Therapeutic relationship nurse–patient in hemodialysis therapy

Abstract Introduction Building a therapeutic relationship aims to achieve therapeutic goals. The aim of the study was to determine the importance of the therapeutic relationship between nurse and patient in hemodialysis therapy. Material and Methods The study included 77 patients with end‐stage kidney disease (ESKD) and on long‐term hemodialysis in one of Warsaw's dialysis centers. The diagnostic survey method was used with the questionnaire technique. A survey questionnaire developed by the author was used as the tool for the study. The analysis was carried out using StatSoft Statistica 13.1 PL statistical package and Microsoft Office. Results According to the respondents, the main elements of a therapeutic relationship are empathy (82%), mutual trust (68%), and respect (60%). 86% of patients believed that the nurse–patient relationship was important in renal replacement therapy, significantly less frequently with reference to patients aged 70 years and older (p < .05). Patients positively evaluated the nurse‐patient therapeutic relationship, indicating that it influences the sense of security, helps in coping with difficult moments, and increases the quality of medical care. Conclusions The establishment of a therapeutic relationship with the patient should be the basic course of action of every nurse.

patient and the nurse to be good. 4,5 An irreplaceable element of a good and fruitful therapeutic relationship is empathy. Empathy is the ability to step into another person's shoes and to identify with that person's emotional state, behavior, attitude, and feelings. 6 An empathetic person is one who tries to understand and accept another person's point of view without making critical judgments and showing hostility. Empathy protects against the duplication of patterns and routine in contacts with the sick. In the context of the clinical situation, however, it is often equated with the ability to be fully with the other person. Being so fully present also means being able to see when to be active and when to be an observer, when to speak honestly and when to refrain from commenting. It can be stated that empathy is not only a moral and philosophical issue but one of the most important competencies of a modern nurse. Without empathy there is no trust, without trust, there is no sincere and good therapeutic nurse-patient relationship, which is helpful in the treatment process.
A chronic disease is undoubtedly one source of stress that can be experienced in human life. It is a difficult and complex situation in many aspects-cognitive, emotional, social, and existential. It requires the patient, and often his immediate environment, to cope with difficulties resulting from the disease itself as well as from therapy. 7 A chronic kidney disease is one such type of disease, which requires renal replacement therapy in its final stage. This treatment includes dialysis (peritoneal dialysis, hemodialysis) or kidney transplantation. The first mentioned therapy is characterized by repeated procedures until transplantation if there are no contraindications, or until the end of life. Estimates are that 2 million people worldwide suffer from kidney failure, and the number of patients diagnosed with the disease continues to increase at a rate of 5-7% per year. 8 The population of patients receiving dialysis continues to grow rapidly. Worldwide, approximately 89% of patients on dialysis receive hemodialysis. 9 Hemodialysis is the dominant therapy in the world. Therefore, the following research question was posed: what is the perception of the therapeutic relationship by hemodialysis patients?
The aim of the study was to determine the importance of the therapeutic relationship between the nurse and the patient in the treatment of patients undergoing chronic treatment with hemodialysis.

| MATERIAL AND METHODS
The study was conducted in the period from November 2019 to January 2020. It included 89 people who were chronically hemodialysed during this period at the dialysis center of the University

| The importance of the therapeutic relationship in the opinion of the respondents
The vast majority of patients (85.7%) stated that the therapeutic nurse-patient relationship was important in renal replacement therapy. Four respondents (5.2%) had the opposite opinion, and 9.1% did not express their opinion clearly. Patients aged 70 and more were convinced significantly less often than the younger ones that the therapeutic nurse-patient relationship was important in renal replacement therapy (63.6% vs. younger patients: 3.3%-95%), p < .03.
The respondents (n = 66) who believed that the therapeutic nurse-patient relationship was important in therapy mentioned that importance. In most cases, this relationship gave patients a sense of being understood by the other person (33.3%), gave them strength to fight the disease (27.3%), less often helped to restore hope (10.6%), helped them practice the ability to understand their problems by looking at them through the eyes of a different person (9.1%), helped to control helplessness (7.6%), and strengthened the positive aspects of health behaviors (6.1%). Two people mentioned a different meaning-one indicated that it "improves the assessment of the patient in their own eyes", the other indicated "pleasant conditions of hemodialysis". Two people replied they "don"t know" (3%).

