Reluctant collaborators: do patients want to be involved in decisions concerning care?

Individualized care in a Finnish healthcare organization

This paper reports the findings of a study exploring the provision of individualized care in a regional hospital in Finland. Individualized care was defined in terms of how patient individuality was taken into account and how patient participation in decision-making was facilitated. The data were collected from hospitalized patients (n = 203) using a questionnaire specially developed for this study. The response rate was 89%. A strong support to facilitate patient participation in decision-making was reported. Most shortcomings concerning the provision of individualized care related to consideration of the patient's cultural background and the involvement of the patient's family in the planning of care. Patients' age and the type of ward were associated with the provision of individualized care: patients aged 65 or over were more satisfied than younger age groups with the way in which their personal life situation had been taken into account. Patients from the gynaecological ward thought, more than patients from the surgical ward, that their situation had been taken into account during hospitalization.

Perspectives on cancer patient education

OBJECTIVES

To provide an overview on cancer patient education.

DATA SOURCES

Literature related to demographic and health care trends, patient education, health literacy, and cancer patient information needs.

CONCLUSIONS

Cancer patients need information related to diagnosis, treatment, side effects, self-care needs, and effects on work and relationships. Planned patient teaching includes a variety of teaching strategies and written materials, and contributes to better patient outcomes. Inadequate health literacy and other barriers present challenges to providing effective patient education.

IMPLICATIONS FOR NURSING PRACTICE

More research is warranted in developing assessment tools and effective health education techniques and in measuring outcomes and costs related to patient education. The education needs of cancer patients will not drastically change in the next century. How nurses meet those needs, however, will change as we apply new learning theories and technologies of teaching.

'Self-care' and its relevance to developing demand management strategies: a review of qualitative research

The promotion of self-care has been recognized as an important aspect of managing demand for health care more effectively. Self-care is increasingly being seen by policy makers as a hidden health care resource to be viewed in the context of health care provided by the formal health care sector. Quantitative studies are important for understanding the effectiveness of interventions in terms of the impact they may have on health service utilization. However, questions remain about the reasons people may or may not adopt self-care, the mechanisms for change and the way in which social context may affect the way in which people respond to self-care interventions. Qualitative research that has focused on people's self-care practices provide insights into these aspects. The qualitative studies reviewed here suggest that a number of factors need to be considered when devising health care interventions for managing demand better. These include an assessment of the meaning of the disease to the person so that self-care information can be designed in a way that fits people's prior beliefs and lifestyles. Timing and the stage in a person's illness career are also important factors to consider when designing effective self-care interventions. Social interaction and the impact of significant others may affect whether or not a self-care regime is followed, and autonomy and control are also relevant to designing acceptable self-care strategies. Incorporating these aspects of self-care as a dynamic and interactive process is important for both devising and assessing the impact of interventions aimed at the better management of demand.

Shared decision making in clinical medicine: past research and future directions

Shared medical decision making is a process by which patients and providers consider outcome probabilities and patient preferences and reach a health care decision based on mutual agreement. Shared decision making is best used for problems involving medical uncertainty. During the process the provider-patient dyad considers treatment options and consequences and explores the fit of expected benefits and consequences of treatment with patient preferences for various outcomes. This paper reviews the literature on shared medical decision making. Several questions are considered. Although several studies suggest that patients do not want to be involved in decision making, these studies typically fail to separate decisions about technical aspects of treatment from preferences for outcomes. There is considerable evidence that patients want to be consulted about the impact of treatment. Studies on the acceptability of shared decision making for physicians have produced inconsistent results. Shared decision making is more acceptable to younger and better-educated patients. It remains unclear whether shared decision making requires expensive video presentations or whether the same results can be obtained with simpler methods, such as the decision board. We conclude that shared medical decision making is an important development in health care. More research is necessary to identify the effects of shared decision making on patient satisfaction and health outcomes. Further, more research is necessary in order to evaluate the most effective methods for engaging patients in decisions about their own health care.

Strategic physician communication and oncology clinical trials

PURPOSE

Clinical trials are the primary means for determining new, effective treatments for cancer patients, yet the number of patients that accrue is relatively limited. The purpose of this study was to explore the relationship between physician behavior and patient accrual to a clinical trial by videotaping the interaction.

