Rapport: The Art of Caring for Patients

In the previous section, we learned that empathy allows us to recognize emotions, grow deeper understandings of other people, and acknowledge differences between our self and others (Malezieux et al., 2023).  We have not yet discussed how empathy produces a supportive relationship between the nurse and patient, also known as rapport (Figure 5).

Rapport: Describes a close and harmonious relationship in which the nurse and patient understand each other’s experience and communicate well. Notice how empathy provided some impetus for a therapeutic nurse-patient relationship.  Immersion in a patient’s experience significantly enhances both provider empathy, and also concern for the patient’s welfare (Han et al., 2021).  Through recognizing the patient’s experience, health professionals resonate with key emotions and take action to improve these conditions (Lown, 2016).  This resulting collaboration tends to form a therapeutic alliance, which is key to establishing rapport.

Establishing therapeutic alliance

To work in harmony with their patients, the nurse must build a therapeutic alliance.

Therapeutic alliance:  A collaborative relationship between the nurse and patient, culminating in a shared and mutually agreed-upon agenda for care.

This alliance is essential to living the patient’s values of care, as patient-centred care would not exist without collaborative goals of care (Holmström & Röing, 2010).  While empathy is required to build a collaboration, empathy is not at all sufficient on its own.  The skills required to build therapeutic alliance generally require a greater level of assertiveness (Huggett et al., 2022).  In fact, rapport-building skills differ from several empathy skills already discussed.

The ATTACH mnemonic (Table 2) outlines key differentiators for establishing a therapeutic relationship, noting that these skills go far beyond listening to also introduce some level of boundary between the nurse and patient during their clinical encounters.

Assertive communication is the ‘secret sauce’ to establishing therapeutic alliance. With appropriate levels of assertiveness in conversation, the nurse can co-create care experiences which reflect both the patient’s experience and nursing care needs (Hodge et al., 2022).  Sung and Kweon (2022) note that assertive communication demands nurses remain active participants in care, shaping the patient experience by proactively managingemotional distress and setting an agenda for care.  This is why assertiveness skills are essential to building rapport within crisis intervention training programs (Sung & Kweon, 2022).

Clinical Skill: Conveying warmth and comfort

Due to the culture and sociohistorical position of nursing as a profession, many nurses fear being labelled as aggressive when asked to practice more assertively.

This fear highlights a key skill that is likely lacking in the nurse’s daily practice: conveying warmth through communication.

Conveying warmth has nothing to do with providing complements or letting the patient guide the therapeutic agenda.  In fact, the concept of warmth is already integrated into several humanistic nursing theories, including Watson’s Caritas® processes.  It is hypothesized that warmth facilitates intersubjective caring, as warmness emphasizes shared understandings between the nurse, patient and environment (Perkins, 2021).  In this way, warmth creates an implied expectation that the nurse and patient will build ‘harmonic coherence’, or a form of shared consciousness which transcends each individual’s consciousness awareness to produce care (Perkins, 2021).

If warmth sounds like the softer side of nursing, that’s because it is.

Conveying warmth is addressed within many nursing theories primarily because the ideal is built into the ethos of our profession.  But, what makes a nurse’s communication style feel warm and comforting to the patient?

Paradoxically, the caring nurse needs to decrease their level of emotional involvement in the patient’s life (Moreno‐Poyato & Rodríguez‐Nogueira, 2021) to instead live their ‘authentic’ truth when providing nursing care (Nienhuis et al., 2018).  Warmth, therefore, has little to do with getting ice water… and a lot to do with learning to live the values and of a caring nursing.  Warmth requires assertiveness, to express concern for the patient seeking care (Mariyanti et al., 2022).  This might include communicating with patients in a way that alleviates anxiety, reduces uncertainty or minimizes conflict (Howick et al., 2018; Sung & Kweon, 2022).

It’s hard to teach nurses how to be warm or comforting.

While it is hard to teach the concept of warmth, the nurse’s ability to convey warmth during clinical interactions plays a significant role in the likelihood of building a working alliance. As noted within Table 3, patients are likely to collaborate with professionals who display a high degree of warmth, over those who were highly competent (Tan et al., 2023).  This effect is referred to as the primacy of warmth over competence, and it explains key trends within nursing.  For example, we know that demonstrating empathic concern strengthens the therapeutic alliance for nursing care (Huggett et al., 2022; Moreno‐Poyato & Rodríguez‐Nogueira, 2021). 

Clinical Skill: Affirmation of experience

By acknowledging the patient’s experience, the nurse conveys respect not just for the patient but also for the value of working together as two people. 

Authentic conversations essentially affirm a person’s experience, which sets the stage for a strong therapeutic alliance (Nienhuis et al., 2018).  Jean Watson argued that presence wasn’t enough, because it had to resonate with the patient’s experience.  Watson’s idea of authentic presence stems from the practice of “enabling, sustaining, and honoring the faith, hope, and deep belief system and the inner-subjective life world of self/other” (Pullyblank, 2023, p. 158).

I’m confused… how does Watson’s work relate to the skill of affirmation?

Watson’s statement is rather esoteric until you consider her definition of a caring relationship, a form of therapeutic alliance.

Let’s take the example of a lonely patient with limited social supports.

To achieve emotional resonance, patients experiencing loneliness actively seek out support in their interactions with other people (Hu et al., 2020).  As a result, vulnerable and socially isolated individuals also tend to be the most responsive to psychosocial interventions provided by the nurse (Gardiner et al., 2020; D. Zhang et al., 2023).  The therapeutic impact of empathy is best explained by its effect on promoting personhood and personness (Hodge et al., 2022).  This is also what Watson’s ten Caritas® processes describe – see Table 4.  That is, Watson defined a set of actions designed to bridge the gap between nurse and patient (Akbari & Nasiri, 2022).

Emotional resonance is very likely to increase one’s sense of interdependence and collaboration within the nurse-patient relationship (Jambon et al., 2019; McIntyre et al., 2019).  Nurses who match their patient’s emotions tend to score higher on measures of trust, empathy and rapport (Holland et al., 2021).  Similarly, these reciprocal interactions are very likely to enhance the quality of caring behaviors (Cialdini et al., 1997).

Simply put, by operationalizing ten Caritas® processes, Jean Watson has summarized a complex set of skills required for “harmonically braided streams of consciousness” between the nurse and patient (Perkins, 2021, p. 157).  While Watson’s can be interpreted from the perspective of nursing presence, it fits best with the idea of witnessing the patient’s experience of care.

Did You Know?!? Many nurses struggle to affirm undesirable aspects of the patient’s experience. If you struggle with seeing the negative in patients first, positive empathy skills can help you consider each patient’s strengths, hopes and aspirations more mindfully (Conoley et al., 2015).  By reflecting these strengths back to their patient, the nurse creates a therapeutic alliance that builds upon existing virtues instead of focusing solely on the patient’s lack of capacity, or limitations (Conoley et al., 2015).
Scroll to Top