ISSU ES I N CLINICA L NUR SIN G

Patient participation in nursing care: towards a concept clarication from a nurse perspective
Monika JM Sahlsten
Go teborg, Sweden
MSc, RN

Doctoral student at Institute of Nursing, Health and Care Sciences, The Sahlgrenska Academy at Go teborg University,

Inga E Larsson

MSc, RN

Doctoral student at Institute of Nursing, Health and Care Sciences, The Sahlgrenska Academy at Go teborg University, Go nersborg, Sweden teborg, Sweden and Lecturer, Department of Nursing, Health and Culture, University West, Va

Bjo rn Sjo stro m

PhD, RN

Professor, School of Life Sciences, University of Sko vde, Sko vde, Sweden

Catharina SC Lindencrona

BS(Ed), MS(AdmNEd), Dr MedSc, RNT

Senior investigator (ret.), Department of Health and Welfare, Stockholm, Sweden

Kaety AE Plos
Sweden

BSc, PhD

Senior Lecturer, Institute of Nursing, Health and Care Sciences, The Sahlgrenska Academy at Go teborg University, Go teborg,

Submitted for publication: 13 October 2005 Accepted for publication: 8 March 2006

Correspondence: Monika Sahlsten,Granva gen 12 SE-468 30 Vargo n Sweden Telephone 46 521 220072 or 46 707 315758 E-mail: monika.sahlsten@swipnet.se

STRO M B, LINDENCRONA CSC & PLOS KAE SAHLSTEN MJM, LARSSON IE, SJO (2007)

Journal of Clinical Nursing 16, 630637 Patient participation in nursing care: towards a concept clarication from a nurse perspective Aim. The aim of this study was to investigate the meanings of the concept of patient participation in nursing care from a nurse perspective. Background. Participation is essential and increases patients motivation and satisfaction with received care. Studies of patient participation in nursing care are not congruent regarding denition, elements and processes. This lack of clarity is amplied by several terms used; patient/client/consumer involvement or collaboration, partnership and inuence. Despite the fact that several nursing theories have emphasized the importance of patient participation, an empirically grounded theory has yet to be published. Methods. Seven focus group interviews were held with nurses providing inpatient physical care at ve hospitals in West Sweden. The focus groups consisted of Registered Swedish nurses (n 31) who described the meaning and implementation of patient participation in nursing care. A Grounded Theory approach has been applied to tape-recorded data. Constant comparative analysis was used and saturation was achieved.

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Issues in clinical nursing

Patient participation in nursing care

Results. Mutuality in negotiation emerged as the core category for explaining nurses perspectives on patient participation in nursing care. It is characterized by four interrelated sub-core categories: interpersonal procedure, therapeutic approach, focus on resources and opportunities for inuence. Mutuality in negotiation constitutes the dynamic nursepatient interaction process. Conclusions. The study claries that patient participation can be explained as an interactional process identied as mutuality in negotiation based on four components. Relevance to clinical practice. The results are important and can be used in nursing practice and education. Application in a clinical context means nursing care organized to include all the components presented. The results can also be used in quality assurance to improve and evaluate patient participation. Key words: focus groups, Grounded Theory, mutuality, negotiation, nursepatient interaction, patient participation

Background
Patient participation is an important basis of medical treatment and nursing care and a legal right in many countries (Nordgren & Fridlund 2001, Eldh et al. 2004). The patients position has changed. The traditional view is replaced by expectations of active patients involved in their own care. Despite this, patients have experienced inattention in e.g. encounters, communication and participation (Eldh et al. 2004, Pellatt 2004), dissatisfaction and complaints appear to be increasing (Coulter & Magee 2003). Participation is essential and known to reduce stress and anxiety (Lauri & Sainio 1998). It also increases patients motivation and satisfaction with received care (Williams et al. 1998). However, each nurse and each patient may have their own opinion or ideas of both meaning and implementation. The registered nurse is a key person whose opinions, attitudes, strategies and competence determine how patient participation is implemented. Several researchers have identied prerequisites of patient participation in nursing care. Ashworth et al. (1992) emphasized a common knowledge base and adaptation to the patients problems in addition to both parties being equally important and nobodys identity being threatened. Cahill (1996) stated that a relationship must exist and that the nurses knowledge should be placed at the patients disposal and some power and control must be handed over. The nurse must engage the patient intellectually and/or in physical activities and participation must benet the patient. Sainio et al. (2001) noted that the nurse must provide adequate and correct information. Patient must have the intellectual ability to understand and choose between alternatives and make decisions about their own nursing care.

