Nurses are with patients and families during some of the most difficult and vulnerable moments in life. There are few other professionals who have the opportunities that nurses have to deeply touch the lives of others. Nurses provide care at birth, death, and throughout lifetimes - promoting health, preventing illness when possible, and providing care through illness when necessary.

 Nurses offer care and healing. Healing is a word that has a root meaning “to make whole”. Nurses help patients to become as whole as possible as they cope with illness or adapt to the challenge and limitation imposed by injury or disease. Nurses help patients to become whole by seeing them as whole and worthy of regard and respect – whatever their circumstance. Nurses bring healing and wholeness to patients with knowledge, skill, and very importantly, perhaps most importantly, with compassion, caring, and presence.  

All of nursing takes place within human relationships and communication is the key to establishing relationships of caring and regard. When patients and families feel truly cared for their suffering is eased and their health optimized. When excellent nursing care is offered patients and nurses find meaning in the experience.
Margaret Newman’s (2008) recent book title captures the power of nursing: Transforming Presence – the Difference that Nursing Makes.  The purposes of this article are to review essential aspects of the nurse-patient relationship and describe communication strategies that can help to create transforming and healing relationships.

Definitions of Nursing
During the twentieth century nursing knowledge deepened and expanded.  Definitions of nursing from three nurse theorists, Virginia Henderson, Margaret Newman, and Hildegard Peplau, are offered as examples of the excellent work that has helped the discipline of nursing to evolve with increasing clarity of vision and purpose. Henderson, an influential nurse leader of the twentieth century defined nursing in the 1960s in a way that continues to be highly relevant today:
“The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge” (Henderson, p. 15).

Newman (1994) defines nursing as caring in the human health experience. She describes health as expanding consciousness, that is, health as an evolving process of developing self-awareness and insight within the larger context of the environment and with the increasing capacity to recognize alternatives and possibilities. Nurses become therapeutic partners with patients as they search for the pattern and meaning of their lives (Newman, 1981). According to Newman, nursing requires unconditional acceptance of the pattern of the whole and unconditional love, which manifests itself in sensitivity to self, others, and the creative process. Caring in the human health experience transforms the nurse and the patient – new possibilities are experienced and envisioned and consciousness is expanded.

Peplau, as cited in Jacik (2000), defined nursing as an alliance between a helping professional and patient characterized by specific caring behaviors: Professional knowledge and skill; attentiveness to the patient’s experience; and a positive connection that goes beyond an exchange of information. The relationship between the nurse and patient involves the genuine interest and emotional involvement of the nurse. According to Peplau, the nurse is always participant and observer.

Caring is a privilege. The direct and active involvement of the nurse as described by Henderson, Newman, and Peplau is demanding, challenging, and rewarding – and requires exquisite self-knowledge and self-care.
 
Professional Communication: Creating Relationship

Arnold and Boggs (1999) conceptualize the nurse patient relationship as having three elements. The theoretical component encompasses the scientific basis for establishing and maintaining the professional relationship. The technical aspect includes specific skills and strategies. The final element, artistry, emphasizes the creative element of establishing relationships where the uniqueness of the nurse contributes to the goal of helping another to realize their fullest potential. The theoretical, technical, and artistic aspects of professional relationships are inextricably linked.
    
Nurse-patient relationships are established purposely, focused on the needs of the patient, maintained intentionally, and ended carefully (Arnold and Boggs, 1999). Professional relationships have three phases, generally – a beginning, middle, and end. The work of the first phase of the relationship is to establish trust, assess the circumstance and identify the problems that will be the focus of the work. The middle is the working or problem-solving phase. Interventions are tried, evaluated and refined. The final phase is the ending or termination phase. The nurse and patient review the relationship, summarize their work together, plan for the future, and say good-bye.  
    
In therapeutic relationships communication is goal-directed and focused on the health care situation (Arnold, 2003).  Goals for the relationship include: Helping the patient feel understood and comfortable (Varcarolis, 2006); identifying and exploring patterns, concerns and problems; and coming to understand new possibilities and alternatives (Newman, 1994). Qualities that facilitate therapeutic relationships include: respect; unconditional positive regard; nonjudgmental acceptance; genuineness; trustworthiness; attentiveness; and caring (Arnold and Boggs, 1999).

