Exploring Rapport Formation Between Nurses and End-of-Life Patients

Abstract

This study aims to deepen the understanding of rapport formation between nurses and end-of-life patients by synthesizing existing qualitative research. Using meta-ethnography, this research integrates findings from various studies to explore the essence and process of rapport formation from nurses' perspectives. A comprehensive search across MEDLINE, EMBASE, CINAHL, and Web of Science databases in August 2024 identified 13 relevant studies. The quality of these studies was assessed using the Critical Appraisal Skills Programme checklist. The analysis identified 5 key themes in rapport building: “secure acceptance and safety,” “genuine and transparent interaction,” “insight into the patient's world,” “bonding enhanced by professional support,” and “advancing connections within boundaries.” These themes underscore the role of rapport in enhancing the quality of palliative care, providing emotional stability, and improving the nurse-patient relationship. This study offers valuable insights for health care professionals to strengthen nurse-patient interactions, emphasizing the importance of rapport in end-of-life care.

End-of-life patients experience physical and psychological stress simultaneously, and the quality of care provided during this time has a significant impact on the quality of their final days.¹ Given these challenges, patient-caregiver rapport is especially critical, because it helps create a supportive environment that encourages open communication and emotional connection between the patient and the caregiver.²

Rapport, however, is a multifaceted concept that poses challenges in its conceptualization. A recent scoping review that attempted to establish a common definition or framework for rapport was ultimately unable to achieve this, thus highlighting the complexity and variability in understanding this concept.³

Despite these challenges, previous studies have attempted to define rapport. Rapport has been conceptualized as being closely related to verbal and nonverbal communication, formed through positive and relaxed connections and understanding that transcend simple conversation.⁴ Rapport is often viewed as a representation of harmony and mutual understanding and is considered a foundation for building trust. In health care, rapport is a key concept for enhancing the patient-provider relationship. Specifically, rapport between nurses and patients is built on empathy and mutual understanding, which contribute to greater patient satisfaction and adherence to treatment.

In end-of-life care, nurses play a frontline role in accompanying patients and their families through their final journey.⁵ The rapport formed between nurses and terminal patients strengthens cooperation and harmony with the family and key figures in the patient's life, ultimately contributing to an environment that upholds the patient's dignity and maximizes the quality of care. Furthermore, this rapport is essential in alleviating the emotional difficulties faced by end-of-life patients, helping them approach their final moments peacefully.

Despite the various studies conducted on rapport, a comprehensive and systematic understanding of the rapport-building process between end-of-life patients and nurses is still lacking.³ Existing studies have mainly focused on rapport formation in individual cases or specific environments, and there is a relative lack of meta-analytical research that synthesizes these studies.^2,6-8 Recent studies have defined rapport in various dimensions from the perspectives of patients and families,⁴ but there is limited research on how these perspectives are concretely implemented in the interactions between nurses and patients.

This study aimed to integrate the existing research on rapport formation between end-of-life patients and nurses through a qualitative meta-analysis for clearly defining the essence, process, and outcomes of rapport formation. Through this, it sought to provide a comprehensive understanding of rapport formation between end-of-life patients and nurses and to identify the key elements in the process of rapport formation, steps that lay the groundwork for nurses to develop practical strategies that enable them to provide better care in their relationships with end-of-life patients.

METHODS

Aim

The purpose of this study was to enhance the understanding of the essence and process of rapport formation by qualitatively analyzing and synthesizing existing studies from the perspectives of nurses caring for end-of-life patients.

Study Design

This study was designed to synthesize the findings of the existing qualitative research to develop a new understanding of nurses' perceptions of rapport formation with end-of-life patients. Meta-ethnography, as proposed by Noblit and Hare, was used in this study. Meta-ethnography is a qualitative synthesis approach that seeks to uncover new conceptual understandings by comparing and translating findings across multiple studies and is used in the present research to focus on the experiences and perspectives of patients and health care professionals.

This study was registered with the International Prospective Register of Systematic Reviews. The research was conducted in alignment with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and the newly developed eMERGe reporting guidelines tailored for meta-ethnographies,⁹ thus ensuring a rigorous and transparent synthesis process.