The word participation has been discussed in differing contexts and situations (Cahill 1996, 1998, Gallant et al. 2002). Studies of patient participation in nursing care are not congruent regarding denition, elements and processes. This lack of clarity is amplied by the use of several terms: patient/ client/consumer involvement or collaboration (Cahill 1996), partnership (Bayntun-Lees 1992, Courtney 1995, McQueen 2000, Taylor 2002) and inuence (Roberts et al. 1995, Henderson 2003). Despite several nursing theories having emphasized the importance of patient participation (Watson 1979, Paterson & Zderad 1988, Peplau 1988, King 1989, Orem 1991), an empirically grounded theory has yet to be published. Cahill (1996) presented a concept analysis based on a literature review aimed at clarifying the meaning of patient participation. This described a hierarchical relationship between similar concepts. Partnership at the highest level means cooperation between patient and nurse in all phases of the nursing care process. At a lower level, patient participation, the patient only participates in some of these phases. Courtney et al. (1996) and Gallant et al. (2002) identied phases in partnership. In the initiating phase, current problems form a basis for planning measures. This is followed by the working phase where the patient considers these measures. In the subsequent evaluation phase, goal fullment is examined, which can change the roles and responsibility of nurse and patient in nursing care. Muetzel (1988) and Christensen (1993) also described participation as a partnership, but in a therapeutic, i.e. goal-oriented, supportive and healing relationship requiring intimacy and reciprocity. Patients were considered to have the right to make their own choices and exercise control. Patient participation in nursing care means that patients should have the opportunity to participate in their own care,
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adjusted to ability and the current situation. The professional nurse is presumed to have adopted a reective, conscious approach and procedure. Sahlsten et al. (2005) illuminated the importance of creating an appropriate relationship of high quality and having a strategy for facilitating participation. Accordingly, there is a need to identify the salient process involved in patient participation. Here, an important step in this process is to identify the meaning of the concept of patient participation from a nurse perspective.

Aim
The aim was to investigate the meanings of the concept of patient participation in nursing care from a nurse perspective.

Design
This study is part of a larger project of patient participation in nursing care from the perspective of both nurse and patient. This study was limited to inpatient physical care. A Grounded Theory approach (Glaser & Strauss 1967, Glaser 1978, 1992, 1998) with focus group interviews was used. This approach involves systematically generating theory or concepts and their inter-relationships, which can be accounted for, explicating and interpreting variations in behaviour. Glaser (1998) claims Grounded Theory can be used in many elds on any type of data or combinations of data. Researchers have suggested a Grounded Theory approach with focus group interviews for descriptions of experiences or the meaning of a phenomenon (Carey 1995, Webb & Kevern 2001). This inuenced the present study. The starting-point for data collection and analysis was the constant comparative analysis (Glaser 1978, 1992, 1998).

nurses recruited from ve hospitals in West Sweden. The intention was to have a range of informants able to contribute with a scope of experiences. The focus groups included nurses; (i) who had earlier participated for at least six months in systematic clinical nursing group supervision, who worked on different wards: orthopaedic, ear nose and throat, eye, gynaecological, childbirth, medical and rehabilitation (focus groups 1 and 2); (ii) who worked on the same rehabilitation or heart failure ward, where patient participation was an explicit care philosophy (focus groups 35); and (iii) who worked on the same neurological ward with neither systematic clinical nursing group supervision nor an explicit care philosophy (focus groups 6 and 7; Table 1). Each focus group met once. Twenty-nine informants were women and two were men (years after registration: mean 16 years, range 238).

