Guest Contributor: Jitana Benton-Lee
PhD student in nursing at Texas Women’s University

Research in nursing has long emphasized the importance of the nurse-patient relationship as a foundational component of care. However, as nurse scholars, we must also critically examine how we ethically engage in research that seeks to understand this relationship, particularly through grounded theory methodologies. Grounded theory offers a powerful approach for developing new nursing knowledge from the lived experiences of patients and nurses, yet it presents unique ethical challenges—especially in maintaining psychological safety for research participants and ensuring that emerging patterns in the data are interpreted responsibly. While recognizing patterns across narratives can be valuable for theory development, it also raises concerns about how researchers categorize and make meaning of participant experiences without oversimplifying their complexity.

As a nurse-researcher developing a theory of psychological safety in the nurse-patient relationship, I am keenly aware of the ethical tensions that arise in studies where nurses and patients share deeply personal experiences. How can we ensure that participants feel safe to share their truths without fear of judgment or harm? How do we navigate power imbalances while engaging in co-constructing new nursing theories? How do we remain both ethically responsible and methodologically rigorous when interpreting and presenting narratives about relational care? This is especially important when recognizing patterns in experiences requires balancing thematic consistency with honoring individual perspectives.

Peplau’s Theory of Interpersonal Relations as an Ethical Framework

Hildegard Peplau’s Theory of Interpersonal Relations (1997) provides a critical lens for understanding how the nurse-patient relationship evolves over time, shaped by mutual trust, professional guidance, and role shifts. When applied to grounded theory research, Peplau’s work challenges us to consider how the process of inquiry itself becomes an extension of the nurse-patient dynamic—where patients and nurses share their experiences not in a clinical setting, but in a research environment that must also foster psychological safety and trust. To uphold ethical integrity, researchers must honor participants’ lived experiences, remain attuned to power dynamics, and ensure that emerging nursing theories reflect the realities of patient care.

This aligns with pattern recognition, as discussed by Settle (2021) on Nursology.net, which describes the nurse-patient relationship as a co-creative process that fosters expanding consciousness and the recognition of emerging health patterns. Pattern recognition is a fundamental cognitive process in nursing, allowing nurses to identify recurring health patterns, behaviors, and responses to guide care decisions. Peplau’s emphasis on relational processes and patient engagement reinforces the importance of recognizing and responding to these patterns in both practice and research. When applied to grounded theory, pattern recognition helps researchers identify meaningful themes from participant narratives, ensuring that theories are derived from authentic patient and nurse experiences rather than imposed assumptions.

Grounded theory demands ethical reflexivity, requiring researchers to remain open to emergent insights while ensuring participants feel psychologically safe sharing their experiences. Peplau’s framework serves as a guide for navigating relational ethics in research, ensuring that participants feel heard, respected, and free from harm. By integrating Peplau’s theory, psychological safety, and pattern recognition, nurse-researchers can co-construct knowledge in a way that is methodologically sound, ethically responsible, and deeply connected to the complexities of nursing practice.

Ethical Considerations in Grounded Theory Research on the Nurse-Patient Relationship

1. Psychological Safety and the Ethics of Theoretical Sampling

Unlike other qualitative methods, grounded theory requires iterative data collection, meaning researchers may return to participants as themes evolve. This raises ethical concerns, particularly when revisiting patients who have shared vulnerable experiences related to power dynamics, trust, or betrayal in nursing care. Pattern recognition plays a key role in this iterative process, helping researchers track emerging themes across multiple interactions. However, ethical dilemmas arise when patterns are identified too early, potentially influencing how researchers engage with participants in later interviews.

For example, Duddle & Boughton (2007) explored power in nurse-patient interactions, revealing that patients who initially felt comfortable sharing later expressed concerns about how their words might be interpreted or used. Researchers must ensure that pattern recognition does not inadvertently shift the focus away from individual participant experiences or pressure participants into discussing themes that they no longer feel safe revisiting. To maintain psychological safety while ensuring that patterns emerge authentically, researchers should:

• Engage in transparent communication about how participant narratives will shape the evolving theory.
• Re-consent participants if new aspects of inquiry arise that were not initially disclosed.
• Allow participants to review and modify their contributions before finalizing analysis.
• Use reflexivity to critically assess whether identified patterns are participant-driven or researcher-imposed.

2. The Ethics of Emergent Inquiry: When the Research Process Becomes Emotional Labor

Grounded theory is unpredictable—a patient’s initial interview may lead to unexpected discussions about trauma, professional mistrust, or unmet care needs. Bramhall’s (2014) study on communication barriers in nursing found that some participants became emotionally distressed when recalling moments where they felt unheard or dismissed by nurses. Because grounded theory relies on emergent inquiry, these moments of distress may reveal new directions in research, yet they also present ethical challenges in managing emotional labor for both participants and researchers.

