Therapeutic Relationship between Nurses and Patients in a Tertiary Level Hospital, Bangladesh

ABSTRACT


INTRODUCTION
Nursing is widely recognized as a noble profession that combines with the medical proficiency and sense of human consideration.For its nobility, therapeutic relationship (TR) between nurses and patients is accepted as the cornerstone of caring (Zugai, Stein-Parbury, & Roche, 2015).Therapeutic relationship refers to developing a meaningful relationship between the nurse and patient, in which a therapeutic alliance is established (Moreno-Poyato et al., 2017).It is an interpersonal engagement aims to help patients to enhance their wellbeing through establishing a mutual trust relationship (Roviralta-Vilella et al., 2019).
The key characteristics of therapeutic interpersonal relationships are therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness (Kornhaber, Walsh, Duff, & Walker, 2016).Nurses listening to concerns, taking problems seriously and acknowledging patient's skills that are pivotal in making patient feel like a person and not just a patient (Turpin, Mc Wasiam, & Ward-Griffin, 2012).The importance of Therapeutic relationship are self-awareness, reflection and professionalism, including how nurses use themselves as an instrument of care provision for a patient from their journey of sickness to recovery (Wright, 2021).However, the nurses need personal manner, Corresponding Author: Nabanita Mondal technical skill, information giving, communication and presence when the patients were anxiety, pain, long waits (Ware, 2017).The metaphor of TR are entering the patient's world, trusting and telling, identifying different needs and uncovering change, patients becoming masters of their own health, patients experiencing health in illness, and nurses going the distance.These core themes were synthesized into a metaphor of the nurse-patient relationship (Strandås & Bondas, 2018).The dramatic changes in health care economics, organizational culture and patient needs claimed that the nurse patient relationship is still perceived as central to patient well-being, health and recovery (Duffy & Hoskins, 2003).A good nurse-patient relationship may enhance the patient's health, not only with regard to illness, physical condition and treatment but also physical, emotional, mental and social well-being and this relationship also has the potential to strengthen the patient's own resources towards maintaining health (Strandås & Bondas, 2018).A good nursepatient relationship reduces the days of hospital stay and cost of health care and improves the quality of care and satisfaction of both nurses and patients (Molina-Mula & Gallo-Estrada, 2020).Thus, it is clear that patients and nurses both are benefited personally and economically from improving nurse patient therapeutic relationship (McAllister, Robert, Tsianakas, & McCrae, 2019).It is necessary to a person to make them the feeling of safety particularly when they are helpless, dependent, and fearful due to sickness (Hreńczuk, 2021).Moreover, when a patient usually has experience of pain, fear, stress, anxiety and may be afraid of the unknown and be worried about the impact of illness; establishing a relationship with nurses might reduce their fears and anxiety (Baillie, 2005).However, the TR does not always seem to be a priority in health care system and patient often feel that they have few opportunities to establish a relationship with staff and perceive a tense and insecure atmosphere in hospital that ultimately affect the health care outcome and quality of care (Moreno-Poyato et al., 2016).The quality of healthcare services in Bangladesh has resulted in a loss of faith in healthcare providers, low utilization of public health facilities, and increased outflows of patients from Bangladesh to hospitals abroad due to patients' negative attitudes and dissatisfaction with healthcare service providers and healthcare systems (Mohiuddin, 2020).Though the quality of care largely associated with patient satisfaction where one of the most important domains of patient satisfaction is interpersonal relations between nurse and patient (Johansson, Oleni, & Fridlund, 2002).There is no study found on nurse patient therapeutic relationship.Only one study found on doctor -patient relationship in Bangladesh and the finding was that the doctor patient relationship was poor from the public and patient's viewpoints (Hamid, Begum, Azim, & Islam, 2021).Despite several importance in therapeutic relationship between nurse and patient, the area also receives little attention in Bangladesh.Even, several studies have been conducted on various issues in nursing; such as barrier to effective communication, patient satisfaction, quality of care but none of the study has been conducted on therapeutic relationship between nurses and patients.These results are one tool that can help the policymakers and hospital administrators may take special attention to establish cultures that visibly value and support nurse-patient relationships and healthcare delivery that reflect all dimensions of the patient's health.Therefore, researcher would like to conduct study on therapeutic relationship between nurse and patient in Bangladesh.

MATERIALS AND METHODS Study Design:
A descriptive study design was employed to explore the therapeutic relationship between nurses and patients in tertiary level hospital of Bangladesh.

Study period:
The study period was from July 2021 to June 2022.

Study Population:
The study population was the registered nurses and admitted patients those who are at tertiary level hospital, namely Khulna Medical College Hospital (KMCH) in Bangladesh that was conveniently selected.Therapeutic relationship from patients' perspective assesses by STAR-P that also consist of 12 items, including three subscales: positive collaboration (6-items), positive nurses' input (3-items) and non-supportive nurses' input (3-items).It is also a 5-point Likert scale response ranging from 0 to 4; Never =0, Rarely =1, Sometimes =2, Often =3 and Always =4.Before scoring, scores of the subscale are reversed.Corresponding Author: Nabanita Mondal Data Collection Methods: Data was collected using structured questionnaire.Researcher was collected data using self-administered questionnaire from nurse participants and from patient participants by face-to-face interview.

Instruments
Data Analysis: Collected data were analyzed by a specially designed computerized "Statistical Package for the Social Science" (SPSS).Both descriptive and inferential statistics was used for data analysis.
Ethical implication: Anonymity and confidentiality of the respondents were strictly maintained.The participation of the respondents in this study was completely voluntarily and they can withdraw at any time they wish.Researcher was grantee that this was not harm to respondents, treatment process and to that hospital.All data provided by the participants will be kept under researcher locked cabinet for three years.After publication of this study in a scientific journal, the data will be destroyed.In the present study the nurse's average age was 34.71 (± 7.37).Around 96.4% of nurses were female and most of them were married (91.1%).Most of nurses (76.8%) were Hindu.

