Nurse-patient power relationship: preliminary evidence of patients' power messages

Comparison of barriers to effective nurse-patient communication in COVID-19 and non-COVID-19 wards

BACKGROUND

Communication is a basic need of humans. Identifying factors that prevent effective nurse-patient communication allows for the better implementation of necessary measures to modify barriers. This study aims to compare the barriers to effective nurse-patient communication from the perspectives of nurses and patients in COVID-19 and non-COVID-19 wards.

MATERIALS AND METHODS

This cross-sectional descriptive study was conducted in 2022. The participants included 200 nurses (by stratified sampling method) and 200 patients (by systematic random sampling) referred to two conveniently selected hospitals in Shahroud, Iran. The inclusion criteria for nurses were considered having at least a bachelor's degree and a minimum literacy level for patients to complete the questionnaires. Data were collected by the demographic information form and questionnaire with 30 and 15 questions for nurses and patients, which contained similar questions to those for nurses, based on a 5-point Likert scale. Data were analysis using descriptive indices and inferential statistics (Linear regression) in SPSS software version 18.

RESULTS

The high workload of nursing, excessive expectations of patients, and the difficulty of nursing work were identified by nurses as the main communication barriers. From the patients' viewpoints, the aggressiveness of nurses, the lack of facilities (welfare treatment), and the unsanitary conditions of their rooms were the main communication barriers. The regression model revealed that the mean score of barriers to communication among nurses would decrease to 0.48 for each unit of age increase. Additionally, the patient's residence explained 2.3% of the nurses' barriers to communication, meaning that native participants obtained a mean score of 2.83 units less than non-native nurses, and there was no statistically significant difference between the COVID and non-COVID wards.

CONCLUSION

In this study, the domain of job characteristics was identified by nurses as the major barrier, and patients emphasized factors that were in the domain of individual/social factors. There is a pressing need to pay attention to these barriers to eliminate them through necessary measures by nursing administrators.

Community nursing delivery in urban China: A social power perspective

Community nurses remain understudied in research on interactional power, especially in China where community healthcare is an emerging practice. Grounded in French & Raven's typology of social power, this article conceptualises the power of community nurses in a Chinese urban context. Through thematic analysis of textual data from 26 semi-structured interviews and two additional focus group discussions with community nurses in Shenzhen, we identified six power varieties, i.e. indirect reward, indirect coercion, legitimate position, peer reference, field expertise, and caring information. We classified these powers trichotomously, as nurse-to-doctor, nurse-to-nurse, and nurse-to-patient, to show the potential influences nurses bring to healthcare relationships. Our analysis indicated nurses' exercise of some powers was constrained by two elements, i.e. doctor-nurse power polarity and patient prejudices against nursing, which together contributed to nurses' adverse power loss. These power adversities permeated the community health environment, contributing to healthcare delivery dysfunctions by undermining nurses' self-improvement, self-assurance, enthusiasm, and cooperation in care. Our analysis, using the insights of social power, develops a novel reading of community nursing delivery in urban China. We argue that nurse empowerment could promote community healthcare delivery. Role enhancement and pro-nursing policy development would reduce adverse power scenarios for community nurses and help convert their potential power resources into practical powers in support of patients' needs.

Meanings of participation in care for older people after hip fracture surgery and nurses working in an orthopaedic ward

PURPOSE

The aim of this study was to elucidate meanings of participation in care for older people after hip fracture surgery and nurses working in an orthopaedic ward.

METHODS

A qualitative phenomenological hermeneutical design was used. We conducted personal interviews with a narrative approach with 11 older people recovering from hip fracture surgery and 12 nurses working in an orthopaedic ward.

RESULTS

The results show that for older people, participation meant being a co-creator in their own care, founded on being met with sensitivity and support, being told what is going to happen, taking responsibility and asking questions and being able to influence care. For nurses, patient participation meant meeting the patients' needs and requests by being open and allowing them to influence care while at the same time recognizing that the patients' possibility to influence care was limited.

CONCLUSION

The study shows that for older people and nurses, the phenomenon of participation has similar meanings but also differences. When older people participate in their care, they become a co-creator in care and confirmed as a person. This highlights the importance of a nurse-patient relationship built on trust, connectedness and communication based on a shared understanding.