As themes develop across interviews, pattern recognition can help researchers identify recurring emotional distress points, common triggers, and systemic issues within nurse-patient interactions. Recognizing these emotional patterns allows researchers to adjust their approach, ensuring that sensitive topics are handled with care while still preserving the integrity of the data. However, there is an ethical risk in assuming patterns too soon—if researchers expect distress and preemptively steer discussions away from difficult topics, they may silence important narratives that contribute to the depth of grounded theory research.

Peplau’s theory reminds us that nurses, even in research settings, carry an ethical responsibility to respond to emotional distress. The challenge is ensuring that this does not compromise research neutrality while still validating participant emotions and experiences. Researchers must also acknowledge their own emotional labor—the cognitive and affective work required to navigate complex, often distressing narratives—while maintaining ethical integrity. Ethical strategies include:

• Providing referrals to support services when research discussions bring up distressing memories.
• Using trauma-informed interview techniques to prevent emotional harm.
• Allowing participants to pause or withdraw at any stage without pressure.
• Remaining flexible in interview strategies, adjusting based on observed emotional patterns while ensuring participant voices remain at the center of the research.

3. Balancing Power: Who Shapes the Narrative in Co-Constructed Knowledge?

One of the greatest ethical tensions in grounded theory research on the nurse-patient relationship is ensuring that patient voices are authentically represented rather than reshaped by professional assumptions. Charmaz (2014) warns that researchers often impose meaning on participant narratives too early, which is especially problematic in nurse-patient studies, where nurses may unconsciously filter data through their professional lens.

While pattern recognition is a valuable tool in identifying recurring themes across participant narratives, it must be applied ethically to avoid overgeneralization or researcher-driven interpretations. If researchers impose patterns too soon, they risk flattening the complexity of participant experiences or reinforcing dominant nursing perspectives rather than uncovering new insights. Patterns should emerge organically, guided by participant experiences rather than imposed frameworks. This aligns with Peplau’s perspective that relational inquiry requires active listening and mutual engagement rather than unilateral interpretation. Ethical safeguards include:

• Using reflexive journaling to track how professional biases may influence interpretation.
• Engaging in member-checking so participants can review and validate findings.
• Allowing patterns to emerge naturally, rather than forcing them into preconceived frameworks.
• Including direct quotes in theory development to preserve the integrity of participants’ voices.

Implications for Nursing Research and Nursology
Grounded theory has immense potential to expand nursological knowledge on the nurse-patient relationship, but its ethical foundation must be firmly rooted in reflexivity, relational integrity, and participant-centered inquiry. As Nursology.net (n.d.) emphasizes, nursing knowledge development must be humanistic, interdisciplinary, and grounded in authentic experience. By integrating Peplau’s Theory of Interpersonal Relations, psychological safety, and pattern recognition into grounded theory research, nurse-researchers can:

• Navigate relational ethics with intentionality, fostering trust and mutual understanding throughout the research process.
• Prioritize psychological safety as a research responsibility, ensuring that participants feel secure in sharing their lived experiences without fear of harm or misrepresentation.
• Develop new nursing theories that authentically reflect patient and nurse experiences, advancing knowledge that remains deeply connected to practice and care.

As I continue my research on psychological safety in the nurse-patient relationship, I remain committed to centering participant voices, ensuring ethical rigor, and co-constructing nursing knowledge that upholds the discipline’s core values of trust, respect, and humanistic care.

References

Bramhall, E. (2014). Effective communication skills in nursing practice. Nursing Standard, 29(14), 53-59. https://doi.org/10.7748/ns.29.14.53.e9355

Charmaz, K. (2014). Constructing grounded theory (2nd ed.). SAGE Publications.

Duddle, M., & Boughton, M. (2007). Intraprofessional relations in nursing. Journal of Advanced Nursing, 59(1), 29-37. https://doi.org/ 10.1111/j.1365-2648.2007.04302.x

Nursology.net. (n.d.). About Nursology.net. https://nursology.net
Peplau, H. E. (1997). Peplau’s theory of interpersonal relations. Nursing Science Quarterly, 10(4), 162-167. https://doi.org/10.1177/089431849701000407

Pharris, M. D. (2021, December 7). Pattern recognition, the nurse-patient relationship, and health as expanding consciousness (HEC). Nursology.net. https://nursology.net/2021/12/07/pattern-recognition-the-nurse-patient-relationship-and-health-as-expanding-consciousness-hec/

About Jitana Benton-Lee

Dr. Jitana Benton-Lee, DNP, is a DNP-to-Ph.D. student at Texas Woman’s University with a passion for nursing research, education, and health equity. She is an Associate Professor of Graduate Nursing at Northern Kentucky University and Director of the NKY Nursing & Interprofessional Collaborative. Her research focuses on psychological safety in the nurse-patient relationship, healthcare access for underserved populations, and social and structural determinants of health.