Study Procedure

Search Methods and Eligibility Criteria

A systematic search was undertaken across several electronic databases, including MEDLINE, EMBASE, CINAHL, and Web of Science, in July 2023. The search strategy involved predefined terms relevant to “rapport,” “bonding,” “trust,” “end of life,” “palliative,” and “hospice,” which were combined using Boolean operators (AND, OR). In addition, terms specific to qualitative research methodologies, such as “interview” and “qualitative,” were included to ensure a precise focus on qualitative studies. Reference lists of pertinent articles were also reviewed to identify additional studies.

Two researchers independently performed the database searches, screened titles and abstracts, and assessed full texts based on predetermined inclusion criteria. Any disagreements were resolved through in-depth discussions to reach a consensus.

The eligibility criteria were as follows: (1) studies focusing on the perspectives of nurses regarding rapport or trust building with end-of-life adult patients, (2) studies using qualitative research methodologies, (3) studies published in English, and (4) studies appearing in peer-reviewed journals. Exclusion criteria included (1) studies in which the focus on nurses' perspectives was ambiguous, (2) studies that did not clearly present qualitative findings in mixed-methods research, and (3) studies for which the full text was not accessible.

Quality Appraisal

The methodological quality and trustworthiness of the selected studies were appraised using the Critical Appraisal Skills Programme tool, which comprises 10 questions designed to evaluate the credibility, relevance, and coherence of qualitative studies.¹⁰ The 2 authors independently assessed the quality of the included studies, with any disagreements resolved through thorough discussion.

Data Extraction and Synthesis

The data synthesis process involved an in-depth comparative analysis of the selected studies to identify similarities and differences. This synthetic approach aimed to integrate the findings from qualitative research to provide a broader understanding of how nurses perceive and develop rapport with end-of-life patients.

The data extraction focused on identifying first-order constructs (direct quotations from study participants) and second-order constructs (the researchers' interpretations of those quotations). These data were iteratively analyzed, refined, and organized into a cohesive narrative that captured both the diversity and commonalities in nurses' experiences of rapport building.

Throughout this process, broad themes were refined into specific categories, and the original data were revisited to confirm and validate findings. These results were then synthesized into higher-level themes (third-order constructs) that formed a comprehensive understanding of rapport formation in palliative care settings. Continuous discussions between the 2 authors ensured consistency in interpretation and resolved any differing perspectives.

RESULTS

Thirteen studies were included in this meta-ethnographic synthesis (Figure 1). The characteristics and details of the included studies, along with the results of the quality assessment, are summarized in Tables 1 and 2, respectively. Although some of these studies included patients or family members as participants, this synthesis focuses exclusively on the perspectives of nurses to analyze the process of rapport formation from their viewpoints.

FIGURE 1.

The flowchart of the search for eligible studies.

TABLE 1.