| The respondents' assessment of the influence of the therapeutic relationship on the effects of their therapy
In most cases, the respondents believed that the current therapeutic relationship between the nurse and the patient influences their sense of security (4.5), helps them cope with difficult moments (4.4), and improves the quality of medical care (4.4), but slightly less often they believed that it helps to accept the disease and therapy (4.3) and that it increases the effectiveness of the therapy (4.1). Women significantly more often than men believed that the therapeutic relationship between the nurse and the patient helps to accept the disease and therapy (4.5 vs. 4.1), p < .05 ( Table 2).
Most of the respondents (87%) believed that the contact of a nurse with a patient in a dialysis center was therapeutic (includingyes: 54.5%, rather yes: 32.5%), two respondents (2.6%) were of the opposite opinion, and 10.4% of the respondents did not express their opinion. receiving treatment for a shorter period of time: 0%; rather yes: over 5 years: 40%, others: 12%-33.3%), p < .01. All three respondents who were treated with hemodialysis and did not accept this therapy declared that they would rather involve nurses more in the therapeutic relationship, p < .02 (Table 4).

| DISCUSSION
In 2018, 20418 patients in Poland underwent hemodialysis. 10 Due to economic reasons, despite numerous arguments in favor, patients in Polish dialysis centers rarely receive psychological assistance.
The therapeutic relationship between the nurse and the patient seems to be of significant importance in the group of ESKD patients who undergo repeated hemodialysis treatments. It should be emphasized that the therapeutic relationship, which is most often associated with psychotherapy and psychotherapist, is used in other medical professions, including nursing. Between the nurse and the patient that a specific type of bond is established, which aims to achieve specific behaviors in the patient that strengthen health and support the therapy. 11 Most of the examined patients correctly understood the concept of a therapeutic relationship. As elements of a therapeutic relationship, the respondents most often mentioned empathy (significantly more often men, people with higher education, and people who do not accept therapy), trust, and respect, while village residents sig-  on the effects of their therapy. In the first place, there were answers that this relationship gives a sense of security, helps in coping with difficult times, helps in accepting one's illness and therapy, and even increases the effectiveness of therapy and the quality of care. In the analyzed group, women significantly more often than men believed that the therapeutic nurse-patient relationship helps in accepting the disease and the therapy.
The nurse-patient contact is not therapeutic for all respondents, but for the majority (97.4%) it is sufficient. Village residents, patients with dialysis lasting >5 years, and patients who did not accept their therapy expected greater involvement of the nursing staff in the therapeutic relationship. Therefore, with reference to these groups of patients, nurses should show greater commitment to the therapeutic relationship. the need to make quick decisions, the responsibility for others, and the constant contact with people, unfortunately, increase the incidence of this disease in staff. 24,25 All of these elements mean that a certain routine, getting to know the patient during the years, may result in an unintentional but noticeable omission, noticed by patients.
The therapeutic relationship between the nurse and the patient, in the opinion of the respondents, is of great importance in renal replacement therapy, but only 87% of them considered the nurse's current relationship with them to be therapeutic. Despite such a good assessment, patients expected an increase in the involvement of nursing staff in the therapeutic relationship, which should be noted, taking into account socio-demographic variables, the duration of therapy, and its acceptance by the patient or lack thereof.
T A B L E 3 The assessment of satisfaction with the quantity and quality of the nurse-patient relationship in the dialysis center conducted by the respondents, all together, and depending on the variables Source: Own research.
The study was limited due to a small number of respondents and due to the involvement of only a single dialysis center. More research is needed on a larger group of patients with the use of standardized tools.

| Implications for clinical practice
The work of a nurse is characterized by contact with another person that is sick or at risk of a disease and often undergoes a specific therapy.
T A B L E 4 The expectations of the studied patients undergoing hemodialysis regarding the increased involvement of nurses in the therapeutic relationship depending on the variables Therefore, the therapeutic relationship with the patient should be the basis of every nurse's work. The establishment of a therapeutic relationship that is experienced by the patient as safe, supportive, and trustworthy is not a simple thing, but very important, as an expression of the nurses' commitment and profound professional responsibility. The hemodialysis procedure is a repeated procedure, lasting about 4 h, which the nurse can use to support the patient by respecting the patient, genuinely interested in him as a person, emotional warmth, tolerance, and nonjudgmental acceptance of the patient, especially the ability to listen carefully, empathy, and real patient's own strength and abilities, while being aware of the limitations resulting from the disease or therapy, and presenting appropriate health behaviors. Emphasis should be placed on the individual character of the therapeutic relationship, the need to recognize the needs of a specific individual, and, based on them, implement a specific action plan. It seems necessary to pay more attention to establishing and maintaining a therapeutic relationship, the advantages of which are noticed by patients. It also influences the broadly understood quality of care.

| CONCLUSIONS
The concept of a therapeutic relationship and its elements are known to the respondents. Its correctness has a positive effect on all spheres of the bio-psycho-social condition of patients, stimulating them to cooperate in the fight against the disease and in therapy. The establishment of a therapeutic relationship with the patient should be the basic course of action of every nurse. Nursing care in conjunction with the therapeutic relationship achieves the right quality in the care of a hemodialysis patient.