From Vulnerability to Disclosure: A Normative Approach to Understanding Trust in Obstetric and Intrapartum Nurse-Patient Communication

This study qualitatively examined how nurses, nurse practitioners, and nurse midwives construct the meaning of patient trust in their work caring for pregnant and laboring women. Twenty-two interviews were conducted with nurse participants employed at clinics, hospitals, and birth centers across Southeastern United States. Using a normative theoretical approach within the multiple goals framework, we identified five emergent themes that characterize trust as it shapes nurses' communicative goals: trust as the woman's acceptance of vulnerability and risk, the woman relinquishing control, the woman conceding to the nurse's expertise, the woman feeling heard, and the woman's disclosure of information. The results support previous studies, which conceptualized trust as vulnerability, risk, and disclosure whereas the remaining themes are original to this study. The results are interpreted both in light of existing links between trust and communication and the shifting and conflicting goals of nurses as they attempt to achieve their primary goal of optimal health outcomes. Passive constructions of trust that conflate it with women's acquiescent behaviors could have implications for the quality of communication between nurses and patients. In addition, trust, as understood by these participants, becomes situated as an instrumental means to achieving patient cooperation and desired health outcomes rather than a relational goal that supports women's agency throughout obstetric and intrapartum processes. This may be at odds with the modern movement toward patient-centered care and shared decision-making in U.S. maternity care.

A Scoping Review to Identify Barriers and Enabling Factors for Nurse-Patient Discussions on Sexuality and Sexual Health

Background: Sexuality and sexual health (SSH) are essential aspects of care that have evolved since a 1975 World Health Organization (WHO) report on SSH. However, nurses still consider discussing the subject with patients a challenge. This scoping review aimed to map, synthesize, and summarize findings from existing literature regarding barriers and enabling factors for nurse–patient SSH discussions in care contexts. Methods: A scoping review model inspired by Arksey and O’Malley was used to search for and synthesize studies published between 2009 and 2019. The databases searched were the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medical Literature Analysis and Retrieval System Online, i.e., MEDLARS Online. A total of nineteen articles were eligible to be included. Results: Two main categories of enabling factors were identified, i.e., a professional approach via using core care values and availability of resources. Three major categories of barriers were identified: beliefs and attitudes related to age, gender, and sexual identity; fear and individual convictions; and work-related factors. Conclusions: Applying professionalism and core care values as well as making resources available are likely to promote SSH discussions between nurses and patients. Moreover, there is a need for a norm-critical approach in education and practice.

Patient-public engagement interventions for health system improvement in Sub-Saharan Africa: A systematic scoping review protocol

BACKGROUND

Research has found health system improvement cannot be achieved without continuously engaging patients, their families and all stakeholders in the design, management and delivery of health care services. Following the Alma Ata declaration on Primary Health Care in 1978, the focus of health system improvement has tended to shift from physician or hospital-centric approaches to a more democratic vision of engaging the public and/or patients in the commissioning, planning, organisation, operation and control of the health care system. Thus, patient-public engagement (PPE) has become an important tool in health system improvement particularly for countries with poor health outcomes including countries in sub-Saharan Africa which carries an estimated 24% of the global burden of diseases in both human and financial costs. The aim of this scoping review is to describe and systematically map PPE research in sub-Saharan Africa, and then to synthesise this research in relation to key theories of PPE, identify the key drivers and barriers of PPE and to identify the knowledge gaps that may usefully be addressed by future research.

METHODS

This scoping review will follow Arksey and O'Malley's best guidelines for conducting scoping reviews and also follow the standard guidelines for reporting using the Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews checklist. A systematic search of peer-reviewed English language literature published between January 1999 and December 2019 will be conducted on four databases: Scopus, CINAHL, Medline (Ovid) and Embase. The initial screening of titles and abstracts will be undertaken independently by two reviewers, followed by full text screening involving three independent reviewers. A thematic framework synthesis will be employed in the analysis of data to identify the various PPE interventions, and outcomes mapped to a framework of engagement continuum to understand its overall effect on health system improvement in sub-Saharan Africa.

DISCUSSION

To our knowledge, this scoping review will be the first to systematically investigate PPE interventions implemented across sub-Saharan Africa, map the outcomes of identified interventions to a framework of engagement continuum and to understand its overall effect on health system improvement. Findings of this review will be published in an open-access peer review journal and disseminated at scientific conferences.

Emancipatory reflection on a nursing practice-based ethical issue about nurses’ paternalistic decision-making for patients

Objective

This study aimed to demonstrate and promote the skill of critical emancipatory reflection through reflecting on a nursing practice-based ethical issue about nurses’ paternalistic decision-making for patients. Meanwhile, critical awareness will be developed and the underlying issues of paternalism in nursing decision-making will be analyzed. Then, by applying the procedure, improvement in nursing decision-making practice will be expected.