Characteristics of Studies Reviewed

First Author (Year)	Country	Aims	Setting	Participants (Sample Size)	Research Design	Data Collection	Data Analysis	Key Findings Related to Rapport
English11 (2023)	New Zealand	To understand the experiences of health professionals in developing rapport during telehealth calls	Hospices providing community services	31 palliative professionals including 20 nurses	Qualitative interpretive description study	Semistructured interviews and focus groups	Reflexive thematic analysis	• Getting on together: Rapport is crucial in telehealth calls, although it can be challenging to discern when it is developed. • Rapport is a soft skill: Rapport can be learned and practiced but requires intentional effort to be sustained in each interaction.
Jeong12 (2023)	Korea	To explore the subjectivity of nurses' patient-centered communication for end-of-life patients	Hospice wards or centers	50 hospice nurses	Q-methodology	Semistructured in-depth interviews	6 practical steps of Q-method	• “Sincere listener”—prioritizing active listening and empathetic engagement • “Sufficient time devoter”—highlights the need for dedicated time to understand patient needs and provide holistic care
Koppel6 (2022)	United States	To explore nurse and patient experiences of developing rapport during oncology ambulatory care videoconferencing visits	Cancer center	12 oncology nurses	Qualitative descriptive design	Semistructured interviews	Conventional content analysis	• Patients appreciate rapport that goes beyond medical care, feeling valued as individuals rather than just patients. • Videoconferencing is effective for some visits, although not ideal for all types of care interactions.
Baik1 (2020)	United States	To identify barriers and facilitators to care conversations in home hospice care	A large not-for-profit hospice agency	32 health care team members including 24 nurses	Qualitative descriptive study	Semistructured interviews	Content analysis	• Trust is essential: Trust building is key to establishing effective goals-of-care conversations between health care providers and patients.
Johnstone13 (2018)	Australia	To explore the specific processes that nurses use to foster trust when caring for older immigrants in end-of-life care	Metropolitan health services	22 nurses	Qualitative descriptive study	Semistructured interviews	Thematic analysis	• Fostering trust encompassed the 3 stages: establishing trust, strengthening trust and sustaining trust.
Ryan14 (2016)	Ireland	To explore the nature and importance of therapeutic relationships in palliative care for individuals with intellectual disabilities	Health service Executive area	91 staffs including 55 nursing staffs	Qualitative research	Focus group interview	Content analysis	• Trust and continuity of care are crucial for therapeutic relationships. • Knowing the individual is essential, but palliative care staff found it difficult to engage directly with patients with intellectual disabilities.
Seccareccia15 (2015)	Canada	To explore key elements of communication in palliative care units	Inpatient palliative care units	39 health care providers including 11 nurses	Qualitative study	Semistructured and focus group interviews	Grounded theory method of analysis	• Patient-centered care: Tailoring communication and care to individual patient needs leads to better outcomes. • Barriers to communication: Challenges include the complexity of end-of-life discussions and balancing emotional involvement with maintaining professional boundaries.
van Gurp8 (2015)	Netherlands	To explore how teleconsultation affects the relationships between home-based palliative care patients and specialists	Home-based palliative care	12 home-based palliative care team members including 4 nurses	Qualitative study	Semistructured interviews and open interviews after the observations	Grounded theory approach	• Technologized intimacy: Patients reported a sense of intimacy and emotional relief during teleconsultations, even in the absence of physical proximity.
Komatsu16 (2014)	Japan	To understand oncology nurses' experiences in patient counseling and support services in ambulatory care settings	Ambulatory care settings in cancer treatment facilities	21 oncology nurses	Qualitative study using grounded theory	Focus group interview	Grounded theory techniques	• Connecting with patients: the importance of understanding patients' needs and building trust by showing empathy and acceptance
Bahrami17 (2011)	Australia	To explore why nurses' perceptions about cancer patients' QoL might be different from those of cancer patients	Major public hospitals	10 nurses	Descriptive exploratory qualitative study	Interviews	Content analysis	• Weak rapport and relationships affect nurses' perceptions of patients' QoL, improved through openness and nonjudgmental attitudes.
Stajduhar18 (2011)	Canada	To examine how relationships between home care nurses and family caregivers intersect with access to palliative home care services.	Palliative home care nursing services	56 home care nurses	Qualitative ethnographic study	In-person interviews “Think aloud” recordings after home care visits	Thematic analysis	• Relationships are essential for building trust and understanding patient needs. • Trust facilitates open dialogue and better care decisions. • Maintaining boundaries is challenging. • Time constraints: Limited time impacts the ability to build strong relationships. • Feelings can affect the level of care provided.
Iranmanesh7 (2009)	Iran	To elucidate the meaning of a caring relationship with people who have cancer	Oncology unit in a major cancer hospital	8 nurses	Qualitative phenomenological hermeneutic approach	Narrative interviews	Phenomenological hermeneutic analysis	• Emotional closeness: Closeness in the nurse-patient relationship is vital for effective care. • Mutual trust: Trust and understanding between nurses and patients develop over time, influenced by personal and professional experiences.
Mok2 (2004)	China	To explore the nurse-patient relationship in the context of palliative care	Palliative care setting	10 hospice nurses	Qualitative, phenomenological approach	Open-ended, unstructured interviews	Van Manen's phenomenological approach	• Forming a relationship of trust, becoming part of the family, refueling with emotional energy, and enriching experiences for both nurses and patients • Trust and connectedness were foundational elements.

Abbreviation: QoL, quality of life.

TABLE 2.

