Health Science Journal

Keywords

Respect, nursing intimacy, nursing care.

Introduction

Concurrent perspectives in nursing believe that the nurse-patient intimacy is central to patient health, well-being and recovery [1,2]. Practicing intimate care within the health care environment appears to significantly impact to therapeutic effectiveness and patient’s outcomes. Therapeutic effectiveness and quality of care are related to the level of intimacy between the nurses and patients [3]. Therapeutic intimacy has been also referred as a phenomenon worth to be investigated in terms of positive health outcomes, across a number of disciplines [4]. Therapeutic intimacy in nursing appears to be a complex concept which is difficult to be precisely defined. Issues of intimate care and nursing intimacy have not received, so far, the required research attention although intimacy gained recently an increasing importance in nursing. Several authors highlight the need to explore and clarify the nature of intimacy and to further illustrate its therapeutic potential in nursing [5,6]. Nursing intimacy impacts at all levels of nursing profession and its importance in organizational processes of care may assist nurse recruitment and retention. Recognizing the importance of nursing intimacy also contributes to increasing the social value of care and interdependency. As Folbre states, health care providers, social scientists, and scholars, know that care work is underestimated, it is misunderstood, taken for granted, undervalued and underpaid [7]. The complexities and the value of care work remain unnoticed by policy makers as well as family members and employers. However, the above mentioned areas are mostly unexplored. In the same vein, there is little published research evidence on the nature of intimacy in nursing and the practical implications of the close nurse-patient relationships.

Background information

Nursing intimacy is an increasingly important concept in nursing regarding the nurse-patient relationship and it appears to be inherent to the therapeutic potential of nursing science [5]. Despite the health care crisis and the vulnerable nurse-patient interactions due to the changing health care environment and the nursing shortage, experienced bedside nurses know that intimate interactions help patients feel safe and comfortable during illness. Intimate interactions and provision of intimate care require specialized knowledge and skills. The term professional intimacy focus on how nurses negotiate intimate care and learn this specialized knowledge and skill over time.

Dowling identified the attributes of intimacy to be self-disclosure, reciprocity and passivity. Additional related concepts identified as involvement, closeness and engagement [8]. Intimacy is also related to discussion on love and caring in nursing [9]. This demonstrates a mutual attempt of caring between the nurse and the patient. For caring to occur, both the nurse and patient must communicate openly with trust and respect for each other [10], and the nurse must engage with the patient [11]. However, Dowling argues that nurses are encouraged to find what could be termed as a safe equilibrium and are expected to care with empathy and kindness but, at the same time, maintain a degree of emotional detachment [12]. Dowling also states that it is perhaps only nurses who are truly self-aware that can really engage in intimate relationships with their patients. However, self-awareness develops over time with experience. Moreover, the risks of self-disclosure appear greater if the nurse has not developed self-awareness. This issue is also closely associated to communication issues between the nurse and the patient, which in turn affects the development of intimacy [12].

Mattiasson and Hemberg underscore the multidimensional nature of intimacy. They suggest that intimacy varies according to the needs of the individual, physical, psychological, social and spiritual. Theses needs form the basis of potential contact and closeness and intimacy can take the closely related forms of psychological, emotional and physical closeness [13].

Intimate care is defined as the nursing care that involves psychological, emotional and/or physical closeness [5,6,14,13]. Lawler and Williams stated that intimacy in nursing is often characterised by delivering care that involves physical closeness [5,15]. Intimate care requires nurses to be physically and emotionally close to a patient and perform actions that include touching, handling or examining sensitive areas of the body [5,16,17]. Similarly, literature identifies three types of intimacy in the clinical nursing field, namely, physical intimacy, emotional and psychological intimacy and therapeutic intimacy [13,15,18].

Physical intimacy: Provision of intimate nursing care has a physical dimension that requires a close contact which often relates to touch. As literature states in nursing practice, touch is a primary component and fundamental to care giving. The beneficial nature of touch on individuals have been discussed across the literature [16,19] and contradictory options were stated. Although touch has a positive effect on patients, sometimes is perceived as an invasion of an individual's personal, private space and research indicates that touch may be interpreted in different ways. Touch can be perceived by some patients as beneficial and important [16], whilst others perceive it as invasive and uncomfortable [21].