Data collection
Focus group interviews
Data were collected through open interviews in each of the seven focus groups, with the aim of uncovering the informants perspectives in depth. The dynamics generated in groups were used in order to achieve rich and detailed perspectives (Merton 1987, Asbury 1995, Krueger & Casey 2000). The data were gathered over a period of ve months. For practical reasons, the focus group interviews were carried out when the informants work situation permitted. Despite this, eight nurses quit because of present duties on the ward (four) and to acute illness (four). The focus group interviews lasted 11.5 hours and were held in rooms adjacent to the wards and were carried out by the same nurse researcher. The focus group interviews concentrated on the meaning and implementation of patient participation. The discussion of each area was verbally summarized. The informants commented on what was most prominent and signicant. They were also asked to reect on, supplement, verify and
Table 1 Participants in focus groups

Participants
The sample consisted of seven focus groups. The selection was purposeful and informants consisted of 31 registered

Focus groups Focus group 1* Focus group 2* Focus Focus Focus Focus Focus group group group group group 3 4 5 6 7

Nurses from different wards Orthopaedic, gynaecological and medical wards Earnosethroat, eye, gynaecological, childbirth, medical and rehabilitation wards Rehabilitation ward Heart failure ward Neurological ward

Number of nurses in each focus group 4 6 4 4 6 3 4

*Former participants in systematic clinical nursing group supervision. 632 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 630637

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further develop the content. Several researchers have recommended this type of validation (Carey 1995, Kidd & Parshall 2000, Krueger & Casey 2000). Each focus group interview was audiotaped in its entirety and transcribed verbatim. The co-assessor (IL), who observed, made notes, contributed with questions and managed the tape recorder, was present during all the focus group interviews.

constantly testing the emerging body of results against new data until saturation was reached, i.e. the emerging pattern was not changed by new data.

Findings
A summarizing table containing the categories generated from the data analysed from subcategories, categories and sub-core categories to core category is presented (Table 2). The three rst-mentioned, veried by direct quotations, are presented in a separate article. Here, the theoretical interrelations between core category and the sub-core categories are described.

Ethical issues and approval

The ethics of scientic work was adhered to. Since the sample referred to employed nurses, no formal permit from an ethics committee was required in line with national and local Swedish directives. Each study participant gave his/her informed consent after verbal and written information. A guarantee was given that all information would be treated condentially outside the focus group and that participation could be halted at any time.

Mutuality in negotiation
Mutuality in negotiation emerged as the core category for explaining nurses perspectives on patient participation in nursing care. It is characterized by four interrelated sub-core categories: interpersonal procedure, therapeutic approach, focus on resources and opportunities for inuence. Mutuality in negotiation constitutes the dynamic nursepatient interaction process. Here, mutuality means a dynamic interaction between nurse and patient characterized by intimacy, contact and understanding. It includes exchange and co-operation between two equal parties, nurse and patient, sharing a goal or purpose. This requires both to be emotionally prepared. The nurses were presupposed to initiate this interaction on their own initiative and build a relationship with the patient as partner. This is based on the nurses professional status and position. It was also assumed that the nurse would stabilize, i.e. use a patients unique abilities and balance these with actual needs by means of the greatest possible co-operation. Negotiation refers to discussion between nurse and patient and a common starting-point, which should lead to an acceptable agreement. The aim is to increase the patients inuence in planning and implementation of nursing care. The negotiation presupposes readiness to act and a dynamic interaction between active parties nurse and patient. Readiness to act is by its nature invisible but becomes visible when negotiating. The nurse was assumed to have knowledge of how relationships are developed and the ability to facilitate participation by means of deliberate strategies. She must be able to supply knowledge adapted to the patient a necessary condition for making informed choices, which in turn should result in increased responsibility and independence. The informants description of patient participation shows that mutuality in negotiation is dependent on each of the sub-core categories:
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Data analysis
The data were analysed using constant comparative analysis (Glaser & Strauss 1967, Glaser 1978, 1992, 1998). Concurrent data generation and analysis was carried out. After each focus group interview, the audiotape was listened to and a written summary was made by the interviewer. A preliminary analysis was performed with emerging categories along with ideas, questions and memos, i.e. theorizing write-up of ideas about codes and their relationships. This was used to gather additional data from subsequent focus groups. After all focus group interviews were completed, a nal analysis of all data was carried out. Two persons, independently read the interviews transcribed verbatim and carried out an open coding. Meaningful parts, describing actions and events, were dened and conceptualized into substantive codes (e.g. decide). The codes were grouped for similar content into overall categories (e.g. decision). In the subsequent theoretical coding, properties and dimensions of the different categories were described and subcategories generated (e.g. co-determination and selfdetermination). Relations were searched for between the generated categories, which was accepted or rejected according to new data. Theoretical code families dimensions and strategies were used to nd relations between the categories (Glaser 1978). When the core category was identied, the open coding was replaced by selective coding. After that, the analysis was focused only on the core category and categories describing nurses approaches and procedures. Validity was built into the analysis by