Methods

Taylor’s model of emancipatory reflection with four steps, including construction, deconstruction, confrontation, and reconstruction, is utilized to guide the author’s reflection.

Results

Guided by the socialization theory, the author’s personal and professional socialization is seen to be associated with the formation of the value of paternalism. The theory of reflexivity is applied to unearth the related issues, including deeper personal value, work environment, as well as historical and cultural contexts. Moreover, the power derived from policy, work relationship, and nursing administration, which could induce paternalism in the author’s nursing decision-making practice, was critically debated using the hegemony theory. Finally, new insights into paternalism will be achieved, which enable change in terms of how to facilitate patients’ autonomous decision-making.

Conclusions

The process of refection makes it clear that respecting patients’ right and performing patient-centered caring are the bases to change the paternalism existing in the nursing decision-making practice currently. The reconstruction step assists the author in terms of how to value the patients’ autonomy and balance patients’ safety and choice, rather than being overprotective; carry out risk assessment, and search for strong evidence to counterbalance the positive and negative aspects of risk-taking; communicate with patients appropriately in a manner that they can comprehend; spend more time to explore patients’ preference and choice; make every effort to elevate the patients’ decision-making capacity; implement patient-centered care and shared decision-making in nursing practice; consult with other colleagues and obtain the required support when limitations or challenges exist; try to justify and avoid hidden paternalism behind policy or guidelines; deal with the power in hand well and fairly; and also positively face the powers that constrain the author.

'He should feel your pain': Patient insights on patient-provider communication in Rwanda

Background

Patient–provider communication is an interpersonal interaction between a patient and a health care provider.

Objective

This study explored patients’ communication preferences and perceptions on what factors influence the patient–provider communication in primary health care settings in Rwanda.

Methods

In-depth semi-structured interviews with 15 individuals including 8 with limited literacy. A thematic inductive analysis was used.

Results

Patients valued communication with providers and expressed the need for interacting with caring, empathic providers who can share all the information they want and involve them in their own care. Health literacy and power issues were factors that may influence patient–provider communication. Patients with limited literacy appeared to rely highly on health care providers for making decisions about and managing their health care.

Conclusion

The expressed preferences, including those of patients with limited literacy, aligned well with the patient-centred care model. There were indications of a power imbalance weighing on the provider’s side. Although patients with limited literacy were reliant on providers for decision-making, they were ready to be more involved in the care, suggesting a potential for improved patient involvement even for patients with paternalistic care preferences. These patients’ insights can impact policies and curricula to optimise clinical practice. Generated knowledge will contribute to the indispensable yet underdeveloped field of health communication in sub-Saharan Africa.

Practice implications

Findings call for more inclusion of patient perspectives in the patient–provider encounter. This could require more training of professionals and research on the topic, both in Rwanda and in other regions.

The Respect That Other Deserves: A Game Between Forces and Weaknesses in the Field of Health Care

Caring for people with diminished faculties and forms of disease and handicap that break down their personality places high demands on care staff. Anchored in a caring science with a holistic and humanistic approach, this article analyzes the trajectories of control that emerge in nurse care interactions. A suggested answer is the responsibility of the nurse to be aware of the power inequality, to recognize the potential for patients to feel intimidated, and to create a therapeutic alliance. The right use of power in the nurse-patient interaction guarantees that the patient's needs are foremost and the patient's vulnerability is sheltered.

Ethnomethodological studies of nurse-patient and nurse-relative interactions: A scoping review

OBJECTIVES

Researchers in nursing science interested in the study of nurse-patient and nurse-relative interactions have displayed an ever increasing interest in ethnomethodology and conversation analysis. This review assesses the scope of this literature. We categorize the papers in thematic categories determined both inductively and deductively and synthesize the main findings of this literature within category. Finally we discuss the interactional determinants of the lack patient participation, the limitations of the field, and focus on implications.

DESIGN

A scoping review on nurse-patient and nurse-relative interactions.

DATA SOURCES

Forty articles focusing on nurse-patient interactions and nurse-relative interactions. All the articles relied on ethnomethodology and/or conversation analysis.

REVIEW METHODS

A literature search has been carried out on Medline (all articles until June 2016; keywords were: nurs*.ab. and "conversation analysis"; nurs*.ab. and ethnomethodology). A similar search was performed on other platforms. The scope of the literature was identified by inductively and deductively analyzing the themes of the relevant articles.

