early investigations of the nurse-patient relationship evolved from social science definitions, such as those of Margaret Mead (1956) or Bruno Bettelheim (1962) in "To Nurse and Nurture." These fit with core themes of "caring" within the nursing literature, as well as the current focus on interpersonal process (Orlando, 1961; Peplau, 1952). Ramos (1992) has comprehensively delineated the development of that literature within nursing. As medical sociologists began to study nurse-patient interactions, they based their analyses on Parsons' (1951) differentiation between instrumental and expressive functions within a social system. In this conceptualization, physician, nurse, and patient roles recapitulated the prevailing roles of father, mother, and child within the American family. …