The phenomenon of patient participation in their nursing care : a grounded theory study.

Abstract

In recent times there has been an emphasis on patients participating in their own nursing care. Studies have demonstrated that when patients participate in their own care, they experience positive outcomes, such as greater satisfaction with care, a sense of control, decreased vulnerability, and being effectively prepared for discharge. Practising nurses are of the view that patients should be involved in the planning, implementation, and evaluation of care in keeping with nursing's philosophy of provide holistic or patient-centred care. Despite this there is literature to show that nurses' espoused pro-participatory attitudes were not always enacted in the practice setting. There was a paucity of research to explain why this situation existed. Therefore, the purpose of this grounded theory study was to explore, describe, and analyse nurses' and patients' perspectives on the phenomenon of patient participation within the context of hospital nursing practice in Western Australia.Data were collected through formal and informal interviews with nurses, patients, non nurses, a doctor and relatives, focus group interview with nurses, participant observation, listening to nurses' handovers, examination of nurses' notes, and published literature. Thirty three Registered Nurses and 32 patients from medical, surgical, and extended care wards were formally interviewed. Additionally, 28 nurses and 17 patients were informally interviewed during participant observation. The total hours of participant observation was 142. The constant comparative method was used to analyse the data.The findings revealed that the basic social problem that faced nurses and patients was incongruence in their understandings of the meaning of patient participation and in their philosophies about nursing care. This had led to nurses and patients adopting three styles of participation, that is, participation inclusion which involved patients participating in all aspects of their care, including making decisions about their treatments, participation marginalisation which encompassed patients participating only in their daily living activities and pain management, and participation preclusion which involved patients not participating in any aspects of their care. This resulted in nurses and patients coming together with their own different styles of patient participation, which caused conflict in viewpoints about how care should be provided and received at the bedside. Exacerbating the problem of incongruence were the hospital contextual conditions of economic constraints, management structures, presence of technology, and culture of medical dominance. These contextual conditions also modified the process that nurses and patients used to deal with the problem.The basic social process that nurses and patients used to deal with the problem of incongruence was labelled accommodating the incongruence and involved three phases. It was found that varying intervening conditions that affected the nurses, patients, or both, and the day-to-day ward environment modified this process. The first phase, which was labelled coming to terms with the incongruence, involved nurses and patients encountering and acknowledging that there was an incongruence. The second phase, which was termed rationalising the incongruence, involved nurses and patients observing and assessing each other's behaviours. The third phase, which was labelled seeking resolution: minimising the incongruence, involved nurses and patients adjusting their behaviours so as to achieve some balance. This third phase was nurse-driven with patients playing a subsidiary role. This was considered to be due to nurses being at their optimum physical level of functioning and in their own socio-cultural work environment as opposed to patients who were ill and therefore vulnerable. Nurses adjusted their behaviours, depending on the patients' preferred style of participation, by either increasing patients' control and level of participation, as well as increasing their own level of control, to upgrade patients' input; or decreasing patients' control and level of participation and decreasing their own level of control to downgrade patients' input; or alternatively converging patients' control and level of participation to meet with their own style of participation, without them increasing of decreasing their own control. Through converging, the nurses were able to upgrade or downgrade patients' input. From this nurse-patient interactive process, which was dynamic and reciprocal, a theory of patient participation emerged. This was labelled Accommodating Incongruity. Implications for nursing practice, management, theory, education, research, and consumerism are discussed and directions for future research are provided.