One of the key concepts in nursing is the caring relationship between the nurse and the person in need of care, and the care relationship together with the task to be undertaken form the core of nursing care [1,2]. The care relationship could be understood, according to Aristotelian description, in a poesis perspective and means that there is a goal of nursing action outside the relationship. The caring relationship could also be described from a praxis perspective where there is no goal of nursing actions beyond the relationship itself. In other words a poesis perspective emphasizes the goal while a praxis perspective emphasizes the process leading up to the goal [2,3].

A systematic literature review [4] shows that the concepts of interaction, communication and relationship are not clearly defined in nursing literature. The concepts are close to each other and strongly intertwined and are sometimes used interchangeably. In the literature there are also different concepts of relationships for example, care relationships, nursing relationships, interpersonal relationships, therapeutic relationships and caring relationships and it is not always clear what the differences are and also these concepts are sometimes used interchangeably.

Kasén [5] argues that a care relationship could develop to be a caring relationship. In a caring relationship the whole person is included, which is physical, mental and spiritual aspects. The caring relationship could enable human growth. A caring relationship could be seen as a mutual relationship that requires trust between the both parties. Within the caring relationship the caregiver gives a promise of care and implicit promises of alleviation of suffering and also a promise of togetherness and personal contact [5]. The caring relationship can be understood as balancing between vulnerability and dignity i.e. decreasing vulnerability and maintaining dignity [6]. The caring relationship could also be understood as a relationship that facilitates health and healing by involving the person’s genuine needs [7]. An uncaring relationship was described when the person was an object to be cared for and the caregiver performs the task. When the caring relationship is absent the person is left alone in their anxiety, pain and fear [5].

Løgstrup [8] considers that when two people enter a relationship with each other an ethical demand appears, which is related to the fact that we as human beings are interdependent. Naturally, we encounter each other with trust which is fundamental to all social intercourse. The trust makes us vulnerable when we expose ourselves to each other and trust means that we expect the other to preserve our dignity. During the encounter we have power and responsibility for each other as we hold each other’s lives in our hands. The trust will persevere and the power will be used to promote the other’s potential.

In nursing care, maintaining a helping relationship is a way of caring for human needs. This caring relationship means that the nurse focus on needs, limitations and the potential of the person [9]. The nurses have to be authentic and adaptive to the person in need of care and the situation [4]. Good relationships might also improve persons’ satisfaction with nursing care [10]. The professional relationship is an important aspect of nursing care and can have both positive and negative effects on persons’ experiences of the nursing care [4] and quality care [7].

The relationship in nursing has been studied widely, particular in psychiatric care [11] and in palliative care [12,13]. A study [12] shows that nurses created a close relationship when caring for dying persons and the study also shows differences in nurses’ experiences when caring for dying persons in hospital and in home care. In the hospital settings, the nurse had to provide the family with the opportunity to take part in the care of the person and in home care settings the nurse was invited to the family’s daily life and their means of caring for the dying person. A realist review of literature [10] shows clearly the importance of the relationship between district nurses and persons in need of palliative care. It also shows that few studies explore what a relationship meant and what its purpose is to the nurse. Grandoz Gámez [9] emphasizes that the attention of nursing is determined by the uniqueness of the nurse who is caring, regardless of the context or the person cared for.

Since the relationship seems essential for the outcomes of the nursing care and also affects the person’s experiences of received nursing care it is important to study the relationship further in home-based nursing care where the context of the relationships usually is different compared to hospital care. Another important reason for study the relationship further is that the literature has shown that care suffering arises from negative relationships despite the fact that it is supposed to promote health and well-being [14]. The nurse is responsible for the caring relationship and that the relationship turns out positive. The aim of this study was to explore registered nurses’ experiences of their relationships with persons in home-based nursing care.

A qualitative approach with individual interviews and a thematic content analysis were chosen for this study [15].

During the analysis both explicit and implicit themes were identified [15] that reflect dimensions of relationship in home-based nursing care. Altogether one main theme and five sub-themes were identified (Table 1), where the main theme describes the thread of implicit meaning of the whole interview text [19]. Each sub-theme should be viewed as an interpretation of the content in part of the text. Metaphorically speaking the main theme is the warp that runs through the entire weave of content and the weft are sub-themes that represent different patterns in the weave [20].

The findings indicate that the nurses were aware of the importance of the caring relationship in home-based nursing care and they worked consciously to develop the relationship. The caring relationship in this study could be understood as a trusting relationship, which is needed in order to provide good nursing care at home. This is in line with Berg and Danielson’s findings [21] that show that both nurses and persons in need of hospital care in a medical ward were aware that they were striving for trust through forming a caring relationship and they used their specific skills to form a caring relationship. The finding shows that a personal caring relationship could make trust possible and also that several encounters could create trust on which a relationship can be built. A concept analysis of nurse-patient trust [22] defines trust as the optimistic acceptance of a vulnerable situation, following careful assessment, in which the truster believes that the trustee has his best interest as paramount importance. In addition, Hagerty and Patusky [23] showed that the person in need of healthcare might trust the nurse in one area but not in another. A trusting relationship is one where the nurse cares for and about the person [24]. This is also in line with the nurses’ experiences in present study. According to Hupcey, Penrod, Morse and Mitcham [25] the outcome of trust is an evaluation of the congruence between expectations of the trusted person, i.e. the nurse, and the nurse’s actual behaviours.