Emotional and Psychological intimacy:

Intimacy is also related to closeness on a psychological and emotional level. At this level intimacy and intimate care have a significant impact on patients’ outcomes. This is the case in both the nursing literature [6,3] and related disciplines [4,21].

Therapeutic intimacy: This type of intimacy is closely associated to emotional and psychological intimacy. It involves self-disclosure of personal information and notions of acceptance, respect and empathy [3]. Therapeutic intimacy is referred as a mutual learning experience and a corrective emotional experience for the patient involving respect, recognition and compassion.

Components of the nurse-patient intimacy

According to Canadian Nurses Association [22], there are major components to the nurse-patient intimacy: Trust, Respect, Empathy and Power. Regardless of the context and the role of the nurse in providing care, these components are always present and important. Trust is critical because of the patient’s vulnerable position. Initially, trust in a relationship is fragile, so it is very important that a nurse keep promises to a patient. If trust is breached, it becomes difficult to re-establish. Respect is the recognition of dignity, worth and uniqueness of every individual. The notion of respect in intimate care is primary, regardless of social and economic status, personal attributes or the nature of a person’s health problem. Empathy involves the ability to understand the patient's situation, perspective, and feelings. In empathetic care this understanding should be communicated and checked for its accuracy for the patient’s benefit. The nurse-patient relationship is one of unequal power. Nurses have specialized knowledge and access to privileged information, the authority and influence in the health care system and thus more power than the patient [23].

Practicing intimate nursing care involves all the above notions and components that may enhance quality of care and patients’ outcomes. Mistreating however, these components may lead to implications of intimate care and endanger nurse-patient relationship.

The implications of nursing intimacy

The significance of providing intimate care and building close, intimate relationships with patients were reported throughout the relevant literature. There are however, concerns regarding the implications of such closeness. The stress of close relationships appeared to be a significant issue in providing intimate care, especially for nurses who often feel unsupported in close nurse-patient relationships [24]. Although some methods of organizing nursing work–such as Primary Nursing-appeared to protect against the stress of close relationships [25], they also serve to increase the vulnerability of the nurse.

May investigated interpretations of the term involvement within the nurse–patient relationship and found that these relationships perhaps appear to constitute over-involvement and create conflict and difficulty for the nurse in fulfilling his/her institutional role [26]. Implications regarding emotional cost of nurses and caring, incompatibility of over-involvement and organizational factors and the realities of nursing practice have been highlighted by several authors [26,27].

In intimate care the focus strives towards building helpful relationships. Under-involved or over-involved in a nurse-patient relationship may impede helpful interactions. Setting limits that respect the role of the health care provider and the person who needs care is critical to keep the relationship in a safe place and to preserve the patient’s dignity, autonomy and privacy and the nurses’ professional obligations and rights [28].

In this respect, safe, competent and ethical nursing care requires the ability to establish and maintain therapeutic boundaries with patients. An essential nursing skill is the ability to recognize and respect the boundary signs in nurse-patient relationships. These boundaries may be flexible especially for the period of time needed to establish or maintain a therapeutic relationship. It is important however, to recognize what is a helpful crossing of a professional boundary, and what is not. For providing safe and intimate care, nurses must have a sound understanding of the complexities of professional boundaries. Understanding the patient’s boundaries requires good communication and sensitivity to private issues for each patient. Some interventions and behaviors are therapeutic and acceptable in certain circumstances if, in the nurse’s professional judgment, they help to meet the patient’s therapeutic needs.

The development of intimacy within the nurse-patient relationship is increasingly prescribed and valued [1,2,29]. However, there appears to be a lack of conceptual clarity from a nursing perspective and little published research investigating intimacy in practice. Both of these areas are arguably critical to the successful implementation of the concept in practice. This research aims to contribute to an understanding of intimacy through identifying and exploring the concept from the perspective of practicing nurses.

Methodology

A qualitative inductive approach based on the principles of naturalistic inquiry was selected for the study. Qualitative methodology and inductive theory process was used in order to gain into the field where little is known. As there was no literature in the Greek context that explore nurses’ views on nursing intimacy and intimate care, inductive theory process which is directed towards bringing knowledge into view was the most appropriate method of investigation. In addition naturalistic inquiry offers a qualitative perspective that takes into account people and their experiences.