RESULTS

Six thematic categories emerged: Organization of nurse-patient interaction (eleven articles); Organization of mediated nurse-patient interaction (seven articles); Information, explanation and advice (eight articles); Negotiation and influence asymmetry (six articles); Managing emotions in critical illness (two articles); and Interacting with patients presenting reduced interactional competences (six articles).

CONCLUSIONS

Across most thematic categories it appeared that patient participation is far from ideal as interactional asymmetry was most observed in favor of nurses. When the encounters occurred at the patients' homes this pattern was reversed. Computer-mediated interactions were often reported as non-optimal as the standardized process constrained communication and delayed patients' presentation of their ailments. Micro-analyses of interaction present a clear potential for the development of guidelines for nurse-patient interactions. Implications for practice are described.

An Exploration of the Phenomenon of Formal Care from the Perspective of Middle-Aged Heart Failure Patients

BACKGROUND

Despite a considerable amount of research into heart failure there remains a divergence between the care available and patient's needs. The predominant biomedical perspective is more focused on the disease rather than the patient. In order to deliver formal care appropriate to the needs of middle-aged patients with moderate-severe HF it is imperative to gain the perspective of the individual patient.

AIMS

The aim of the current study was to explore and understand the phenomenon: Formal care as experienced from the perspective of middle-aged patients living with HF.

METHODS

The study was performed using a lifeworld perspective. Data was collected in seven unstructured interviews with middle-aged people living with moderate-severe HF. Data was analysed using a phenomenological approach.

RESULTS

Formal care, as experienced by middle-aged patients living with moderate to severe HF, means hope to once again be able to have access to life. However, the meaning of formal care is ambiguous, which signifies that care means both health and suffering at the same time. The essence's meaning constituents are: dependency of care, surrender to care and unclear participation.

CONCLUSION

The experience of formal care means both well-being and suffering at the same time. Patients' suffering in relation to formal care can be reduced if formal carers act from an ethical patient perspective point of view and if carers regard patients' lived experiences.

Using an adapted approach to the Kano model to identify patient needs from various patient roles

Purpose

– The purpose of this paper is to study how an account of multiple patient roles when using the Kano model in healthcare improvements can support identification of a wide range of patients’ needs.

Design/methodology/approach

– The study presented in this paper was part of a longitudinal action research study. The empirical material was collected by various methods (interviews, a focus group, participative observations, and a survey) over a two-month period within the Children’s and Women’s Healthcare department in a Swedish hospital. The respondents included the management team, healthcare professionals, patients, and the patients’ partners.

Findings

– The study shows that incorporating a view of multiple patient roles into application of the Kano model, and using input on customer needs obtained from patients, relatives, and healthcare professionals, helps to identify a wide range of patients’ needs.

Originality/value

– The view on patients within healthcare is being transformed from one based on servility to that of patients as customers. This paper elaborates on a hands-on way of applying the Kano model based on a view of multiple patient roles as a means to support this new patient view. The application builds on input from various groups (such as patients and healthcare professionals), and, by using input from various stakeholders. This approach appears to overcome a gap, identified in earlier research, of either relying solely on patients, or solely on healthcare professionals, when identifying patients’ need. Rather input from several groups – patients, relatives, and professionals – are suggested to be used in combination.

Designing quality of care--contributions from parents: Parents' experiences of care processes in paediatric care and their contribution to improvements of the care process in collaboration with healthcare professionals

AIMS AND OBJECTIVES

The aim of this article was to explore whether current quality dimensions for health care services are sufficient to capture how parents perceive and contribute to quality of health care.

BACKGROUND

New quality improvement initiatives that actively involve patients must be examined with a critical view on established quality dimensions to ensure that these measures support patient involvement.

DESIGN

This paper used a qualitative and descriptive design.

METHODS

This paper is based on interviews with parents participating in two experience-based co-design projects in a Swedish hospital that included qualitative content analysis of data from 12 parent interviews in paediatric care.

RESULTS

Health care professionals often overemphasize their own significance for value creation in care processes and underappreciate parents' ability to influence and contribute to better quality. However, quality is not based solely on how professionals accomplish their task, but is co-created by health care professionals and parents. Consequently, assessment of quality outcomes also must include parents' ability and context.

CONCLUSIONS

This paper questions current models of quality dimensions in health care, and suggests additional sub-dimensions, such as family quality and involvement quality.

RELEVANCE TO CLINICAL PRACTICE

This paper underscores the importance of involving parents in health care improvements with health care professionals to capture as many dimensions of quality as possible.