In present study, the trusting relationship at home is, among other things, a reciprocal relationship that does not occur by itself and needs the nurses’ to consciously work at. Kasén [5] argues that the caring relationship can never be fully reciprocal as this would mean that the person’s suffering would not be alleviated. The caring relationship is inherently asymmetrical and means that the person with health problems is a suffering human and the nurse is caring and responsible. Buber [26] highlights that a fully reciprocal therapeutic relationship would be at the expense of its healing characteristics. The choice to embrace the approach I-Thou and entering the relationship and abandon the approach I-It [26] could be understood as an ethical choice [27] in home-based nursing care. On the other hand the asymmetry that exists in the caring relationship could potentially be unethical if it is not balanced with reciprocity [28]. According to the findings in present study it seems that the context of home-based nursing care encourages the reciprocal aspect of the relationship and reduces the asymmetry within the caring relationship. The encouragement of reciprocity in the caring relationship seems to relate to the fact that the nurse enters the home as a guest and has to balance between being personal, and in that encourage reciprocity, and being professional. This does not mean an equal relationship, and should not be confused with the ethical demand within the relationship [8].

Løgstrup [8] asserts that all human relationships are in some aspect reciprocal in that humans are interdependent and influence each other. Interdependence can be understood as what the nurse does for the person the nurse also does to herself. Despite the interdependence the nurse in home-based nursing care cannot, as a professional, demand to receive from the relationship as it is always an ethical relationship where what the nurse gets could be seen as a gift. Giving and receiving gifts could lead to confirmation of each other within the ethical relationship and not accept the other’s gift may be perceived as a lack of confirmation [8]. Buber [29] asserts that the desire for confirmation and the ability to confirm others is fundamental to human life with others and being personal. We can assume that the nurse’s ability to provide confirmation is an important part of building the relationship in home-based nursing care.

The findings of present study also indicate that nurses work in different levels of the relationship and closeness was not always the primary goal. Using the description by Buber [29] it can be described that the nurses had two movements, one to enter the relationship with the person in need of care and another to preserve a distance. The choice of the primary nurses in present study was to consciously chose to enter the relationship and work towards a deeper level of the relationship. This meant that the nurse had more contacts, was engaged with the person, knew the person well, and developed a common story. A common story, is according to Kasén [5], defined as the person’s request for the alleviation of suffering and the nurse’s answer to the request. The importance of a common story could be an argument for a higher continuity with the primary nurse in healthcare at home, in order to protect the caring relationship.

In situations of being the secondary nurse and the stand-in nurse, the movement of preserving distance [29] often was the choice of the nurses in present study, where they consciously chose to work in a more shallow level of the relationship. This choice of a more distanced relationship in home-based nursing care could be understood as a way to respect the person’s integrity when nurses knew that they could not continue with the nursing care and the relationship. We can assume that it could be experienced as unethical for a secondary nurse and a stand-in nurse to ask the person to share deeper feelings and then leave the person without any follow-up.

The choice of level in a relationship in home-based nursing care is also dependent on the will of the person in need of care. An example of this was described in a study by Ejneborn Looi and Hellzén [30]. Staff at municipal psychiatric group dwellings described some of their relationships with long-term psychiatric clients as characterized by distance. The distance was reflected in that the staff could not reach and get the contact with the client when clients did not invite them and refused the staff’s support.

The findings in present study also indicate the presence of intentional and unintentional professional boundaries in the relationship, which according to Ejneborn Looi and Hellzén [30] occurred when the staff chose to adhere to their professional role and not be too personal with the clients [30]. Reasons for professional distance in a caring relationship could, according to Bergum and Dossetor [31], be fear of getting too involved or fear of not having the time to get involved at all. A standpoint of distance in a caring relationship means the risk of not being able to establish and build a trusting relationship with the person in need of nursing care at home and thereby no fruitful caring relationship.

A study [32] shows that time and geographical distance are important factors when building relationships between nurses and persons in home-based nursing care. Another study [33] shows that time and the continuity between the nurse and the person are preconditions for establishing a trusting relationship. It is especially the first visit that requires time to build the base for a trusting relationship. It is also important that the person can reach the nurse by a telephone call. Present study shows that the trusting relationship could be maintained through contacts by distance-spanning technology which also meant that the continuity could be supported. Knowing each other’s faces seems to be important for trust when using distance-spanning technology. Lévinas [34] asserts that the relationship to the other’s face is an ethical relationship with a particular responsibility. This means that nurses are responsible in home-based nursing care to protect the trusting relationship when different technology applications for distance communications are used in contemporary home-based care. A previous study [35] shows that when the person trusts the DNs they also felt confident with the use of technology in healthcare at home. The development of different distance-spanning technologies can open up new solutions to perform care and maintain relationships at home [36,37]. As a reaction to this development of increased use of distance-spanning technology, Meleis [1] argues that many theorists in nursing are going back to basics in human relationships, where the sharing of information during situations of health and illness and the interaction is a tool for building relationships. This emphasis on the importance of basic human interaction highlights the importance when implementing distance-spanning technology in home-based healthcare to work consciously to build and protect the trusting relationship in order to provide good healthcare.

A trusting relationship is a prerequisite for good home-based nursing care whether it is based on face-to-face encounters or remote encounters through distance-spanning technology or a mix of both, and it is by nature an asymmetric relationship where the nurse has the responsibility to care for the person in need of care.

In order for nurses to build a trusting relationship in home-based nursing care they have to accept that they enter the home as a guest and communicate something about themself as the person in need of healthcare needs to know who is entering and visiting the home, or who is communicating through distance-spanning technology. The relationship in home-based nursing care requires conscious efforts from the nurse and a choice of a suitable level of the relationship when maintaining the relationship through home visits as well as through distance-spanning technology. The working context of home-based care is anticipated to change, with the introduction of new technology and revised templates of care. In this process nurses have to safeguard the possibilities of building trusting relationships with the persons in need of home-based care.

The authors confirm that this article content has no conflict of interest.