A therapeutic nurse patient relationship is the central element in the nursing process (Hewitt, & Coffey, 2005).  The therapeutic nurse patient relationship is a synergistic process which includes the nurse employing  the general attributes of conveying sympathy, accepting individuality, providing support, showing respect and maintaining professional  boundaries (Dziopa & Ahern, 2009; Granados Gámez, 2009 ).  The therapeutic nurse patient relationship can be described as involving the mutual satisfaction of the nurse  and  the   patient that helps to achieve better health outcomes (O'Connell, 2008). The therapeutic nurse patient relationship will develop as the nurse by using his/her specific skills responds to the needs of her patient (Granados Gámez, 2009; Marchese, 2006).

 The development of the therapeutic nurse patient relationship needs time, it is not established quickly (Scanlon, 2006).In nursing theory there are four main phases involved in the development of the therapeutic nurse patient relationship. These  are orientation, identification, exploitation, and resolution phase (Behice , Serap  & Zennure ,2008; Marchese,2006). Each phase has its own significance in the development of therapeutic nurse-patient relationship ( Marchese,2006).These are now explored in more detail below;

1) Orientation phase- during the orientation phase there is a discussion between the nurse and the  patient  about the patient health status and their needs ( Marchese,2006). They both set the goals for introductory and forthcoming meetings, which assist the nurse in making treatment   plans that meet patient's needs under changing circumstances (Marchese, 2006).

2) Identification phase- during this phase the nurse provide the relevant information to the patient about the particular disease and the treatment options (Marchese, 2006). The final aim of this phase is to provide a chance for the patient to achieve a level of eagerness to accept for his/her care (Behice , Serap , & Zennure , 2008).

3) Exploitation phase - in this phase the patient develops the capacity for self-care and independence. The bond between the nurse and the patient has been established. Primary goals have been met, providing an opportunity for further development (Behice , Serap , & Zennure , 2008).

4) Resolution phase- this is the final phase. The patient will feel a sense of security because he/she has achieved his/her goal of wellness that is the main aim of the therapeutic nurse patient relationship (Behice , Serap , & Zennure , 2008).

Factors affecting the development of therapeutic nurse patient relationship: trust, effective communication skills, patient education and empathy are the four important factors which plays an important role in the development of therapeutic nurse patient relationship (Kasen, Nordman, Lindholm & Eriksson, 2008)

 Trust- trust is a fundamental  element in  the development of  a therapeutic nurse patient relationship (Granados Gámez, 2009; Scanlon, 2006) .The patients' trust in nurses is necessary in developing a therapeutic nurse patient relationship, as trust has  a major influence on patients' acceptance of care and treatment (Belcher & Jones, 2009;  Shattell,  Starr & Thomas 2007 ). However, gaining trust in a relationship can only occur when any differences in power, culture and attitude are respected (Fenwick 2006 ).  In order to gain accurate information from the patient, trust needs to be established (Gardner, 2010). Moreover, a trusting relationship allows the patient to focus on achieving optimal health instead of doubting reliability of care and information (Belcher & Jones ,2009 ).

Communication-communication in the nursing profession is defined as interaction between the nurse and the patient (Finch, 2005).  It involves the nurse's ability to understand patient's thinking, body language and feelings this will enables the nurse to establish a clear rapport with the patient and assess the patient's condition and health issues more precisely (Markova & Broome, 2007). Effective communication between the nurse and the patient plays an important role in developing the therapeutic nurse patient relationship as it brings forward patient quality care and accurate information transferred among health care professional for the benefits of the patient (Jootun & McGhee,2011).According to Nelson & Allison (2007) communication problems have negative effects on the establishment of a therapeutic relationship. However, communication is significantly improved when there is a deep respect for the patient, where respect is shown by a willingness to listen (Nelson & Allison, 2007 ). Fenwick (2006 ) states that communicating with patient involves respecting their values and beliefs during communication exchange.

Patient education-it is an essential component in providing health care; however, the communication lines must be established for education to be successful. During the education process, nurses need to avoid medical terms and jargon to prevent frightening and intimidating patients (Brown & Edwards 2008 pg 51). When patients are feeling alienated with complex medical terms, they are unlikely to feel comfortable with the nurse, therefore the relationship is compromised. According to Belcher & Jones (2009), the nurse and patient must feel comfortable with each other for a level of trust to begin. The nurse should begin by carefully explaining the medical terms necessary to understand the content being taught.

 Empathy -empathy is crucial when attempting to develop a therapeutic relationship between  the nurse and the  patient. According to Nelson & Allison (2007) spending time in listening and sharing information is a key factor in assisting cross-cultural communication. Empathizing with people from a different cultural background involves listening, understanding and appreciating what they are saying without judgment. (Brough, 2004). Without empathy, a patient may feel unheard, unsafe and thus unable to open up and communicate with the nurse. According to O'Connell (2008), feelings of empathy and compassion will motivate the nurse to come to know the patient as an individual with respect for their beliefs.

As well as being an essential element in all nursing practice the therapeutic nurse patient relationship is act as a building block that helps a transitioning graduate nurse to develop their knowledge and skills as a registered nurse (Brough, 2004) Graduate registered nurse faces difficulties  in developing a trusting nurse patient relationship because he/she  has  beginner's  knowledge  and skills but have little experience in  performing  their duties individually  that is  why they do not  feel much  confident/competent  in  establishing therapeutic nurse patient relationship (Hengstberger-Sims, Cowin, Gregor, Andrew & Rolley, 2008). Therefore, GRN needs more time to develop their knowledge and skills in order to build a trusting nurse patient relationship (ANMC code of ethics for nurses in Australia, 2008). Self reflection will also help  him/her to become competent / confident so that he/she can apply their learned  knowledge in practice (Belcher & Jones, 2009).Graduate registered  nurse feel  more competent/confident  in developing  a  therapeutic nurse patient relationship  when  he/she got  clinical supervision  and  support  from his/her clinical preceptor and co-workers (Foster, & Hawkins, 2005). Evidence-based practice helps GRN to develop the skills of critical- thinking, decision- making and problem -solving which result in better patient health outcome that is the main goal of the therapeutic nurse patient relationship (Hanberg & Brown, 2006; Tart, Kuatz, Rudisill & Beard, 2011).  Anxiety is a possible barrier in the development of the therapeutic nurse patient relationship. The graduate registered nurse may be anxious because it is his /her first experience to develop a therapeutic nurse patient relationship (Randall, & Binding, 2004). In fact , many factors act as  barriers  for  GRN when he/she tries to  develop  a  therapeutic nurse patient relationship ,such as  high expectations, self -awareness, stressful environment, lack of support, lack of cultural competence, language differences  and difficulties in maintaining professional boundaries( Milton, 2008 ;Norfolk, Birdi & Patterson, 2009).GRN is  still trying to adapt themselves to the new environment  so sometimes it is challenging for  his /her to maintain professional boundaries . Maintaining professional boundaries is essential so that the nurse and the patient can interact in a safe environment (Gardner, 2010; Swift, 2009).  The  GRN can be successful in maintaining  boundaries when he/she works  in accordance with a  care plan; always learns from self-reflection; is  susceptible to situations; and able to initiate, maintain and terminate the nurse-patient  relationship appropriately (Milton, 2008). Working with professional boundaries will help the transitioning graduate nurse to practice safely within their scope of practice to provide better quality care (Belcher & Jones, 2009).

 The therapeutic nurse patient relationship enables the patient to share their positive and negative feelings with the nurse without any fear and with proper understanding. Achieving that level of truthfulness proves to be valuable and   sometimes can be a turning point in the life of the patient (Halldorsdottir, 2008).