Factors affecting the communication competence in Iranian nursing students: a qualitative study

Background:

Communication competence in nursing students is one of the nursing education requirements, especially during the internship period, the final stage of the bachelor nursing education in Iran. Several factors can influence this competence and identifying them could help provide safe care by nursing students in the future.

Objectives:

This study aimed to investigate factors that influence nursing students' communication competence.

Patients and Methods:

A purposeful sampling technique was used to select 18 nursing students who had completed their internship. Semi-structured interviews were conducted and data were analyzed by the conventional qualitative content analysis method.

Results:

After data analysis, three main categories were achieved: organizational factors, humanistic factors and socio-cultural factors. The main and latent theme that affected the students' communication competence was not being accepted as a caregiver in the clinical environment.

Conclusions:

With regards to students not being accepted in health care environments, it is recommended to plan special programs for empowering students to acquire better social state and acceptance by the health care team.

Improvements in neonatal care; using experience-based co-design

Purpose

– The purpose of this paper is to identify and improve patient care processes by collaborating patients, relatives and healthcare professionals.

Design/methodology/approach

– To identify and improve patient care processes by collaborating patients, relatives and healthcare professionals.

Findings

– Healthcare problems captured from collaboration between patients and healthcare professionals fall into simple, complicated and complex problems. Healthcare staff and patient experiences with patient processes differ, and a collaborative approach is needed to capture all areas needing improvement.

Research limitations/implications

– The conclusions are drawn from a project with few participants in a context that probably influenced the results. In contrast, other studies in the same area confirm the results.

Practical implications

– The study outcomes have direct implications for healthcare professionals who can learn from patients involved in quality improvements such as this experience-based co-design (EBCD) project.

Originality/value

– The paper contributes to limited studies on EBCD involving patients in healthcare quality improvements.

Integrating an evidence-based intervention into clinical practice: 'transitional relationship model'

The transitional relationship model (TRM) facilitates the discharge process by providing peer support and hospital staff involvement until a therapeutic relationship has been established with a community care provider. A quasi-experimental, action-oriented research design was employed in which psychiatric wards at six hospital sites implemented the model in three waves. Helpful strategies were identified by each wave of wards for consideration by subsequent wards. Using an ethnographic approach, qualitative data were examined to uncover experiences and perceptions of TRM implementation and to help identify key issues that were supporting or hampering implementation. Specific strategies that facilitate the implementation of TRM include: (1) the use of educational modules for on-ward hospital staff training and peer training; (2) presence of on-site champions; and (3) supportive documentation systems. Issues identified as barriers to implementation included: (1) feeling drowned, swamped and overwhelmed; (2) death by process; (3) team dynamics; and (4) changes in champions. Staged large-scale implementation of the TRM allowed for iterative improvements to the model leading to positive outcomes. This study highlights the need to address work environment issues, particularly interprofessional teams.

Radiographers' self-assessed level and use of competencies-a national survey

OBJECTIVES

To describe radiographers' self-assessed level and use of competencies as well as how sociodemographic and situational factors are associated with these competencies, particularly related to work experience.

METHODS

A cross-sectional design was employed. Radiographers (n = 406) completed the self-administered 28-item questionnaire encompassing two dimensions: 'Nurse-initiated care' and 'Technical and radiographic processes'. The level of competencies was rated on a 10-point scale and the frequency of use on a 6-point scale.

RESULTS

Most competencies received high ratings both in terms of level and frequency of use. In 'Nurse-initiated care' the competency 'Adequately informing the patient' was rated the highest, while 'Identifying and encountering the patient in a state of shock' and 'Participating in quality improvement regarding patient safety and care' received the lowest ratings. In 'Technical and radiographic processes' the highest rated competencies were 'Adapting the examination to the patient's prerequisites and needs' and 'Producing accurate and correct images'. The lowest frequency of use was 'Preliminary assessment of images'.

CONCLUSION

The main findings underline the radiographers' high competency in both 'Nurse-initiated care' and 'Technical and radiographic processes'. The lower rated competencies emphasise the importance of continuous professional education and quality improvement.

MAIN MESSAGES

• Assessing radiographers' clinical competencies is fundamental for ensuring professional standards. • Most competencies received high ratings both in the nursing and in the radiographic dimensions. • The highest rated competencies focussed on information and adaptability to the patients needs. • The lowest rated competencies focussed on encountering the patient in shock and image assessments. • Age, years in present position and work place only explained a relatively small part of competency.

