Commentary on Shattell M (2004) Nurse–patient interaction: a review of the literature. Journal of Clinical Nursing 13, 714–722.


  • Jean Watson PhD, RN, HNC, FAAN

    1. Distinguished Professor of Nursing, Murchinson-Scoville Endowed Chair in Caring Science, University of Colorado Health Sciences Center, Denver, CO 80262, USA
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Jean Watson, Distinguished Professor of Nursing, Murchinson-Scoville Endowed Chair in Caring Science, University of Colorado Health Sciences Center, Denver, CO 80262, USA. E-mail:

Conventional directions within biomedical science for medicine and nursing care are recognized universally as inadequate with respect to holistic health and compassionate, relational caring processes. Disillusionment with practices and practitioners alike abound, as technology and economics have driven practices to new levels of ethical concerns.

Simultaneously, there is growing attention to deeper levels of reform, if not transformation, needed to invite new images, visions, and hope for human caring and holistic health, which expand conventional systems and institutional practices. This new level of attention is grounded in evolving theories as well as new levels of consciousness with respect to the deeply human dimensions of change, moving beyond the limited economic levels of attention to reform to human capacities for creative solutions.

This evolved perspective involves new ways of thinking and acting that are based upon relationships, authentic communication, trust and subjective meaning; for example, those humanistic, caring and compassionate parameters that invite self-insights, self-control and self-knowledge, as well as self-healing aspects. These new parameters are necessary for sustaining health and healing outcomes.

Such a shift toward authentic relationships, holistic views of care, ethical caring communication and so on, invite, if not require, new theories and philosophies. The nurse–patient interaction paper by Shattell (2004) presents one theoretical model for developing nursing knowledge related to nurse–patient interaction within an holistic context.

In this paper, nurse–patient interaction is acknowledged as a central element of clinical nursing practice. It is honored with a high degree of relevance to care/caring quality, as well as improved communication and competence that can be enhanced by a theoretically based, nursing-knowledge model.

Shattell's article reports findings in the literature which acknowledge the ambivalence associated with patient's views toward nurses and nursing; findings in this area report that patients hold paradoxical and contradictory thoughts, e.g. ‘nice nurses’ alongside ‘equally negative statements associated with their specific (negative) nursing care experiences and needs’. To uncover more understanding related to this phenomenon, Shattel has offered a theoretical basis for nursing knowledge for nurse–patient interaction; this foundation is followed by a review of literature and areas for further discussion.

Her paper attends to this important dimension for nursing practice and knowledge development. However, it is interesting to note that the theoretical orientation Shattell offers is not a nursing theory, but a sociological theory, i.e. Goffman's symbolic interactionism theory.

Goffman's work could inform nursing and knowledge development, but it is only one level of interaction theory. Certainly this theory can be useful in explaining and helping to interpret nurse–patient interactions. Nevertheless, it seems to me that incorporating and including extant nursing theory to ground nursing knowledge development is necessary for nursing science and allowing the discipline of nursing to inform and guide professional practice and knowledge development.

Thus, an approach that builds up and acknowledges Goffman, while incorporating contemporary caring nursing theories could offer a more contemporary and broader view of caring relationships. For example, by integrating Goffman with extant nursing theory, new knowledge and philosophical foundations, new insights could emerge, giving new meaning and understandings of those core caring relationships and interactions that are at the very heart of healing and broader holistic health outcomes in nursing and health care generally.

More specifically, many of the contemporary theories of caring in nursing literature offer a comprehensive view of nurse–patient relationships that go beyond the somewhat past-era modern sociological theory–interaction model of Goffman. The current works in nursing theory and nursing science address expanded ethical concepts contained within relationships and interactions (see research of Swanson 1999, Montgomery 1994, Halladorsdottir 1991, Boykin & Schoenhofer 1993, Smith 1999, Watson 1985, 1988, 1999a,b, 2002, 2003, 2005,Dossey et al. 2004 and others).

These contemporary scholars in caring relationships and holistic practices address concepts and research in such emerging scientific-knowledge areas as authentic presence, intentionality, consciousness, transpersonal dimensions, caring relationship, caring moments, etc. It seems to me, with all due respect, Goffman's theory for nursing may be helpful at one level of analysis, but is limited to a restrictive, external sociological interpretation of the deeply human nursing–patient experiences and subjective phenomena, which serve as the foundation for nursing practice and knowledge development.

Nevertheless, having said that, on the other hand, Shattell makes a compelling case for Goffman's theory of ‘face’ (wherein both individuals interpret and act in order to maintain the face of self and other). However, here too, other contemporary nursing theories in caring literature are incorporating ‘ethics of face’ and soul-to-soul connections in caring relationships. This latest work is guided by integration and extension of the theory of human caring, alongside European philosopher Levinas (Levinas 1969, Watson 2003, 2005). This thinking incorporates the notion that ‘face-to-face human relationships' and authentic connections are the core of ethical, moral practices, necessary to sustain humanity. In addition to extant nursing theory in this area, recent interdisciplinary reports and guidelines are recommending a deep level of reform. This contemporary focus is based upon Relationship-Centered Care/Caring (Tressolini & the Pew-Fetzer Task Group 1994).

Other developments in ‘mindbodyspirit’ medicine, spiritual dimensions of caring practices and healing are all emerging within new theoretical models of medical and nursing practices. These directions for theory, knowledge development and informed practices, go beyond the Goffman model, but do not necessarily require that such work as Goffman's be dismissed either.

If one were to use Goffman as one related theoretical starting point to nurse–patient interactions, while building further into contemporary nursing literature, I think the author would have discovered intersecting and expanded views in the nursing caring literature. If so, the points posed above would undoubtedly have been uncovered and incorporated into this work. If not, my hope is that it will be expanded in the near future to be congruent with some of the latest contemporary nursing views.

Indeed, once one reviews the nursing literature on patients' perspectives on nurse–patient interactions, the caring relationship model comes into play more dramatically. For example, Shattell reports studies that found patients hospital experiences as disconnecting and disconfirming, feeling they were treated like objects. This research on patient experiences parallels some of the classic caring research recently reported by Halladorsdottir (1991) and Swanson (1999).

However, the research questions posed in the Shattell article remain relevant to nursing knowledge and practice. These questions invite/require new theories as well as research methodologies in order to move forward in knowledge development toward advancing nursing science.

One such model for innovative exploration of relevant nursing, and related health science knowledge, necessary for informing and exploring healing relationships was proposed by Quinn et al. (2003). This work was part of a national project funded by the Samueli Institute. This national interdisciplinary nursing work was informed by nursing caring theory and offers an innovative critique of healing relationships; further it serves as a methodological guide. Work such as the Samueli project can extend and inform Shattell's beginning work, by addressing face-to-face and human-to-human caring relationships in an expanded moral–ethical and nursing theoretical framework.

Finally, I concur with Shattell in her commitment to this area of nurse–patient interaction as a central concern to nursing knowledge–practice; it may even hold the key to sustaining nursing during this period of disillusionment due to non-relationships, or destructive interactions. I invite an expanded orientation to nursing knowledge and concept of relationship and wish for a model that goes beyond ‘interaction’ to ‘authentic caring relationships’. This shift requires expanding our focus from sociological theory to nursing caring theory. Once that occurs, the rest of this important scholarly work all falls into place.