PATIENTS AND METHODS

Forty-eight patient-physician interactions involving 12 different oncologists were videotaped in several clinics at the H. Lee Moffitt Cancer Center and Research Institute (Tampa, FL). The purpose of each interaction was to present the possibility of a clinical trial to the patient. A coding system, the Moffitt Accrual Analysis System, was developed by the authors to code behaviors that represented both the legal-informational and social influence models of communication behavior. Thirty-two patients agreed to participate in the clinical trial.

RESULTS

Videotaping was found to be a viable, valid, and reliable method for studying the interaction. Physicians who were observed to use both models of influence were found to enroll more patients. Thus, patients were more likely to accrue to the trial when their physician verbally presented items normally included in an informed consent document and when they behaved in a reflective, patient-centered, supportive, and responsive manner. Discussion of benefits, side effects, patient concerns and resources to manage the concerns were all associated with accrual.

CONCLUSION

This research has implications for modifying physician behavior and, thus, increasing the numbers of patients accruing to oncology clinical trials.

A literature review of patients' compared with nurses' perceptions of caring: implications for practice and research

Caring is a salient feature of nursing practice and has been studied extensively from the nursing perspective. Nonetheless, little has been forthcoming in relation to patients' perceptions of the meanings and processes of caring. The present literature review shows that whereas nurse clinicians focus on the psychosocial aspects of caring, patients assign the highest value to technical skills and professional competence. Similarly to patients, a small proportion of nurses view competent clinical expertise as the fundamental component of caring. Noncaring behaviors include physical and emotional absence, belittling and inhumane actions, and lack of recognition of a patient's uniqueness. Patients' participation in decisions regarding their care may or may not be an element of a caring interaction. Ethnonursing studies describe the "caring culture" as one based on likeness, consensus, and conformity. Based on review findings, implications for practice and research are outlined.

Inflammatory bowel disease. 3: importance of partnership in care

In the preceding articles (Vol 8(13): 858-62; Vol 8(14): 926-30), the pathogenesis and aetiology of inflammatory bowel disease (IBD) and its medical and surgical treatment options were considered. In this final part of the series, the concept of an alliance between the patient with IBD and healthcare professionals in terms of healthcare choices is examined. The article explores the role of the clinical nurse specialist in IBD in relation to education, psychological support and compliance with treatment regimens. There is also a discussion of the social and psychological impact of IBD on the patient, and an exploration of the positive effects such a participatory relationship may have on health and quality of life.

Public participation in the design of educational programmes for cancer nurses: a case report

Genuine involvement of the public in planning, monitoring and evaluation of health care is a prerequisite to a better quality of service. Similarly users of health services and their carers can contribute much to the planning and delivery of professional education, although this contribution has only recently been acknowledged in any strategic way by nursing educational and professional bodies. This paper provides one example of user and career involvement in the design of continuing education and higher education in cancer care nursing within the University of Leeds School of Healthcare Studies. The author reflects upon the positive aspects and some of the challenges presented in the achievement of public involvement in nurse education.

Maintaining equilibrium: a grounded theory study of the processes involved when women make informed choices during pregnancy

OBJECTIVE

To map the processes involved when women make informed choices during pregnancy.

DESIGN

A grounded theory approach was used. Data were collected by means of focused interviews and observation.

SETTING

Naturalistic, in antenatal clinics and participants' homes.

PARTICIPANTS

Pregnant women receiving care in a variety of maternity settings in England.

KEY FINDINGS

The core category was named Maintaining Equilibrium, whereby the woman attempted to make choices that would preserve the balance of her and her family's life. Substantive categories were Regulating, Contextualising and Actioning.

IMPLICATIONS FOR PRACTICE

The core and substantive categories are discussed in relation to midwifery practice, with particular reference to how women judged the trustworthiness of the information and its source, and the strategies they used to operationalise their choices. The need is stressed for midwives to be sensitive and flexible regarding meeting the information needs of women, in order that women may reach their own decisions about how best to maintain their equilibrium.