How do persons with dementia participate in decision making related to health and daily care? a multi-case study

BACKGROUND

Many countries have passed laws giving patients the right to participate in decisions about health care. People with dementia cannot be assumed to be incapable of making decisions on their diagnosis alone as they may have retained cognitive abilities.The purpose of this study was to gain a better understanding of how persons with dementia participated in making decisions about health care and how their family carers and professional caregivers influenced decision making.

METHODS

This Norwegian study had a qualitative multi-case design. The triad in each of the ten cases consisted of the person with dementia, the family carer and the professional caregiver, in all 30 participants. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2, moderate dementia; (3) able to communicate verbally. The family carers and professional caregivers were then asked to participate.A semi-structured interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day centre. How the professional caregivers facilitated decision making was the focus of the observations that varied in length from 30 to 90 minutes. The data were analyzed using framework analysis combined with a hermeneutical interpretive approach.

RESULTS

Professional caregivers based their assessment of mental competence on experience and not on standardized tests. Persons with dementia demonstrated variability in how they participated in decision making. Pseudo-autonomous decision making and delegating decision making were new categories that emerged. Autonomous decision making did occur but shared decision making was the most typical pattern. Reduced mental capacity, lack of available choices or not being given the opportunity to participate led to non-involvement. Not all decisions were based on logic; personal values and relationships were also considered.

CONCLUSIONS

Persons with moderate dementia demonstrated variability in how they participated in decision making. Optimal involvement was facilitated by positioning them as capable of influencing decisions, assessing decision-specific competence, clarifying values and understanding the significance of relationships and context.

Negotiating care: patient tactics at an urban South African hospital

Objectives:

To examine the various ways in which patients sought to influence the care they received in the admission and adult medical services of a large urban, academic hospital in South Africa. These included the steps taken by patients to increase their access to services and improve their experience of care.

Methods:

Part of a qualitative study of rationing behaviour, the methods combined, observations, interviews and a survey.

Results:

Patient's actions were oriented to two main goals: obtaining care and preserving their sense of self and dignity. These actions shaped patients’ pathways in five key ways: meeting the entry criteria for admission; presenting as a cooperative, expert patient; mobilizing social networks among health care staff; making use of complaints mechanisms; and deploying narratives of resistance.

Conclusions:

Patients made tactical use of small spaces at the margins of the health care system. Although, with some exceptions, they had limited impact on the care received in the hospital, they highlight patients as active players and point to the ways in which patient agency can be strengthened in the light of the shift towards chronic disease care and greater patient involvement in care.

Power in telephone-advice nursing

Power is a central aspect of nursing, especially in telephone-advice nursing, where nurses assess callers' medical problems and decide what measures that need to be taken. This article presents a framework for understanding how power operates in social interaction between nurses and callers in telephone-advice nursing in primary care in Sweden. Power is analysed as the result of nurses and callers being oriented to five social structures that are relevant to their actions in this context, namely the organization of telephone-advice nursing, the social stock of medical knowledge, the professional division of labour between nurses and doctors, structures of social interaction and structures of emotions. While structural constraints govern some actions to a high degree, calls take place in an organizational free room that give nurses more leeway for acting more creatively. The discussion focuses on the introduction of new technologies of control, for instance computerized decision support systems and audio recording of calls, and on how they reduce the free room. Empirical data consist of 276 audio-recorded telephone calls to 13 nurses at six primary-care centres and of qualitative interviews with 18 nurses.

[Evaluation of nurses' competency in nurse-patient communication about medications: conversational analysis approach]

PURPOSE

The purpose of this study was to develop evaluation criteria for conversations about medication and to demonstrate conversational analysis with actual dialogues on medication as examples.

METHODS

This study was a secondary analysis of qualitative research using conversational analysis which showed functional phases and patterns of dialogue about medication (greeting, identifying the patient, medicating, finishing). Nurse-patient conversations were videotaped and transcribed and 75 conversations were used for analysis.

RESULTS

Not all functional phases were showed in the conversations about medication. Therefore, conversations about medication can be considered as incomplete dialogues. The evaluation-criteria were represented in terms of the structure and content of the dialogues. Structural evaluation-criteria were the same as the functional phases, as functional stage is the standard for evaluation. The criteria of evaluation for content suggested 3 domains, content, expression, and interaction with 20 items scored on a Likert-type scale of 5-points. Finally, analysis of actual conversations about medication according to the evaluative criteria were provided.

CONCLUSION

The results provide the basic data to develop educational programs and strategies to improve nurses' competency in conversation about medication.