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MJM Sahlsten et al. Table 2 Overview of the meaning and implementation of patient participation from nurses point of view categorized according to Grounded Theory Core category Mutuality in negotiation Sub-core category Interpersonal procedure Categories Communication Interplay Sub-categories Contact Dialogue Dare Invite Conrm Await Reassurance Empathy Professional distance Self-knowledge Probing Resource inventory Checking Written information material Allocation of responsibility Use of networks Refocus self-image Preparing meetings Information requirement Right of choice Co-determination Self-determination Joint responsibility Self-responsibility

Therapeutic approach

Therapeutic relationship

Focus on resources

Exchange of information and knowledge

Opportunities for inuence

Information Choice Decisions Responsibility

1. How the negotiation is shaped depends on the nurses knowledge of participation, which is based on interpersonal procedures and strategies. The nurses responsibility is to initiate the negotiation and establish functioning co-operation. It is important for both nurse and patient that the negotiation is characterized by an interpersonal procedure. This requires knowledge, experience and conscious strategies on the part of the nurse regarding the categories communication and interplay (Table 2). Examples of quotations that illustrate these underlying categories are:
Communication: Making contact is a prerequisite of getting the patient to express what he is thinking. You have to get a feel for the patient and study him, if its not expressed verbally, you can see it in his body language while youre talking with him. Interplay: As a nurse, you must dare to take part, ask questions and accept the patients answers and not be afraid to say what you think. //Its important that the patient feels involved from the start and is allowed to say what he wants.

communication and interplay. It is essential for both nurse and patient that negotiation is based on a therapeutic approach. This requires knowledge and experience of the category therapeutic relationship (Table 2). Examples of quotations that illustrate this underlying category are:
Therapeutic relationship: As a nurse, I must be reassuring and we have to feel respect for each other.//First, you have to be open and want to understand the situation as the patient understands it.//I cant be pals with the patient, a certain distance is required.//As a nurse, you have to get to know yourself to know your weak and strong sides.

2. How the negotiation is shaped depends on the nurses knowledge of participation, which is based on a therapeutic approach where the nurse uses herself in a deliberate and appropriate way of promoting patient control. Here, the nurse stabilizes the co-operation, the patient is treated as an equal partner in joint work characterized by effective
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3. How the negotiation is shaped depends on how the nurse facilitates participation, which is based on a continuous focus on resources. A nurse takes as a starting point, and builds on, the patients own resources. Both nurse and patient need information and knowledge a nurse develops co-operation by exploring the patients conceptions and knowledge as well as sharing his/her own. This presupposes that the nurse, by means of deliberate dialogue strategies, facilitates regarding the category exchange of information and knowledge (Table 2). Examples of quotations illustrating this underlying category are:
Exchange of information and knowledge: I have to nd out what the patient knows.//I ask questions, listen and observe to see if the

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Issues in clinical nursing patient has understood.//Sometimes, you have to discretely help the patient nd a new self-image and see other possibilities.//If possible, the patient should plead his own case, thats where I have to encourage and prepare. We plan when, where, how and why before this meeting.