The study population consisted of registered nurses who worked in clinical areas for at least one year. A non probability convenient sampling strategy was applied for the study. Data were obtained using semi structured interviews that lasted between 15 and 30 minutes. Themes of investigation included nurses’ views on the definition of nursing intimacy, intimacy in clinical fields, and intimacy and patient care. Demographic data were also included.
The setting of investigation involved two general hospitals in Athens. The study permission was granted to the researchers by the Board of the Directors and the Director of Nursing. Each study participant was given written information about the study before the interview and signed an informed consent form. The participants were also assured about their anonymity and confidentiality. The hospitals provided to the researchers a quiet room in order to conduct the interviews. Privacy was assured during the interviews.

Content analysis was used for analysing the collected data. For every answer common themes or shared meanings were identified. Common themes and shared concepts were identified in the data and after testing and retesting the data against the predominantly proposed categories, main and core categories emerged. Findings were presented in a narrative form reflecting the nurses’ views on nursing intimacy.

FINDINGS

Twenty four (24) registered nurses participated in the study. The age of the participants ranged from 24 to 47 years old with an average of 35.8 years. Eighteen of the participants were female while six were male. Years of employment ranged from 1.5 to 20 years with an average of 12.8 years.

Initially participants were asked to state

what they think nursing intimacy is.

Data analysis revealed the following common themes and concepts that emerged from the participants’ answers:

1.Respect

2.Violation

3.Meeting patients needs

According to these themes, three sub-categories were formulated.

The first sub-category referred to respect and intimacy as participants appeared to relate the concept of nursing intimacy with demonstrating respect to hospitalized patient. This was made explicit in the examples and descriptions of intimacy:

“Nursing intimacy means care with respect…showing respect to the patient and to his needs regardless age, state of mind, disease...Also practicing nursing in a responsible and respectful way…in a right way…”

“Nursing intimate care first and foremost is to respect the patient, to be compassionate and empathetic…”

“Every patient regardless nationality and religion is entitled to good nursing care…this means respect the individuality of the patient and excellent professional behavior …this is nursing intimacy.”

The second sub–category referred to avoiding violation and nursing intimacy. Participants described nursing intimacy as an effort to protect patients’ rights and restrain patient abuse. More specifically they stated:

“Intimacy is to not to violate patient’s rights…is to pay attention to patient’s views and values”

“Intimacy is a way of caring without violation. It’s a process of practicing respectful nursing care without insulting or being insulted.”

“Nursing intimacy is when I give to the patient the right to decide for himself without violating his rights…”

The third sub–category referred to intimacy and meeting the patients’ needs, as participants appeared to relate nursing intimacy with meeting the patients’ needs. Participants stated:

“Nursing intimacy is meeting the needs of the patient as a whole… with dignity and caution…”

“I see nursing intimacy in the way we approach the patient… having in mind the primary goal of care which is meeting the patients needs with respect, responsibility and kindness.”

Data analysis at this stage showed that nurses define nursing intimacy as respecting the patient, protecting patients’ rights and meeting patients’ needs. The notion of respect appeared to be central to most of the participants’ statements. In this respect, a main category has been formulated namely:

“Intimacy and Respect the Patient”

Following that, nurses were asked to explain how they can ensure nursing intimacy in their ward. The common themes and concepts which emerged from the participant's answers are as follows:

1. Knowledge

2. Professionalism

3. Good nurse-patient relationship

4. Ethical rules

5. Quality care environment

According to these themes and concepts five sub–categories were formulated, describing nurses’ views on how nursing intimacy can be assured in the clinical field. The first sub-category referred to knowledge and ensuring intimacy, as participants appeared to value professional knowledge with regard to intimacy. In particular, nurses stated:

“Intimacy can be ensured by respecting the patient, my colleagues and myself; being tolerant and by applying scientific knowledge at everyday practice”
“With respect, responsibility,

consistency and knowledge.”

“With high levels of knowledge, good cooperation with colleagues and respect, intimacy can be assured in my ward.”