Identifying outstanding clinical nurses: the 'star' shines in oncology

There are some oncology nurses who are special. They are 'good' nurses but they are more, somehow they 'shine'. They are 'stars'. Many nurses will identify the same nurse as a 'star' but what makes a nurse a 'star'? Twelve semistructured interviews were conducted in which oncology nurses were asked to describe an oncology nurse who stood out in terms of clinical practice. The 'star' nurse was easily and readily recalled and described by participants. Analysis revealed 21 grouped themes relating to the 'star' nurse. Each theme was allocated to one of four headings: 'Nurses' ways of Being; Doing; Knowing; and Giving and Receiving' (Stiles, 1990). The 'star' nurse is professional, committed and caring; delivers excellent nursing care both basic and technical; is knowledgeable; has advanced communication skills, and establishes strong relationships with clients and peers. From this, it is clear that caring and psycho-social aspects of care are only part of the make up of the 'star' nurse, and that the complexity of the 'star' nurse has not been highlighted in the literature.

Facing the issue of dependence: some implications from the literature for the hospice and hospice nurses

Research and clinical practice suggest that dependence upon others causes distress to those with a life-threatening illness and that the hospice may serve to reinforce feelings of loss of autonomy. Hospice nurses can contribute to good care and act therapeutically to maximize an individual's potential for independent activity where this is possible and desirable. However, literature from other contexts demonstrates variability in the extent to which this is achieved. This paper outlines the problem of dependence in those with a life threatening illness. Therapeutic nursing is explored in relation to issues which may arise in a hospice context, potential relationships between therapeutic nursing and partnership are noted, particularly with regard to the possible meanings of dependence which for some individuals comes to be apprehensively associated with impending death.

Coping strategies used by hospitalized stroke patients: implications for continuity and management of care

This paper describes findings from an English study into the perceptions of multi-professional practice given by stroke patients, their informal carers and hospital staff. Unstructured interviews were conducted with nine stroke patients and eight informal carers. Case studies were developed from the interview data which formed the basis of a questionnaire designed to ascertain the aims of care for the case studies and the location of professional responsibility for meeting these aims. This was returned by 31 respondents from a range of professional backgrounds. The findings indicate that patients and carers sought out relationships with staff and other patients in order to gain information to help them understand their uncertain futures. Professional staff were reluctant to pass specific information on to patients as it might be misleading in each individual case. The uncertainty surrounding individual recovery means that supportive relationships initiated by patients and carers may need to be recognized and nurtured.

An investigation into the description of patients' problems by nurses using two different needs-based nursing models

This paper describes an investigation into how nurses describe patients' problems and the possible effects of an espoused nursing model on these descriptions. A descriptive study was conducted on two medical wards in a Welsh District General Hospital. Data collected were subjected to content analysis using Gordon's Functional Health Patterns to order the data. The two wards investigated, whilst being very similar in many ways, utilized different nursing models. Findings showed that the nurses studied, when describing patients' problems, most commonly used medical diagnoses or the medical reasons for admission. Patients' problems identified predominately addressed bio-physical needs with scant attention given to psycho-social needs. Despite the use of two different nursing models the language and emphasis of problem description were very similar and there was no evidence of the application of the conceptual underpinnings of the two models. It is suggested that although the use of a ready-made nursing language may have drawbacks, the British nurse should understand and assess the value of the North American Nursing Diagnosis Association's (NANDA) nursing diagnoses. Without such involvement this system may be implemented in the United Kingdom (UK) without the input and influence of practising nurses.

Patients' reactions to attempts to increase passive or active coping with surgery