Quality Assessment Results of the Included Studies

First Author (Year)	Was There a Clear Statement of the Aims of the Research?	Is a Qualitative Methodology Appropriate?	Was the Research Design Appropriate to Address the Aims of the Research?	Was the Recruitment Strategy Appropriate to the Aims of the Research?	Were the Data Collected in a Way That Addressed the Research Issue?	Has the Relationship Between Researcher and Participants Been Adequately Considered?	Have Ethical Issues Been Taken Into Consideration?	Was the Data Analysis Sufficiently Rigorous?	Is There a Clear Statement of Findings?	How Valuable Is the Research?	Total Score
English11 (2023)	2	2	2	2	2	2	2	2	2	2	20
Jeong12 (2023)	2	2	2	2	2	2	2	2	2	2	20
Koppel6 (2022)	2	2	2	2	2	1	2	2	2	2	19
Baik1 (2020)	2	2	2	2	2	1	2	2	2	2	19
Johnstone13 (2018)	2	2	2	2	2	2	2	2	2	2	20
Ryan14 (2016)	2	2	2	1	2	1	2	2	2	2	18
Seccareccia15 (2015)	2	2	2	2	2	1	2	2	2	2	19
van Gurp8 (2015)	2	2	2	1	2	1	2	2	2	2	18
Komatsu16 (2014)	2	2	2	2	2	2	2	2	2	2	20
Bahrami17 (2011)	2	2	2	2	2	2	2	2	2	2	20
Stajduhar18 (2011)	2	2	2	1	2	1	2	2	2	2	18
Iranmanesh7 (2009)	2	2	2	2	2	2	2	2	2	2	20
Mok2 (2004)	2	2	2	2	2	2	2	2	2	2	20

Theme 1: Sincere and Long-Term Presence

The process of rapport formation was described in most studies as gradual,^{2,6-8,12,13,15-18} akin to a seed sprouting and growing into a tree over time (Figure 2). In the initial contact, patients began to form “first connections”—the initial rapport—when they sensed the nurse's consistent and dedicated presence, which laid the foundation for the relationship's subsequent development.^15,18 As time progressed and interactions between the patient, family, and nurse were repeated, rapport gradually strengthened. The most crucial concept here was the nurse's consistent and dedicated presence over time.^{2,6-8,12,14,15}

FIGURE 2.

Overarching themes of rapport formation between nurses and end-of-life patients.

I learned from people that they need us to be there and spend time with them. Over time I realized that this is the most important thing in the care.^7(p1303)

I stayed with him, gave him support by telling him I would be around if he needed help. I saw him become more relaxed…and I found he was changed.^2(p480)

Theme 2: Secure Acceptance and Safety

One of the most fundamental elements in forming a rapport with end-of-life patients and families was ensuring that they felt safe and accepted by the nurse. Research indicated that when patients felt respected and understood by their nurse(s), they experienced emotional stability, and feeling safe, relaxed, natural, and unburdened.^{2,11,13,15,18} Such an environment allowed patients and families to express their thoughts and feelings freely, without discomfort, calculation, or the need to hide anything.^1,2,18 They believed, “I can talk to this nurse about anything comfortably (I can get closer).” Such an atmosphere of acceptance and safety was the foundation for rapport formation and was essential for establishing trust between the patient, family, and nurse(s).

If you are not comfortable with each other, then nothing is going to happen, nothing of importance. But if you don't have that rapport, you can't get them to open up to you.^11(p978)

She (the family caregiver) started to phone me if there was a problem. If something was different or if she wanted something, she felt comfortable just calling the office.^18(p122)

Theme 3: Genuine and Transparent Interaction

Once a foundation of secure acceptance and safety had been built, it became possible to engage in more genuine and transparent interactions, another key element of rapport. When a nurse communicated with authenticity, honesty, and transparency in the relationship with the patient and family, they felt a true connection with the nurse.^11-13,17 This type of interaction facilitated the smooth flow and sharing of information, opinions, experiences, and feelings, fostering a climate of openness, sincerity, and mutual trust.^{1,2,6,11-13,17,18} This flow helped to create a deep understanding and connection between the nurse and patient, building trust and encouraging the patient to express their emotions without hesitation. Research indicates that such genuine interactions significantly contributed to establishing a stable relationship in which patients felt they can rely on their nurse.