“If people in my department, practice care with respect and knowledge, I believe that can ensure nursing intimacy…”

The second sub–category referred to professionalism and ensuring intimacy, since nurses appeared to relate nursing intimacy with professionalism. Statements highlight these concepts:

“Intimacy can be ensured when the nurse -patient relationship is been directed by professionalism and acceptance...”

“The professionalism and the good cooperation of all health care providers can ensure provision of intimate care…”

“Intimate care can be ensured with continuing education , training and professionalism…”

The third sub–category referred to the good nurse-patient relationship and ensuring intimacy. In this sub-category nurse participants viewed that a good nurse-patient relationship is of utmost importance for ensuring intimacy in the clinical field. Particularly:

“As a nurse I can ensure intimate nursing care in my department by keeping in mind that I must respect patients by treating them with kindness and courtesy, and above all by establishing a good nurse-patient relationship.”
“….understanding patients’ problems and maintaining a good relationship with them…”

“Intimate care can be ensured when there is good communication between the patient and the nurse and good working conditions.”

The fourth sub–category referred to ethics and intimacy. Nurses valued ethical rules in ensuring intimacy. More specifically they stated:

“By respecting ethical rules we offer the best possible care.”

“Implementation of intimate care means compliance with ethical rules, and respecting nursing protocols. In those ways I can ensure nursing intimacy in my ward.”

“…by respecting the patients’ personality and by applying ethical principles in every practice.”

The fifth sub–category referred to quality care environment and ensuring intimacy. A professional environment which ensures quality of care appeared essential for nurses in order to ensure intimacy in clinical wards. Specifically:

“…by having a secure and quality care environment we can assure intimacy..”

“Creating an appropriate environment with quality standards and quality of work...”
“As a nurse I can ensure intimacy by showing respect to patients, by showing respect to my working place and by improving the quality of care in my ward.”

Data analysis and interpretation at this stage revealed that nurses can ensure nursing intimacy in the clinical field by valuing issues related to the overall context of care such as the working environment, the nurse-patient relationship, the quality of care, the ethics and the professionalism. In this respect, a main category has been formulated, namely:

“Intimacy and Respect Context of Care”
Finally, the participants were asked to describe how nursing intimacy can enhance good patient care. Three common themes and concepts identified in the data:

1. sufficient number of nurses

2. consistency

3. therapeutic environment

Following that, three sub–categories were formulated describing nurses’ views on nursing intimacy and good patient care

The first sub-category namely sufficient number of nurses and intimate care focused on issues of adequate staffing. Some Nurses stated:

“With adequate nursing staff nursing intimacy can enhance good patient care.”

“With a sufficient number of nurses who will have the knowledge to provide high quality of care.”

“When there is sufficient number of nurses and sufficient time for meeting patients’ needs, then intimate care can be applied…this means also quality care.”

The second sub–category referred to consistency and intimate care. In this sub–category nurses viewed that consistency of care is closely related to intimacy and thus quality care. Specifically:

“…nursing intimacy means consistency among others…that enhances the quality of the provided nursing care…”

“Nursing intimacy enhances good patient care by being consistent to what we have to do in order to help the patient.”

“…ensuring confidence and consistency through intimate care we get better health outcomes.”

The third sub–category referred to therapeutic environment and intimate care. Nurses appeared to relate quality of care with appropriate therapeutic environment and nursing intimacy. In this respect statements have as follows:

“…by creating an appropriate therapeutic environment, in which the patient can get the best result… physical, mental and spiritual…”

“Our aim is that patients feel safe in a good therapeutic environment that reduces anxiety and fear and increases the trust between the nurse and the patient…these can be achieved by intimate care and these are quality of patient care…”

“When we practice care with intimacy and have a good therapeutic environment, then we can have a better quality of care.”

Data analysis and interpretation at this stage demonstrated that according to nurses’ views nursing intimacy can enhance quality of patient care by paying attention on issues related to application of care such as adequate staffing, consistency in nursing care and therapeutic environment. In this respect, a main category has been formulated namely:

“Intimacy and Respect Application of Care”

Concluding, following the analysis of the data three main categories were formed:

1. INTIMACY ↔ RESPECT THE PATIENT

2. INTIMACY ↔RESPECT CONTEXT OF CARE

3.INTIMACY↔ RESPECT APPLICATION OF CARE

Central to these main categories is the notion of respect. This led the researchers to formulate one core category namely “Nursing Intimacy and Respect”.

