discusion

Nurse-Patient Interaction 381

the odds of a patient acquiring nosocomial pneumonia by 9.5%. Kovner, Jones, Zhan, Gergen, and Basu (2002) found an inverse relationship between RN staffing and post- surgical adverse events. A study of the effect of nurses' educational level on surgical pa- tient mortality found, after controlling for all other risk factors, that surgical patients who were cared for in hospitals where a higher proportion of direct-care RNs held bachelor's degrees had a better survival rate over those treated in hospitals where a lower proportion of staff nurses held bachelor's degrees (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). Al- though these studies do not imply causation, nurses who incorporate evidence-based infec- tion prevention and control recommenda- tions into their practice can decrease infec- tious adverse events and the odds of failure to rescue while reducing health care costs.

BARBARA A. GOLDRICK

Nurse'Patient Interaction

Nurse-patient interaction refers to the dyadic reciprocal interactions that occur between nurses and patients in the context of provid- ing and receiving nursing care. Early nursing theorists such as Peplau, Orlando, Travelbee, and Widenbach, who drew attention to the process of interaction in nursing practice, prompted researchers to describe, operation- alize, and measure the efficacy of nursing in- teractions. In 1977, Diets and Schmidt classi- fied the rapidly expanding research on nurse- patient interaction as descriptive or correla- tional studies, studies that measure the indi- ces of nursing by using hypothetical interac- tions, and studies that describe or evaluate nursing interactions using conception or in- teraction frameworks borrowed from other disciplines (e.g., counseling psychology). These initial research efforts were largely fo- cused on single channels of communication (e.g., nurse conversation or touch) and pro- duced only partial information about the in- teraction. Resulting failures to capture rele- vant clinical data prompted the redesign of

instruments and studies specifically for exam- ining nurse-patient interactions. As one ex- ample, the Nurse Orientation System devel- oped by Diets was used by researchers to examine the effect of nursing on patient expe- riences of pain (Diets, Schmidt, McBride, & Davis, 1972).

Researchers continued to study those as- pects of the nurse-patient interaction that were quantifiable, using predominantly de- ductive approaches; and despite the use of increasingly sophisticated techniques, the re- sults of many studies raised concern about the quality of nurse-patient interactions. Some researchers attempted to explain their find- ings in terms of nurses' lack of communica- tion skills or their busy workloads; others pointed to problems inherent in the research, citing a lack of attention to the patient's role in nurse-patient interaction, unsubstantiated assumptions about the nature of nurse-pa- tient interactions, and failure to take into con- sideration important contextual factors that influence nurse-patient interactions as major issues. In addition, in the absence of adequate definitions of nurse-patient interaction or its components (e.g., touch) researchers used narrow and simplistic conceptualizations. As a result, in deciding a priori what behaviors were important to study, researchers risked missing important behaviors or focusing on insignificant behaviors; as a consequence, they ended up with incomplete or invalid de- scriptions.

As support for "caring" in nursing devel- oped in the 1980s, theorists drew attention to the complexities inherent in the process of providing nursing care, stimulating a resur- gence of interest in examining nurse-patient interactions with a variety of new ap- proaches, such as grounded theory, conversa- tional analysis, ethology, and discourse anal- ysis. By using inductive approaches, research- ers identified nurse and patient behaviors that were important to study (rather than deciding this a priori), explored interaction patterns from the perspective of the nurse and pa- tients, and considered important factors of context and relationship. Studies completed by researchers such as Carl May, Maura

382 ENCYCLOPEDIA OF NURSING RESEARCH

Hunt, Jocalyn Lawler, and Janice Morse are representative examples. Using these new ap- proaches, researchers identified exceptional nursing interaction skills, such as "tactics," "comfort talk," "minifisms," and other pre- viously unrecognized interaction strategies that nurses typically used in clinical settings— skills that were rarely part of communication courses and often devalued.

One of the most important developments in the study of nurse-patient interactions is the use of video technology. Videotaping ob- servations preserves the observational con- text, verbal content, nonverbal behaviors, and interactive processes for analysis and coding. Of particular advantage is the ability to repeatedly review videotapes, both in real time and in slow motion. This facilitates in- depth study of a wide range of simultaneous behaviors, including rarely occurring events and subtle or rapid changes in behavior. Vid- eotaped observations are particularly useful when studying interactions with patients who are preverbal, unconscious, or otherwise un- able to recall interactions with sufficient de- tail.