Strategies used in the pursuit of achievability during goal setting in rehabilitation

We used conversation analysis of six audio- and video-recorded goal-setting meetings that were attended by patients and their respective treating team to explore and describe the interaction of participants during interdisciplinary goal setting, and to identify the strategies used to agree on goals. The health care professionals involved in the six sessions included four physiotherapists, four occupational therapists, four nurses, one speech and language therapist, and one neuropsychologist. The participants included 3 patients with multiple sclerosis, 2 patients with spinal cord lesions, and 1 patient with stroke from an inpatient neurological rehabilitation unit. Detailed analysis revealed how the treating team shaped the meetings. The most notable finding was that there was rarely a straightforward translation of patient wishes into agreed-on written goals, with the treating team leading goal modification so that goals were achievable. Despite professional dominance, patients also influenced the course of the interaction, particularly when offering resistance to goals proposed by the treating team.

Patient-centered education: applying learner-centered concepts to asthma education

OBJECTIVE

To review studies of patient-centered asthma education.

METHOD

CINAHL, Medline, Psycinfo, Eric, PsycARTICLES, and web of science databases were searched. RESULTS Asthma education programs are often based on health behavior theories. Many studies lack rigor in the assessment of the program's efficacy and effectiveness. Asthma education that promotes self-management primarily uses a problem-based approach. Few studies have examined the way educators teach and patients learn. Patient-centered approaches to education have mainly focused on communication between the patient and the health professional. Decision making as part of shared responsibility may vary with every patient. Patient-centered care shares similarities with the Self-Determination Theory as a learner-centered approach to education.

CONCLUSIONS

Many asthma education studies have been completed with varying levels of efficacy and effectiveness reported. Most programs focus on changing behavior with few studies examining educator behavior and/or the patient's learning styles. With a patient-centered approach being the preferred model of care, the incorporation of learner-centered approaches to patient education may prove useful in the future.

Client-nurse relationships in home-based palliative care: a critical analysis of power relations

AIM

To elicit an in-depth understanding of the sources of power and how power is exercised within client-nurse relationships in home-based palliative care.

BACKGROUND

As in all social relations, power is present within client-nurse relationships. Although much research has focused on interpersonal relationships in nursing, the concept of power within the client-nurse relationship in palliative care settings has not been extensively investigated.

METHODS

Applying a critical lens, secondary qualitative data analysis was conducted. Seventeen nurse and 16 client transcripts from a primary study were selected for secondary data analysis. These 33 transcripts afforded theme saturation, which allowed for both commonalities and differences to be identified. Data analysis involved analytic coding.

RESULTS

Study findings help make explicit the underlying power present in the context of home-based palliative care and how this power is used and potentially abused. In analysing the sources and exercise of power, the linkage between macro and micro levels of power is made explicit, as nurses functioned within a hierarchy of power. The findings suggest that educational/occupational status continues to be a source of power for nurses within the relationship. However, nurses also experience powerlessness within the home care context. For clients, being able to control one's own life is a source of power, but this power is over-shadowed by the powerlessness experienced in relationships with nurses. The exercise of power by clients and nurses creates experiences of both liberation and domination.

CONCLUSIONS

Nurses who are willing to reflect on and change those disempowering aspects of the client-nurse relationship, including a harmful hierarchy, will ultimately be successful in the health promotion of clients in home-based palliative care. Additionally, it should be recognized that nurses work within a specific health system context and, therefore, their practice is influenced by policies and funding models implemented at various levels of the health care system.

RELEVANCE TO CLINICAL PRACTICE

The insights gained through this investigation may assist nurses and other health professionals in reflecting on and improving practices and policies within home-based palliative care and within home care in general.

Empowering discourse in patient education

OBJECTIVE

A systematic literature review, using a metasummary technique for qualitative studies (n=15) was conducted to describe the nature of empowering discourses between patient and nurse.

METHODS

Computerised searches from 1995 to October 2005 were conducted on the Ovid Medline database using the keywords empower(*), power(*), resource(*), participat(*), facilitat(*), negotiat(*), communicat(*), interact(*), dialog(*), discours(*), discuss(*), encount(*), conversat(*) and 'nurse-patient relations'. All statements concerning empowering discourse were integrated into 29 abstracted findings. Frequency and intensity effect sizes were then calculated.

RESULTS

Empowering discourses vary from study to study. Analysed as a whole, an empowering discourse has specific characteristics and structure. Both patients and nurses have essential roles within this type of discourse and their relationship is characterized by an appreciation of each other's expertise within these roles.