It is generally regarded as valuable for patients to exercise control over aspects of their medical treatment. Although psychological and other interventions are commonly used with the aim of increasing patients' ability or willingness to control events, it is not known whether patients experience these procedures in the way assumed. The present study compared responses to (i) a psychological intervention designed to increase patients' readiness to exercise control and cope actively and (ii) a comparable intervention intended to induce acceptance and passive coping. Hip or knee arthroplasty patients were visited preoperatively by a researcher who administered the active (N = 15) or passive (N = 15) intervention in a dialogue with the patient. Patients' verbal responses to the interventions were analyzed qualitatively to identify the range of reactions to each type of intervention. Patients readily accepted the passive message on the grounds of doctors' and nurses' authority and the value of the patients' emotional detachment from their surgery. Few responses to the active message indicated acceptance that patients have control over their care and its outcomes; instead, recipients typically interpreted it in terms of the need for obedience to medical and nursing authority. In conclusion, patients do not automatically accept messages intended to change ways of coping. In particular, the attempt to increase patients' readiness to take control over aspects of care can be perceived by patients in an opposite way to that intended. This and previous studies suggest that patient control over aspects of treatment is a professional and theoretical construction that often means little to patients.

Trends in community care and patient participation: implications for the roles of informal carers and community nurses in the United Kingdom

This paper argues that the interfaces between formal and informal care-giving are changing as a result of two current trends; the increased scope of home-based nursing care and the emphasis on participation both within nursing and in the wider health and social care arenas. These various changes are explored in relation to the provision of intensive and complex nursing care in the home. It will be argued that the changing interfaces between formal and informal care have important implications for the respective roles of nurses and informal carers which hitherto have been relatively overlooked. These implications urgently need addressing in research, policy and public debate if professional nurses are to provide appropriate help and support to informal carers.

Patient participation in decision-making

We review the research both for and against patient participation in decision-making and conclude that (a) patients want to be informed of treatment alternatives, (b) they, in general, want to be involved in treatment decisions when more than one treatment alternative exists, and (c) the benefits of participation have not yet been clearly demonstrated in research studies. However, studies that have addressed the latter issue suffer from methodological problems such as small sample sizes and lack of control for potential confounding variables. We conclude that patient participation in decision-making is justified on humane grounds alone and that physicians should endeavor to engage patients in decision-making, albeit at varying degrees, when more than one effective treatment option exists. We propose that methods be developed to evaluate a patient's level of "readiness" to participate in decision-making and that interventions that match the patient's level of readiness be applied to increase participation.

The scope for the involvement of patients in their consultations with health professionals: rights, responsibilities and preferences of patients

The degree and nature of patient involvement in consultations with health professionals influences problem and needs recognition and management, and public accountability. This paper suggests a framework for understanding the scope for patient involvement in such consultations. Patients are defined as co-producers of formal health services, whose potential for involvement in consultations depends on their personal rights, responsibilities and preferences. Patients' rights in consultations are poorly defined and, in the National Health Service (NHS), not legally enforceable. The responsibilities of patients are also undefined. I suggest that these are not to deny, of their own volition, the rights of others, which in consultations necessitate mutuality of involvement through information-exchange and shared decision-making. Preferences should be met insofar as they do not militate against responsibilities and rights.

Participation of expectant mothers in decision making in maternity care: results of a population-based survey

The purpose of the study was to acquire knowledge of the opportunities that expectant mothers had to participate in decision making regarding their care in maternity clinics during their last pregnancy. The study is a part of a larger national survey 'Family planning services in Finland' carried out by the National Research and Development Centre for Welfare and Health. The rationale for the study were the known benefits of participation in one's care and its emphasis in health policy documents. The subjects were a random sample of women aged between 18 and 44. The response rate was 73% (n = 1289). The data were gathered by a mailed questionnaire and analysed statistically. According to the results mothers had fairly good opportunities to participate in decision making. However, there were statistically significant differences in opportunities between the women. The mothers who were most satisfied were aged 25-29 years, lived in a permanent relationship, had 12 years of basic education and had three children. Opportunities to participate in care have improved from the 1970s to the 1990s. The results have many implications for the development of nursing practice in maternity clinics and the deepening of the knowledge base in nursing education. The study, being the first national survey on this topic, also gives suggestions for further studies.

Evidence-informed patient choice. Practical issues of involving patients in decisions about health care technologies

Evidence-informed patient choice involves providing people with research-based information about the effectiveness of health care options and promoting their involvement in decisions about their treatment. Although the concept seems desirable, the processes and outcomes of evidence-informed patient choice are poorly understood, and it should be carefully evaluated.