I think it feels good, cause you have established a relationship and there is that flow of information and you just hear them relax a bit more.^11(p978)

Some patients don't want to complain, and so they don't speak up when they have new pain or are more nauseous. If you have that rapport, you can kind of get to those underlying issues a little easier.^6(p7)

Theme 4: Insight Into the Patient's World

Genuine and transparent interaction led to a deeper understanding of the patient's world. Nurses formed a stronger bond with patients by carefully discerning their experiences and perspectives.^12-14,17,18 This went beyond merely assessing the patient's condition to include recognizing the patient as a whole person and understanding their true inner thoughts and underlying feelings.^1,6,12,14,17 In this process, the nurse sensitively identified what the patient truly desires, values most, and undoubtedly needs.^1,12 When a nurse understood the patient's innermost self, the patient felt genuinely respected and believed that the nurse truly comprehends their pain and needs.¹⁸ This deep understanding played a crucial role in forming a meaningful rapport between the nurse and patient.

When you sincerely sympathize with and listen to the patient's situation at the end of life, you can figure out what the patient really wants.^12(p6)

Just to know them on a more personal level and their families…the whole person, not just the cancer.^6(p7)

So you kind of get to know everything, so you do…even their favorite colors…their whole background, and their families.^14(p433)

Theme 5: Bonding Enhanced by Professional Support

Bonding enhanced by professional support was a critical aspect that distinguishes rapport formation from general relationships. Nurses strengthened their bond with patients and family by providing timely, necessary information and delicate care based on a deep understanding of the patient and their own professional expertise.^{1,6,11,12,15,18} This bond reflected that the care provided by the nurse went beyond mere duty, that he or she genuinely considered the patient's well-being. Specifically, support grounded in a nurse's expertise instilled confidence in patients that they would receive the appropriate help when needed, playing a crucial role in reinforcing rapport.⁶ Research indicated that such a relationship, built on professional assistance, was essential for fostering deep trust and stability in the nurse-patient relationship.

In communication, rapport is needed the most, and it comes from actions, not words. Providing competent and precise care is a fundamental foundation for building relationships with patients and strengthening the therapeutic relationship.^12(p7)

The trust develops through the relationships with nursing, with medicine, with physio, OT, spiritual care. It's about developing those relationships.^15(p760)

Theme 6: Advancing Connections Within Boundaries

The ability to form a deep connection while maintaining boundaries was vital in rapport formation. Nurses had to communicate in a way that goes beyond a typical nurse-patient or nurse-family relationship, drawing closer and advancing the relationship while still maintaining therapeutic boundaries.^2,6,16-18 This often resulted in a relationship that is more advanced than usual, sometimes described as being like “friends” or “family.”^2,6,17 However, at the same time, it was crucial for nurses to maintain appropriate therapeutic boundaries to preserve objectivity and a comfortable distance. Research suggested that when nurses effectively maintained this delicate balance, patients felt greater security in the relationship, which further enhanced rapport.¹⁶ Such a deep connection within boundaries ensured that rapport remained strong and continued to evolve, playing a crucial role in providing ongoing trust to the patient and family.

It's like having a new friend that you just kind of learn everything about, and you want the best for them.^6(p7)

Because the relationship has evolved into a friendship, the nurse becomes part of the family. Also, they feel secure because you are a medical professional.^2(p480)

I enter into the patient's world, but I don't drown in his or her emotional world. I maintain my objectivity. It does not sound scientific at all, but I know there should be a comfortable distance between the patient and me. I may decide “this distance is comfortable for this patient” based on the patient's response.^16(p421)

DISCUSSION

This study conducted a qualitative meta-analysis to deeply explore the process of rapport formation between end-of-life patients and nurses with the aim of identifying the essential elements and developmental stages of their rapport. The analysis revealed 6 key themes that were crucial for understanding how rapport was formed, how it was maintained, and how it affected patient care. This study showed how rapport, beyond mere interaction, deepened and strengthened over time. In particular, it built on the concepts of the mutual understanding inherent in harmonious relationships, showing that the rapport between end-of-life patients and nurses formed a deep bond that was continuously strengthened within appropriate boundaries throughout the dying process.

