Escuela – comunidad

Despite the consensus in the literature that trust is the cornerstone in the establishment of the therapeutic NPR (Dowling, 2008; Dziopa and Ahern, 2009 and Scott et al, 2008), trust is still not clearly realised by both the nurse and the patient within the healing environment. Belcher and Jones (2009) studied the perceptions of graduate nurses on

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their experiences in establishing trust in the working environment. This qualitative study identified that the personality traits of individuals, intrinsic motivation of the nurse to help other people and feeling comfortable with the person are the pre-requisites to establish the therapeutic NPR. According to these pre-requisites it is clear that the no two individuals will successfully establish the therapeutic relationship with the same patient. If these pre-requisites are generally accepted as the guiding principles in the establishment of the relationship then patients and nurses should always have the choice of the therapist.

The study further indicates that in the process of sustaining the relationship, the art of building a rapport is based on the commitment of the nurse to provide and the patient to receive care. On the same note, the study highlights that the process is time consuming. Berg and Danielson (2007) in the study of exploring the trust as the difficult concept interviewed the nurses who indicated that you could only develop trust if you have enough time to spend with the patient. Based on the two studies, it may be assumed that time is really a challenge for the nurses to develop a trusting relationship with their patients. While Macdonald (2007:74), Pearcey (2010:52) and Ward et al (2012:35) concur with the above authors that time is the determining factor, considering the setting where the studies were conducted (hospital), it may often not be the universal agreement that “time” is inadequate in the hospital situation as the patients are in the ward for 24hrs. Time can therefore be a challenge in setting such as outpatient department and the PHC setting where the nurses have limited time with their patients.

Of note in the samples from studies Berg and Danielson (2007) and Belcher and Jones (2009), six nurses and seven nurses and six patients respectively, these qualitative studies do not represent the other settings. The use of snowballing technique is also a weakness of the study as acknowledged by the authors in the limitations of the study. It is also noted that the in vivo quote from the studies did not represent the patients‟ perspective of the establishment of the trusting relationship.

The strengths of both studies, however, acknowledged that the establishment of the trusting relationship cannot be attributed to the one aspect but also includes the environmental factors, language barriers, and knowledge and skill levels of nurses and the previous experiences of the patients. From the reviews is it still not clears how either

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the nurse or the patient knows that the relationship will be therapeutic or not. Trust remains a subjective phenomenon whilst is it identified as the decisive factor in the evolution of the therapeutic relationship. The trust should be reciprocal in both the nurse and the patient for it to be effective (College of nurses of Ontario 2009:3). If trust is being breached the relationship will break down and not be repairable. Betham (2011:33) recommends that further studies to explore the process of establishment of trust are critical.

There is also a general assumption that the long-term interaction with the patient will eventually result in the trusting relationship. Berg and Danielson (2007: 501) warns that the trust may not develop even after a prolonged interaction between the nurse and the patient, is it aggravated by the fact that nurses do not necessarily believe what the patients are telling them (Morgan and Morfatt, 2008:342). Van Rooyen, Le Roux and Kotze (2008:22) argue that nurses who are working with terminally ill patients have demonstrated a good relationship with their patients. They associate the positive aspect of the relationship with the fact that oncology nurses have prolonged relationships with their patients, most often, they are dealing with emotions (personal, patient and

relatives) and they engage the patients‟ family actively in the management of such patients. Camille (2010:27) disagrees that time is not the determining factor in the relationship but the skill of the professional such as listening is of paramount

importance. To some extent, Camille (2010) responds to the increasing complaints related to the role of technology in the working environment where nurses are taking most of their time on the technology (computers) and not interacting directly with patients.

The mixed method study by Pross et al (2010) with 285 nurses participating, the

quantitative phase of the study used the tool that was already tested for the validity and reliability and research findings triangulated through the focus group discussions, storytelling and interviews identified different constructs that determine the effective relationship. The study highlights that actually the first minutes of interaction between the nurse and the patient determines the outcome of the relationship. Even though the knowledge, courage and patience were reported as themes in the research study, all the three were related to the listening skill of the nurse and the feeling from the patient that he/she is being listened to.

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2.5.2 Communication and listening as the determinant of nurse patient