Pain and powerlessness: the experience of living with peripheral vascular disease

Peripheral vascular disease (PVD) is a widespread condition, the most common manifestation being a gradual occlusion of the arteries of the legs due to atheroma, which results in symptoms of ischaemia such as intermittent claudication or rest pain, ulceration and gangrene. Treatment of the condition is palliative and reconstructive, and aims to salvage the limb, restore mobility and function, and relieve pain. It usually involves attempts to revascularize the affected limb, either by surgical procedures such as bypass grafting, or by percutaneous transluminal angioplasty or thrombolysis. In some cases, it may be necessary to amputate the limb or part of it. Despite the chronicity of PVD, little is known about the ways in which individuals with vascular disease cope with their condition and about the effect it has on their life. In this context the aims of this study were to explore the lived experience of peripheral vascular disease, in order to identify key themes and categories, using a phenomenological grounded theory approach. A sample of nine individuals was drawn from patients who had had vascular bypass surgery within the past 18 months. Data were collected using audiotaped one-to-one interviews and the researcher's field notes, and were validated with a group of experienced vascular nurses. Transcripts were analysed using open and axial coding techniques, and major and minor categories were identified and related to other data collected. It appeared that vascular patients experienced powerlessness in relation to the direct effects of their condition and in relation to its treatment modalities. The findings suggested that the 'acute' style of management of PVD often led to unrealistic expectations on the patient's part, which gave rise to the experience of powerlessness. The implications of these findings for the management of patients with PVD are discussed.

Consumerism and health care: the example of fertility treatment

This paper discusses the concepts of consumerism and the consumer of health care, and applies them to the example of fertility treatment, drawing on the health policy literature and data from a study of couples undergoing fertility treatment. It is argued that the concept of the consumer is a slippery one, that it provides only a partial view of being a patient, and that in particular it neglects emotional issues.

Evaluating interventions to promote patient involvement in decision-making: by what criteria should effectiveness be judged?

Interventions to inform patients about health care options and to involve them in decisions about their care are now widely advocated. The question of which criteria should be used to judge the effectiveness of such interventions has, however, received little attention. The provision of research-based information about health care effectiveness to patients and the promotion of greater patient involvement in health care decision-making are likely to have a complex range of effects on: the information provided to patients; patients' acquisition of skills; patients' knowledge and emotions; how decisions are made; the quality of decisions; professional-patient relationships; the use of health care; the health of patients; satisfaction; and the organisation and cost of health services. Opinions about which effects are most important and how they should be measured and valued will be influenced by a variety of factors, including: the rationales and motives underlying interest in patient involvement in decision-making; the forms of patient involvement envisaged; and the types of interventions being considered. In the context of health care systems which aim primarily to improve health status and well-being, health outcomes should take priority over process variables such as decision-making behaviours and patients' knowledge.

Staying in control: women's experiences of labour in water

AIM

To examine women's attempts at control during labour in water.

DESIGN

An exploratory design consisting of tape-recorded, in-depth interviews using the grounded theory approach.

SETTING

A medium sized town in the south of England. The data were collected in the maternity unit of a local general hospital set in a semi-rural location.

PARTICIPANTS

Nine women who had chosen to spend their labour process in water. The participants selected had experienced a normal pregnancy and given birth to a healthy baby at term.

FINDINGS

Labour in water was seen by all but one of the participants as beneficial, particularly as they felt that this gave them more control over the process. They valued their own involvement in determining the outcome of their care. The support of the midwife in making decisions was seen as necessary to remain in control.

CONCLUSIONS

Labour in water was a positive experience for this group of healthy women. The feeling of freedom to make decisions, however, was balanced with a wish for the support of the midwife.

Preconditions for and consequences of self-determination: the psychiatric patient's point of view

In the context of an interview study concerned with self-determination in psychiatric patients, this paper describes the preconditions for and consequences of self-determination from the point of view of psychiatric patients themselves. The data were collected in semi-structured interviews with long-term psychiatric patients (n = 72) and analysed using the method of content analysis. Responses on the preconditions for self-determination were grouped into three categories: firstly, there were those who said that reference to self-determination in the case of psychiatric patients is nonsense; secondly, there were those who said that self-determination requires no preconditions; and thirdly, there were those who said that there are certain preconditions, such as the ability to think and make decisions, activity, obedience, and illness. Both positive and negative consequences were identified in situations where self-determination is maintained, but only negative consequences in situations where self-determination is lost. On the basis of these tentative results, self-determination seemed to be relevant in psychiatric nursing. We are continuing to develop and test an instrument for the evaluation of the opportunity for self-determination in clinical practice.