CONCLUSION

The results of this review show empowerment during discourse between patient and nurse has a complex and multifaceted but analysable nature. More research is needed to find systematic methods of empowering discourse.

PRACTICE IMPLICATIONS

The results of this study increase nurses' understanding of empowering methods in patient education identifying ways of facilitating patient empowerment.

Weighing in primary-care nurse–patient interactions

This article analyzes the interactions through which primary-care nurses and patients accomplish patient weighing. The analysis is based on videotaped nurse-adult patient interactions in clinics in the area of Southern California. Detailed examination of co-participants' naturally situated weighing conduct shows that parties recurrently deliver utterances that go beyond that required to accomplish weight measurement-precisely "where" they "are" within the weighing process shaping how they produce and understand these utterances. Using weighing as a locus of epistemic negotiation and potential affiliation, co-participants interactionally achieve the distribution of weight/weighing knowledge and the character of their social relationship. Confronting their numerical weight results in a social/medical setting, patients can use expansive weighing utterances to claim or demonstrate that they possess pre-existing knowledge regarding weight, asserting independent expertise vis-à-vis nurses and claiming result co-recipiency and co-ownership. Speakers can also use expansive utterances to proffer an interactional opportunity for affiliation, inviting recipients to collaborate in producing a more personalized encounter. Through the acceptance or declination of these invitations, the parties work out "who" they "are" to and for one another.

The meaning of patient participation for patients and nurses at a nurse-led clinic for chronic heart failure

BACKGROUND

The legislation of many Western countries emphasizes active patient participation. Patients with chronic heart failure (CHF), however, have experienced participation differently from the general interpretation of legal definitions. Education improves uptake of self-management strategies yet knowledge is lacking about support of patients' own resources in CHF.

AIM

To explore the phenomena of patient participation and non-participation as shown in patient visits to a nurse-led clinic for CHF and as experienced by the patients and nurses.

METHODS

Data triangulation of field notes from participatory observations and texts from narrative interviews with the patients and assigned nurse specialists. Data were analyzed according to the phenomenological hermeneutic tradition.

FINDINGS

Patients' experience of participation and non-participation was interpreted as "Being responsible and accepting responsibility" and "Lacking an equal relationship while being controlled", respectively. Nurses experienced patient participation as "Getting information and security to act" and patient non-participation as "Not accepting".

CONCLUSION

Conflicting values of patients and nurses, which were interpreted with respect to participation and non-participation, presumably might influence patient information and education negatively. The issue of participation should be raised as a means of attaining concordance and to facilitate patient participation with education specifically tailored to the individual patient's needs.

The phenomena of participation and non-participation in health care--experiences of patients attending a nurse-led clinic for chronic heart failure

BACKGROUND

Patient participation is stressed in the health care acts of many western countries yet a common definition of the concept is lacking. The understanding of experiences of patients with chronic heart failure (CHF) who attend nurse-led specialist clinics, a form of care suggested as beneficiary to this group, may promote a better understanding of participation.

AIM

To investigate the meanings of participation and non-participation as experienced by patients living with CHF.

METHODS

Narrative interviews analysed in the phenomenological hermeneutic tradition inspired by Ricoeur where the interpretation is made in the hermeneutic circle, explaining and understanding the experienced phenomena.

FINDINGS

Participation was experienced as to "be confident", "comprehend" and "seek and maintain a sense of control". Non-participation was experienced as to "not understand", "not be in control", "lack a relationship" and "not be accountable". The findings indicate that the experiences of participation and non-participation can change over time and phases of the disease and treatment.

CONCLUSION

The study suggests an extended view on the concept of participation. Patients' experiences of participation in health care can vary and should therefore be an issue for dialogue between nurses and patients with CHF in nurse-led specialist clinics.

Nurses talking to patients: exploring conversation analysis as a means of researching nurse-patient communication

As governmental priorities worldwide continue to emphasise the inclusion of patients in healthcare consultations, there is a pressing need for a research approach that accurately captures the contribution of both participants within nurse-patient interaction. With this in mind, this paper examines, via selective data extracts, the contribution that conversation analysis (CA) could make to this area of nursing research. In the United Kingdom (UK) over the last two decades, CA has been neglected as a method for exploring nurse-patient communication, and a case is made here for its entry into the mainstream of nursing research. The case is made particularly persuasive in the light of conversation analysts' use of naturally occurring research data, a form of data that is regrettably lacking in much of the published research on nurse-patient interaction.