RESULTS
Among the nurse's majority of them (92.9%) were Diploma nurses.Around half of the nurses (46.4%) had 1 year to 5 years job experience.

DISCUSSION
In this study, therapeutic relationship of nurses and patients were measured in overall and its three subscales.Present study results revealed that there was significant difference (p=.00) between TR perceived by nurses and patients.While the overall TR perceived by nurses was reported as high level but the TR perceived by patients was low to moderate level.The result of this study is inconsistent with the previous study conducted in another country (Geirdal, Nerdrum, Aasgaard, Misund, & Bonsaksen, 2015).But the result is consistent with the earlier study in Bangladesh that conducted on doctorpatient relationship and the findings was that the relationship was high from the doctor's point of view but low from the patient's point of view (Hamid et al., 2021).In this study the patients expressed negative perception towards the nurses.This research reveals that trusting and honest relationship, communication, understanding patient's goals and expectation, listening patients' opinion, negative perception towards the nurses are the most crucial for nurse-patients therapeutic relationship that the patients rated low level.One the other hand nurses did not give any negative answer on their self-performance.
In response to TR subscale positive collaboration perceived by nurses was higher than the patients.This overall result is supported by the item response under this subscale that the nurses perceived rapport, honest relationship, trusting relationship, openness, sharing similar expectation, and working for patients' wellbeing were higher than perceived by patients.In Positive Nurses Input the nurses perceived that they listen to patients, supportive to patient, taking patient's perspective that the patients perceived negatively.The nurses did not feel that the patient reject them and they had no difficulties to empathize patients' problems that means nurses had no emotional difficulties.Patients perceived that the nurses did not withhold the truth from them but sometimes, they stern and impatient with them that indicate non supportive nurses' input.The results were dissimilar with the other study that conducted outside our country (Höfer, Habermeyer, Mokros, Lau, & Gairing, 2015;Geirdal et al., 2015).Although the findings of this study are not directly comparable to other study due to the limitation of evidence with similar settings but found consistability with same types of study in similar setting (Hamid et al.,2021).

CONCLUSION
It is suggested that, nurses may actively participate in facilitating therapeutic relationship to patients who are ill and admitted in the hospital.Its correctness has a positive effect on all spheres of the bio-psycho-social condition of patients, stimulating them to cooperate in the fight against the disease and in therapy.Providing support and establishing relationship may alleviate their stress and help to increase their satisfaction regarding nursing care as well as health care.
The study will contribute to explore the baseline information about the existing nurse patient therapeutic relationship at public hospitals.The findings of the study have an implication for nursing practice, nursing education, nursing administration and nursing research as the basic and foundational data.Therefore, the study implies that intelligent strategies should be formulated by authority to improve nurse patient therapeutic relationship through improving the work environment, increasing the opportunity of in-service training and education.

:
The instrument for data collection consists of two parts: Part I (For Nurses), Part II (For Patients).Part I (For Nurses): It has two parts Part I.A: Nurses Sociodemographic Characteristics Questionnaire comprising with 6 items age, gender, religion, marital status, education in nursing and job experience.Part I.B: STAR -C (Nurse Version) is the part of "A new scale to assess the therapeutic relationship in community mental health care" (STAR) developed by McGuire-Snieckus, McCABE, Catty, Hansson, & Priebe in 2007.This questionnaire has two-part STAR-C and STAR-P.STAR-C was used to assess therapeutic relationship from nurses' perspective that consist of 12 items, including three subscales: positive collaboration (6-items), emotional difficulties (3-items) and positive clinician input (3-items).It is a 5-point Likert scale response ranging from 0 to 4; Never =0, Rarely =1, Sometimes =2, Often =3 and Always =4.Before scoring, scores of the Emotional Difficulties subscale are reversed.Part II (For Patients): It also has two parts Part II.A: Patients socio-demographic characteristics questionnaire comprising with 7 items age, gender, religion, level of education, duration of hospital stays, occupation and living area.Part II.B: STAR -P (Patient Version).

Table 3 : Univariate Analysis on Each Item of Therapeutic Relationship as Perceived by Nurses (N=56)
The result indicated that majority of the nurses (92.9%) were responded always on "I get along well with my patient" mean score was 3.93(SD=.26).Almost all nurses (96.4%) were responded never on "It is difficult for me to empathize with or relate to my patient's problems" mean score was .07(SD=.42).About 91.1% nurses responded always on "I listen to my patients" mean was 3.91(SD=.28).Majority of participants (91.1%) stated always on "I feel that I am supportive of my patient" mean was 3.91(SD=.28).About 92.9% participants were responded never on "I feel inferior to my patient" mean score was .13(SD=.50).Conversely the results also indicated that about 37.5% nurses stated often on "I am able to take my patient's perspective when working

Table 5 : Therapeutic Relationship Perceived by Nurses and Patients on Overall and Its Dimensions and Level of Therapeutic
First of all, I am very happy to address my sincere gratitude to my Major Advisor, Dr. Md.Abdul Latif for his patience, continuous guidance, enthusiasm, sharing knowledge, constant support and intelligent input throughout this research.His dynamism, vision, sincerity and motivation have deeply inspired me.I would also like to express my whole-hearted appreciation goes to my Co-advisor Dr. Mosammet Khaleda Akter and my Ex-advisor Dipali Rani Mallick for their enormous contributions, guidance, valuable suggestions, constant supervision, affectionate advice and cooperation in making this study a success.