This study conceptualized rapport not as something that forms instantly but rather gradually solidifies and grows over time, which can be likened to a “growing tree.” This metaphor illustrates the importance of nurses maintaining consistent and dedicated attitudes in their relationships with patients. These findings are consistent with previous research that concluded rapport formation requires ongoing interactions and time.³ In particular, nurses caring for end-of-life patients must ensure continuity of care during the limited time patients have to prepare for a peaceful death¹⁹; their consistent presence and attention play a crucial role in providing stability to the patient. Such care serves as the root of rapport while providing the necessary nutrients for its growth. Resting on this strong foundation, patients feel respected and understood, which in turn allows them to experience emotional stability.²⁰ Especially in end-of-life care, when discussing and expressing emotions related to death is vital, genuine interactions and a comprehensive understanding of the patient's inner world help to build a stable rapport.¹³

It was also revealed that the rapport between end-of-life patients and nurses, unlike in general relationships, should not grow without limits.^16,18 Some studies suggest that, in helping end-of-life patients organize and reflect on their lives, nurses naturally develop a deep understanding and connection with the patient. This can sometimes shift the relationship beyond the typical nurse-patient dynamic, becoming one more like friendship.² However, other studies caution that unrestricted intimacy may foster dependency and blur professional boundaries, highlighting the importance of maintaining appropriate therapeutic boundaries for a healthy rapport.^16,18 These conflicting views on closeness suggest that setting and maintaining boundaries is a complex issue that involves nurses' subjective judgment.²¹ Although some argue that boundaries should align with the patient's comfort level, research on this topic remains limited. Therefore, further studies on nurses' experiences and perceptions regarding boundary-setting with end-of-life patients are needed, along with educational programs aimed at enhancing rapport-building skills. When nurses maintain this delicate balance skillfully, patients are likely to feel more secure in their relationships with nurses, thereby strengthening rapport.

Although rapport formation is crucial in patient care, the specific skills required for building rapport have not been adequately addressed in current nursing education.²² The absence of structured educational programs can result in a lack of knowledge, passive attitudes, and reliance on preexisting practices, ultimately diminishing the quality of care.²³ This study suggests that rapport-building strategies should be integral to hospice and palliative care education. Because rapport cannot be developed overnight, educational programs must be implemented to help nurses systematically and continuously cultivate these skills from the early stages of their education.^24-26 Such programs would empower nurses to establish and maintain strong therapeutic relationships with end-of-life patients, thereby enhancing the overall quality of end-of-life care.

This study found that the terms rapport and trust are sometimes used interchangeably,^6,11-13,18 with a study noting that rapport and trust were seen as mutually dependent, with each being unable to exist without the other.¹³ However, some studies described that initial rapport facilitates trust building.¹⁵ Trust begins with the belief that nurses will act in their patients' best interests, and rapport may play a key role in establishing that trust.³ Over time, rapport and trust develop in a complementary manner; health care professionals' expertise strengthens rapport, leading to increased trust. Future research should focus on clearly defining the concepts of trust and rapport and analyzing how these 2 elements interact and positively influence each other. This can inform communication training and education for nurses caring for end-of-life patients.

This study holds significant value in providing a comprehensive understanding of the process of rapport formation between end-of-life patients and nurses. By identifying the key elements of rapport formation, it contributes to developing practical strategies that enable nurses to provide better care in their relationships with end-of-life patients. The findings of this study can serve as an important guide for improving patient-centered care and for enhancing patients' quality of life.^27,28

However, this study has some limitations. First, the nature of qualitative meta-analysis makes it challenging to fully reflect the contextual differences of the included studies. The differing environments and cultural backgrounds in which each study was conducted should be considered when interpreting the results. Second, the process of rapport formation may vary depending on cultural and social contexts, which could limit the generalizability of this study's findings. In particular, because rapport formation in end-of-life care can manifest differently across various societies and cultures, additional research in diverse contexts is necessary. Such studies will be crucial in establishing universal principles of rapport formation and for developing practical care strategies applicable in various situations.