Schematically the findings in figure 1.

Figure 1: Findings schematically presented

Discussion - Conclusion

Results demonstrated that Greek nurses strongly relate the concept of intimacy with the concept of respect. Nursing intimacy is viewed and defined as respecting the patient, the context of care and the application of care.

A clear definition of intimacy has been formulated following the study results.

Intimacy in nursing means the principal concept of respect which underlines the provision of nursing care and the nurse-patient relationship.

Although the concept of intimacy in nursing appears to be complex and partially explored relevant literature showed the necessity to define the intimate nature of nursing especially within the nurse-patient relationship [11,26,32,33]. Literature also demonstrates that notions of intimacy, such as developing trusting relationships, caring and provision of intimate care is fundamental to nurses’ work. Through intimate caring acts, including informing, treating with respect, and showing concern for personal stress, nurses maintain patients’ self worth and professional worth [30,33].

Findings of the present study also revealed that nurses can ensure nursing intimacy in the clinical field by valuing issues related to the overall context of care such as the working environment, the nurse-patient relationship, the quality of care, the ethics and the professionalism.Most of the work undertaken so far, in the field of nursing intimacy, supports the study results, since it focuses on intimacy and patient, intimacy and context of care and intimacy and application of care. More specifically, concepts of intimacy and the patient have been discussed by Pearson, McMahon & Pearson [1,2,29] and issues on boundaries, attachment and distance as well as the nurse–patient relationship have been explored in detail [5,31]. Seminal papers on nursing intimacy discussed intimacy not only within the frame of nurse-patient relationship but within the context of care in terms of time availability and environmental factors. In addition, nursing intimacy has been explored in different levels such as physical touch, and therapeutic touch that depicts the close relation of intimacy with application of care [13,15,18].

In the present study, nurses appeared to relate quality of care with appropriate therapeutic environment and nursing intimacy. This finding has important clinical relevance as it reveals the association among issues related to application of care-such as adequate staffing, consistency in nursing care and therapeutic environment-and nursing intimacy and quality of patient care.

Concluding, nurses appeared to understand the true meaning of intimacy and more importantly nursing intimacy. They find out new ways to enhance quality care and they also try to understand first of all themselves, their colleagues and their patients.

It’s been observed that intimacy is related to respect to the patient, respect to context of care and respect to the application of care. Respect means giving everyone his due. It means focusing on the existing hierarchies. It means acknowledging individuals for their own identities, cultures and ideas. It means providing empathetic and respectful nursing care.

Reccomendations

Provision of intimate care is central to contemporary health care systems. Intimate care can ensure high quality of care and this can be achieved by adequate staffing, professionalism, effective, therapeutic and safe environment for the patient and interdisciplinary collaboration. Nurses should be supported in administrative and educational level to provide empathetic and respectful care which is translated to intimate care.

Further research to explore patients' understandings of intimacy might be of importance. Findings on nursing intimacy from the patients’ point of view may be supportive if nursing is to provide effective, valued, patient centred care. In addition, issues of nursing intimacy and the relatives’ perspectives and experiences on it can be also an issue of further investigation.

Finally, it might be beneficial to study the concept of nursing intimacy at an international level focusing on cultural issues, relationships between nurses and patients and provision of tailor-made patient care. Studying how these factors, experiences and understandings increase social and professional values of intimate care work may prove to be important for future research endeavors.

Limitations of the study

The present study focused only on Greek nurses' perception and experiences of intimacy in two study sites. A solely qualitative methodological approach was used for exploring the issues of intimacy. Although, in studies as the present one where the focus strives on studying experiences and opinions, qualitative approaches are recommended, a mixed methodological approach using both qualitative and quantitative methods might assist issues of generalisability and trustworthiness of results. Extended research to a number of study sites at a national level and with larger sample size might be supportive to representativeness issues and may constitute a challenge for researchers interested in this field.

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