Patient participation in nursing care

4. How the negotiation is shaped depends on how the nurse facilitates participation, which is ensured by opportunities for inuence where the nurse, through intentional interaction, strives to increase responsibility by both parties. Nurse stabilizes their co-operation by supporting the patient in believing in own ability in a joint effort characterized by effective exchange of information and knowledge. It is crucial for both nurse and patient that negotiation results in opportunities for inuence, which requires the nurse to facilitate and ensure that the patient has optimal opportunities regarding the categories information, choice, decision and responsibility (Table 2). Examples of quotations that illustrate these underlying categories are:
Information: As a nurse, you have to deliver information, the patient needs to understand the situation to be able to be involved. Choice: If patients have the right to choose at once, they become much more involved in their care than other patients, theyve chosen and feel valuable. Decision: As a nurse, you present alternatives for the patient to decide.//Many patients want to decide for themselves. Sometimes I have another opinion, but I have to consider the big picture. A patient may need to discover things himself in order to grow and be independent. Responsibility: The patient shared responsibility with me as a nurse. //I gave information regarding his medicine and how he should administer it here. He took the responsibility to manage this himself during his stay in hospital.

Discussion
This study provides nurses interpretation and implementation of patient participation explained as an interactional process identied as mutuality in negotiation characterized by four interrelated dimensions. Optimal participation by patients requires intimacy and contact, a dynamic interaction between equal partners based on a foundation of interpersonal procedure, therapeutic approach, focus on resources and opportunities for inuence. This study obviously does not cover all aspects of patient participation, as it was the perspective of nurses in physical care that was investigated. The results are based on these informants (n 31) verbal contributions and ability to discuss and describe patient participation. However, there is no guarantee that this is the way it is practised on the wards.