Although new lines of research show promise and appear to be unraveling some of the unique complexities inherent in nurse- patient interaction, much work remains to understand nursing interactions as they occur in health care settings, including patients' homes or other community settings. Far more attention has been given to identifying and describing components and patterns of nurse- patient interaction than studying the efficacy of different types of interactions in relation to patient outcomes. It appears that some patterns of interaction may be powerful ther- apeutic tools, yet more systematic investiga- tion is needed to demonstrate these effects. Furthermore, negative or undesirable psycho- logical and physiological sequalae associated with interaction patterns should be docu- mented.

Although the definition of nurse-patient interaction has not received careful attention, the focus has been on the verbal and nonver- bal behaviors of the nurse. Yet increasingly, patients are being encouraged to take an ac-

tive role in decision making and their nursing care. To develop innovative and supportive strategies to foster collaboration in care and involvement in decision making, a sound un- derstanding of the nature of interactions be- tween nurses and patient, with a strong focus on the role of patient behavior in these inter- actions, is necessary. In addition, the links between nurse-patient interaction and types of nurse-patient relationships must be ex- plored.

JOAN L. BOTTORFF

Nurse-Patient Relationship

The interpersonal relationship between nurses and patients has become an important subject of discussion, theorizing, and research since Peplau and Orlando introduced the con- cept of the nurse-patient relationship as an essential component of nursing practice. Rec- ognition of the need for individualized nurs- ing care, the introduction of new approaches to care delivery (e.g., primary nursing), in- creasing concerns about dehumanization re- lated to advances in technology, and the emergence of theories delineating caring as a pivotal concept in nursing have reinforced the centrality of the nurse-patient relationship in contemporary practice. The nurse-patient re- lationship is now viewed as essential content in nursing curricula, and clinicians value the development of therapeutic relationships with patients as a significant part of their work. Yet despite the overwhelming endorse- ment of the importance of the nurse-patient relationship, the practical difficulties associ- ated with developing relationships remain unresolved. Of importance are issues related to balancing personal involvement and pro- fessional detachment. Other important issues concern building relationships in contexts where the organization of nurses' work limits involvement or where reporting practices un- dermine the development of trust. Issues also arise from challenges related to renegotiating relationships in response to changes in patient dependence and vulnerability.

xii CONTRIBUTORS

Kay C. Avant, PhD, RN, FAAN

Associate Professor University of Texas School of Nursing Austin, TX

Concept Analysis; Nursing Diagnosis

Cynthia Guerrero Ayres, PhD, RN

Director Health Systems and

Collaborations—New Jersey

American Cancer Society—Eastern Division

North Brunswick, NJ

Clinical Preventive Services Delivery

Terry A. Badger, PhD, APRN, BC

Professor University of Arizona College of Nursing Tucson, AZ

Depression in Families

Judith A. Baigis, PhD, RN, FAAN

Associate Dean for Research and Scholarship

Georgetown University School of Nursing and

Health Studies Washington, DC

Health Conceptualization

Tamilyn Bakas, DNS, RN Associate Professor,

Department of Adult Health

Indiana University School of Nursing Indianapolis, IN

Stroke

Suzanne Bakken, DNSc, RN, FAAN

Alumni Professor of Nursing & Professor of Biomedical Informatics

Columbia University School of Nursing New York, NY

Formal Nursing Languages; SNOMED International; Unified Language Systems

Jane Barnsteiner, PhD, RN, FAAN

Professor and Director University of Pennsylvania School of Nursing Philadelphia, PA

Online Journal of Knowledge Synthesis for Nursing

Mara M. Baun, DNSc, FAAN

Lee & Joseph D. Jamail Distinguished Professor

University of Texas Health Sciences Center at Houston

School of Nursing Houston, TX

Pet Therapy

Cheryl Tatano Beck, DNSc, CNM, FAAN

Professor University of Connecticut School of Nursing Storrs, CT

Meta-Analysis; Phenomenology; Replication Studies

Sandra C. Garmon Bibb, DNSc, RN

Assistant Professor Uniformed Services

University of the Health Sciences

Graduate School of Nursing

Bethesda, MD Leininger's Theory of Culture Care Diversity and Universality; Population Health

Carol E. Blixen, PhD, RN Senior Nurse Researcher Cleveland Clinic

Foundation Department of Nursing

Education and Research Cleveland, OH

Osteoarthritis

Ella Blot, MA, RN, GNP New York University Division of Nursing New York, NY

Urinary Incontinence

Rebecca J. Bonugli, MSN, RN

Clinical Instructor University of Texas Health

Science Center School of Nursing San Antonio, TX

Serious Mental Illness

Joan L. Bottorff, PhD, RN Professor and UBC

Distinguished University Scholar

University of British Columbia

School of Nursing Vancouver, British

Colombia Canada

Nurse-Patient Interaction; Nurse- Patient Relationship

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