Communication that facilitates professional relationships of regard and trust consist of verbal and nonverbal aspects. Nonverbal communication can encompass appearance and dress, body movement, posture, the use of touch, facial expressions, silence and the use of physical space and distance. The tone, rate, and pitch of the voice also serve to communicate. While nurses may focus intently on the words they use in an encounter with a patient, communication theorists estimate that the vast majority of what gets communicated is, in actuality, communicated non-verbally.  Awareness and creative use of nonverbal communication is an essential element of developing professional relationships.

The context of the communication has significant meaning in the development of the relationship. Understanding cultural norms and values of the nurse and patient, and paying attention to the physical and psychosocial setting are very important. Attending to privacy and comfort, and recognizing the meaning of previous experiences between the nurse and patient – and between the patient and other caregivers, can contribute to creative understanding of the context of the relationship, generally, and the encounter, specifically.
Four Important Strategies: Attending, Responding, Clarifying, and Questioning

Attending and Responding
Paying careful attention to and being fully present in the circumstance of the patient can, in itself, be therapeutic.  Using the physical space to create privacy and sitting at eye level with the patient rather than standing over the patient conveys interest and regard.  Letting the patient know how long the nurse is available can help the patient to anticipate and pace the conversation. Active listening – really hearing what the patient communicates offers an opportunity to hear, reflect, understand and feel understood. The use of silence – in an attentive and judicious way can be an effective way to let the patient know that the nurse is fully engaged, present, and attending to the experience of the patient.  

Responding with acceptance (“Yes”, “I hear you”), recognition (“Your experience is important”, “That sounds very difficult and challenging”), caring (“I would like to stay with you”, “I would like to understand what is most important to you”), and offering general leads to continue the conversation
(“Please go on”, “Tell me more about that”, “And then what happened?”) are strategies that enhance communication and help to establish and validate the relationship (Varcarolis, 2006).

Clarifying  
The techniques of paraphrasing, restating, and reflection can help the nurse and patient to be clear about meanings and perceptions in the communication and ultimately offer additional tools to assure that what is being exchanged is being mutually understood.  (Varcarolis, 2006). Paraphrasing involves summarizing for the patient what is heard, in the nurse’s words. The nurse can help the patient to clarify perceptions by sharing her understanding and the nurse can either be assured that her understanding is accurate – or the nurse and patient together can modify their understandings of the communication.  

With restating, the nurse uses the patient’s words and shares them with the patient to assure that her reading of the communication is accurate. The nurse can use the patient’s words and add her understanding of the emotions conveyed, as well.  For example: “You are feeling far from home and alone here in the hospital. I hear sadness as you say that.” “You are pleased to be leaving the hospital and ending this long treatment. I also hear worry about leaving the watchful vigilance of the nurses.”

Reflection is a technique to assist patients to understand their thoughts and experiences more clearly (Varcarolis, 2006). The nurse shares her observations and her understanding of the emotions being conveyed by the patient. Often a question from the nurse can facilitate reflection. “As you described your recent diagnosis of diabetes your voice quivered and your eyes watered. Many patients experiencing worry and fear in relation to a new diagnosis, are you worried?”   

Questions
Sensitivity to the way in which questions are asked is very important. Patients are asked many, many questions and repeating the same questions asked by many others can communicate a lack of interest in and attention to the patient’s experience.  

Matching the type of question with the type of information being solicited is key. Open-ended questions often begin with what, who, where, when, how and ask for information that requires elaboration and more than one word responses. They invite patients to share and reflect and can reveal a patient’s understanding and feelings. Open-ended questions require time to answer, sensitivity in responding, and skill in controlling the conversation.

Closed questions ask for specific facts or pieces of information and often begin with are, do, is, can. Are you in pain? Did you take your medication? Can you tell me the date? Closed questions narrow the focus, take less time, and require less effort. Closed questions do not invite reflection or elaboration but can be very effective in soliciting targeted and specific information from the patient.

The way in which questions are asked can communicate understanding, interest, and caring. Asking questions is a way that either broadens or narrows the focus, depending on the situation, can help the patient to understand what is expected and important in the encounter. Nurses can skillfully contribute to the development of the relationship with sensitive and deliberate use of questioning strategies.

Conclusion
The expert presence of nurses has the potential to offer caring, comfort, and healing possibility to patients experiencing vulnerability and suffering. Developing therapeutic relationships with patients requires intentional focus, technical skill, artistry, creativity, and commitment. The challenges of communicating clearly and well so that relationships of caring and regard are established are enormous – and yet so, too, are the rewards. Excellent nursing care makes profound differences in the lives of patients.