Data were collected in focus groups and some may be considered small, as their size ranged between three and six informants. Several researchers even recommend four to six informants per focus group (e.g. Carey 1994). What was essential for the aim of the study was the substantial content of the focus group discussions, which generated sufcient data to reach saturation. Focus group interviews gave access to reected and experience-based data. In all the groups, the interaction between informants was open and relaxed. This is of great importance as good interaction is signicant for the trustworthiness of data material collected through the method used here and its interpretation (Carey 1995). Lively discussions and the informants considerable experience contributed to deep and rich qualitative data. The reliability of data collection was enhanced by validating main conclusions during each focus group interview. The interviews were performed by the same interviewer, which strengthens the quality because of equivalence between data collected in the focus groups (Kidd & Parshall 2000). Grounded Theory implies the same interviewer throughout the study, as concurrent data collection and analysis is required (Glaser 1978). The researcher is urged to analyse his/her own collected data. The data obtained via the focus group interviews formed the basis of the theory and guided its development (Glaser 1978). The category system, including relationships between categories, was validated as new data were added. Reliability was achieved when the emerging pattern was not changed by new data. Two persons independently performed an open coding of the data. Good concordance was revealed between the two codings. The labelling of a few codes differed, but an examination showed the same or similar content. This study claries elements and processes in patient participation, which have been unclear in earlier studies of this topic. The informants descriptions showed that the patients resources were focused; co-operation and shared responsibility were highly valued, a nding also pointed to by Courtney (1995), Cahill (1996) and Gallant et al. (2002). In contrast with these authors, this study showed that the informants understanding of patient participation was similar to the level partnership, which is an ideal in nursing care. They emphasized the importance of being equal partners, something that Gallant et al. (2002) found to be only discussed in theoretical papers. The ndings show that negotiation is the main interaction strategy in patient participation, a nding also described in other studies (Roberts & Krouse 1990, Roberts et al. 1995, Gallant et al. 2002). Negotiation has been described as shared responsibility and partnership-planning behaviours (Roberts & Krouse 1990); not necessarily including a sense of shared understanding or shared purpose (Henson 1997) but,
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rather, a bargaining to nd common ground between rmly different purposes. This study claries that mutuality is a necessary precursor of negotiation. It is based on a common starting-point where nurse and patient discuss, work and see each other as equal, i.e. a both non-hierarchical and independent relationship. The informants illuminated, as did Roberts et al. (1995), that energy and optimism arise when nurse and patient unite abilities and learn from each other. This leads to patients taking responsibility and becoming more independent, which could imply possibilities for developing more effective care by optimizing patient participation. The ndings conrm and augment a negotiation model in nursing presented by Roberts and Krouse (1988). This includes requests, attribution and expectations being elicited and followed by active interaction and consensus building, and the goal of the negotiation is a decision agreeable to both nurse and patient. In contrast to their model, our study illustrates a more complex picture, i.e. both procedures and approaches employed by nurses and a large number of components (Table 2). The results show certain similarities with Hensons (1997) denition of mutuality a connection with or understanding of another that facilitates a dynamic process of joint exchange between people (p. 80). In contrast to Henson, who states that negotiation behaviours are a way of understanding mutuality, our results clarify a process where mutuality precedes negotiation. This study claries that an interpersonal procedure is a prerequisite of achieving mutuality in negotiation. The nurse patient encounter is one of necessity, not choice, which makes it unequal (McQueen 2000, Ronayne 2001). Accordingly, to prepare for the role as equal co-operation partner, they must acknowledge their initial inequalities, value each others competencies and nd a common starting-point for the negotiation. If this is not done, the traditional view is maintained nurses trained to think of themselves as in control and as experts and patients who see themselves as passive recipients of professional advice. For patients to feel condent to express his/her views openly, a necessity is an emotionally secure environment and intimacy. In this study, a therapeutic approach was found crucial for achieving mutuality in negotiation. Intimacy presupposes that nurses have self-knowledge and use themselves consciously and effectively to achieve a genuinely therapeutic meeting, in line with Travelbee (1971) and Muetzel (1988). Awareness of the patient not only agreeing with the nurses opinion requires attention to ones own attitudes and actions. This ability can be improved by e.g. clinical supervision and mentoring. Focus on resources was found to be a prerequisite of achieving mutuality in negotiation. This gives nurse and
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patient freedom to discuss and negotiate based on a clear view of the situation and its solutions, which are expected to increase the patients sense of responsibility and power. Active involvement and mutual efforts are necessary. To facilitate participation, a nurse needs clearly and intentionally to transfer some of her specialized knowledge and skill, thus enabling the patient to increase his/her competence and freedom to control, something also emphasized by BayntunLees (1992) and Sainio et al. (2001). This presupposes that nurses give priority to continuity in the relationship and assign time for talk to achieve mutual understanding. Opportunities for inuence were found to be a prerequisite of achieving mutuality in negotiation. This presumes that a nurse supports and encourages the patient to express and utilize his/her rights to participate. It is of great importance that opportunities to choose and for joint decision-making be maximized, thereby returning power and authority to the patient; this is also described by Trnobranski (1994) and Henderson (2003). This requires professional re-socialization (cf. Cahill 1998), where nurses need to reect on, question and reconsider previous understanding of patient participation. A conscious approach and intentional strategies of shared responsibility with the patient require openness and motivation on the part of the nurse to consider new thoughts and ideas, the nurses role is changing. Further studies need to be carried out with other stakeholders, rst and foremost patients, using other methods to further develop the results from this study. The perspective can, of course, be broadened and supplemented with e.g. signicant others and additional occupational groups in health care.

Conclusions
We found that from a nurse perspective, patient participation can be explained as an interactional process identied as mutuality in negotiation based on interpersonal procedure, therapeutic approach, focus on resources and opportunities for inuence. The results from this study are important and can be used in nursing practice and education. Application in a clinical context means nursing care organized to include all the components presented. The results can also be used in quality assurance to improve and evaluate patient participation. In a pedagogical context, the results can easily illustrate and clarify implementation of patient participation.

Acknowledgements
We would like to thank the Department of Nursing, Health and Culture, University West, Va nersborg, for nancial support. Our grateful thanks go to the nurses who

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participated in this study and openly shared their thoughts and experiences as professional nurses.

Contributions
Study design: MS; data analysis: MS, IL and manuscript preparation: MS, IL, BS, CL, KP.

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