1. Polansky, Mary BSN, RN

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LIKE ALL NURSING CARE, home healthcare is guided by provider orders, agency policies, and insurer regulations. But home healthcare nurses also have a unique opportunity to build trust with their patients as they deliver care. Although establishing trusting relationships with patients is not mandated by provider orders or insurance policies, trust is essential to the success of nursing care.1


At home, patients welcome nurses, who are strangers, into their personal space at a vulnerable time in their lives.2 This article discusses the importance of trust in patient-nurse relationships in the home healthcare setting.


Seeking optimal outcomes

Establishing a trusting relationship between nurses and patients improves outcomes. These relationships lead to better communication and have been shown to increase patients' adaptation to the state of illness or disability.3,4 In 2018, more than 7 million people benefitted from home healthcare services.5 If patients who trust their caregivers have better outcomes and millions receive home nursing care, then the importance of the nurse-patient relationship cannot be overstated. Knowing this, home healthcare nurses should take as much care in working to build trust with their patients as they would in performing any other nursing responsibility, such as infection prevention or pain management.


Picture a relative or neighbor being discharged from the hospital after a long stay with a serious illness. Imagine that family, their worries, and their needs. How does it feel to be discharged home from a hospital busy with nurses, physicians, and therapists dedicated to patient care? Most patients and family caregivers are not trained, prepared, and equipped to manage the complex care provided by healthcare professionals. Even nurses on the receiving end of care may not be able to meet their own increasing health needs independently.


When patients require home healthcare, they are typically in varying states of pain, fear, and uncertainty. Effective therapeutic communication can help assuage the stress of illness.6 As capable caregivers, trusted nurses provide great relief to patients and families in health crises.7 During home healthcare, nurses must help their patients feel safe to optimize communication during assessment and education.2


Unlike the hospital, the home is familiar and personal. It is where people keep their favorite things, where they are in charge of their days, and where their loved ones live. Home healthcare nurses interact with individuals in this environment in whatever state of neatness or disarray that has developed during the patient's illness. This intimacy can lead to more holistic care, as these nurses may see a broader picture of their patients.1 For example, nurses visiting patients at home notice the challenges of each patient's unique environment, such as steps, throw rugs, or other physical obstacles and safety issues. Perhaps more important, home healthcare nurses also see what their patients value most, including their interests, family, or faith. With a trusting relationship, this comprehensive view of patients enhances the quality of nursing assessments and helps nurses provide more individualized care.


Qualities that build trust

Research on patient experience reveals the qualities that lead to trusting relationships with clinicians. Patients trust competent nurses with good clinical skills who are "friendly, warm, and patient."8 They trust nurses who are available, accessible, in charge, and able to anticipate their needs (even those that are unspoken).3,8


Effective therapeutic listening is crucial when building a nurse-patient relationship. Healthcare documentation is largely computer-based with the electronic medical record, but nurses should make a point of setting aside the computer or tablet during patient interactions. This demonstrates good listening skills and allows nurses to better understand individual patients and their needs.9


Trusted nurses hear what is said and notice what is not, responding to both. Patients may have complex feelings about their health, especially when living with chronic illnesses, and they and their families may share these feelings with someone they trust.4


Nurses should practice active listening to strengthen the therapeutic relationship. For example, upon receiving a patient's assessment of his or her pain, a nurse should make eye contact and assess the significance of the symptoms. Patients may express relief if they are feeling better or may worry that worsening pain is a sign of disease progression or ineffective treatments. Ask questions and understand and validate patient responses.9


As nurses become more familiar with the patient and family, they must take care to maintain professional boundaries. Home healthcare nurses should enter the patient's house "as a guest," consistently demonstrating that they are there as a professional care provider.1 Patients place a high value on home healthcare nurses with excellent clinical skills who understand their needs and approach them as a trusted professional, not as a friend or family member. Maintaining a professional demeanor without slipping into a casual or social relationship demonstrates good boundaries.


A trusting nurse-patient relationship reduces patients' anxiety and stress. Patients receiving home healthcare who have this kind of relationship may experience an increase in faith, hope, and meaning as they share their fears about illness, aging, and death.8


Eligible patients do not have to leave their home for care, but they must invite nurses into their homes.1 Nurses offer a lifeline to patients by alleviating their isolation.1 A trusting relationship increases patients' sense of security and may even make them feel better.1


Patients are forced to adjust to their illnesses and the subsequent limitations imposed on their lives. Trusted nurses may enhance patients' ability to adapt to an illness and manage it.3 It is unsurprising that many patients, such as those receiving hospice care, feel that an illness is manageable with the help of a skilled nurse and home healthcare team.


Trust makes a difference

What is the difference between trusted nurses and those not perceived as being caring, trustworthy, friendly, warm, patient, and in charge? These nurses are technically doing the same job and following the same orders and care plan. Each collaborates with other healthcare team members and conducts home visits according to facility procedures, agency policies, insurer regulations, and provider orders.5 Yet they could have very different relationships with individual patients and their respective families. These differences are rooted in trust and can change patient outcomes.


Success in nursing care depends on the nurse's ability to build trust with his or her patient. Before attempting to establish this kind of relationship, however, home healthcare nurses must remember that they are unknown professionals entering a patient's personal space. Patients trust capable nurses with excellent clinical and communication skills. This trust can help patients return to a healthy state, adapt to an illness or disability, or even experience a peaceful death at home.




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