Promoting autonomy and independence for older people within nursing practice: a literature review

The principles of promoting autonomy and independence underpin many approaches to improving the quality of nursing care for older people in whatever setting, and are in line with wider developments in health care such as the Patient's Charter. However, these concepts require careful definition if nursing practices which might promote autonomy and independence are to be identified. Although the generalizability of the research-based literature in this field is limited by a focus upon older people in continuing-care settings, a review of the literature found a number of indicators associated with attempts to promote patient autonomy and independence. These were grouped into the following categories: systems of care delivery which promote comprehensive individualized assessment and multidisciplinary care planning; attempts to encourage patients/clients to participate in decisions about their care; patterns of communication which avoid exerting power and control over patients/clients and attempts to modify the environment to promote independence and minimize risk. It is suggested that the review identifies a number of principles for nursing practice which can be applied in a range of care settings in order to promote the autonomy and independence of older people.

Building a relationship: communications and relationships between staff and stroke patients on a rehabilitation ward

Communications among staff and patients on a stroke rehabilitation ward form the focus of this article, which reports on some aspects of a larger study using a grounded theory approach. Tape-recorded interviews were transcribed and analysed concurrently according to recommendations for the approach. A main theme entitled building a relationship was identified, and this process was found to occur in a context varying from participative at one end of a continuum to hierarchical at the other. Building a relationship was found to be influenced by role, personal qualities and organizational context. Appropriate relationships between role-holders were subject to negotiation, leading to a resulting congruence or incongruence between participants' expectations of each other and their roles. Personal qualities were brought into play in the process, with patients' views of staff and staff views of patients both being influential. Some of these views seemed to parallel what has been described in earlier literature as 'the sick role' and the labelling of patients as 'good' or 'bad'. Responses to personal qualities led to nurses ascribing meaning to patients' behaviour in terms of adjustment to their stroke, giving time to them to help them to adjust, and withdrawal and handing over to other staff if this strategy failed. Organizational context also had an influence on building a relationship, with time constraints being identified particularly by nurses, and the need to fit in the most essential aspects of care. Place was also important, in that nurses were confined to the ward as a work location, whereas other therapists and doctors worked in other places and sometimes had the facility to take patients off the ward to concentrate on therapy. The findings are discussed against the background of related literature and the conclusion is drawn that the crucial role of nurses in rehabilitation is not recognized and valued, and that shortages of resources-especially suitably qualified and trained nursing staff-are a negative influence on building the relationships which are vital to successful rehabilitation.

Methodological issues in the evaluation of the quality of public health nursing: a case study of the maternal and child health centres in Hong Kong

The demand for the evaluation of the quality of patient and client care has increased in public health nursing as in all disciplines of nursing. In Hong Kong this demand led to the development of a collaborative study with the Department of Health to evaluate the quality of public health nursing in the maternal and child health centres. A multiple case study design was developed to undertake the research using both qualitative and quantitative methods of data collection. The findings from the study demonstrated not only implications for clinical practice which have been reported elsewhere, but also methodological issues for the evaluation of care. These findings indicate three major issues for consideration. The first issue is that of the cultural context of care which includes perceptions of care such as demands on the service and expectations of care. The second issue is the use of health data, including both the methods of recordings as well as the sources of data. The final issue is that of the method of data collection, in particular the implications of the use of language in data collection tools. The findings suggest that both the use of professional language and the need for translation have implications for data collection methods. Indeed in the author's view the development of methodologies for the evaluation of care must address culturally specific issues, particularly where English is not the first language of subjects in the study. In addition the use the use of language in the method of data collection highlights more general issues raised by the use of translation in the collection and analysis of qualitative data.

Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango)

Shared decision-making is increasingly advocated as an ideal model of treatment decision-making in the medical encounter. To date, the concept has been rather poorly and loosely defined. This paper attempts to provide greater conceptual clarity about shared treatment decision-making, identify some key characteristics of this model, and discuss measurement issues. The particular decision-making context that we focus on is potentially life threatening illnesses, where there are important decisions to be made at key points in the disease process, and several treatment options exist with different possible outcomes and substantial uncertainty. We suggest as key characteristics of shared decision-making (1) that at least two participants-physician and patient be involved; (2) that both parties share information; (3) that both parties take steps to build a consensus about the preferred treatment; and (4) that an agreement is reached on the treatment to implement. Some challenges to measuring shared decision-making are discussed as well as potential benefits of a shared decision-making model for both physicians and patients.

The practice of health education in acute care settings in Hong Kong: an exploratory study of the contribution of registered nurses

A multiple case study design was used to explore the practice of health education in acute care settings in Hong Kong. Two case studies, a medical ward and a surgical ward, were selected to reflect the real setting in which nurses carry out health education in acute care. Data collection methods involved the use of non-participant observation and semi-structured interviews. Seven nurses and eight patients were interviewed to explore their understanding of health education concepts, the use made in the wards of health education and the factors influencing such practice in the acute settings. Individual and cross-case analysis showed that respondents' understanding of the concept of health education was limited to patient information-giving. Although the importance of health education in acute patient care was acknowledged, the degree to which health education featured in nurses' practice was minimal. Many available opportunities for health education were missed and factors such as nurses' busy-ness and the associated lack of time and staff were identified as influencing health education practice in these acute care settings. Implications for practice and future studies were discussed in the light of these findings.

Is patient-controlled analgesia controlled by the patient?

Using patient-controlled analgesia (PCA) after surgery, a patient can obtain pain-relieving injections of morphine without the direct involvement of a nurse or doctor. The present study was a response to the conventional view that patients value PCA because of the control which it affords them over their own treatment. Twenty-six patients underwent semi-structured interviews postoperatively, shortly after discontinuation of PCA. Responses were examined qualitatively to identify recurring themes in patients' experience of PCA. Negative as well as positive evaluation was found. PCA was only rarely described as a way of gaining control over analgesia and, in general, this was not valued. Instead, PCA was valued as a way to avoid the difficulty of disclosing pain or securing pain relief within the usual nurse-patient relationship. In turn, PCA strained the nurse-patient relationship where it impeded either the patient's or the nurse's wish for the nurse to take responsibility for pain relief. The results showed that the professionally and theoretically constructed concept of PCA as a method of self-control over pain is inconsistent with patients' experience of it.

Nature of decision-making in the terminally ill patient

The increasing emphasis on the consumer's choice in health care treatment has contributed to the growing trend for decision-making to be shared between the patient and the health care team. If responsibility is to be shared, then it is important that health professionals identify the degree to which patients wish to participate in the decision-making process, in order that they can assist patients to achieve this goal. The seven patient case studies in this pilot study explored terminally ill patients' perceptions of their own participation in the decision-making process. A simple strategy, through the use of picture cards, established patients' actual and preferred forms of decision-making. These cards were presented to the patients at various stages of their illnesses, which permitted a longitudinal analysis of the decision-making process. Patients initially stated that they did not want much input into the decision-making process. In this study, however, as patients became more knowledgeable about their conditions, they desired greater input into the decision-making process. These findings also revealed that, although there was consistency between patients' preferred and actual forms of decision-making when they were initially admitted to hospital, discrepancies became apparent during the later phases of their illness. This emphasises the need for communication between all parties involved in health care decisions.

Elderly patients' participation in discharge decision making: 1

This article is the first of a two part series describing a study that explored patient participation in discharge decision making. The study involved two phases and focused on the participatory relationship between older patients and nurses. In phase one, the author conducted a group interview with primary nurses at two elderly care units specializing in rehabilitation. The second phase involved a series of interviews with five elderly patients during their hospital admission. The data from both phases of the study were analysed using the Ethnograph software package. This first article discusses the views of the nurses while the views of patients are addressed in the second article. Phase one of the study showed that the nurses interviewed had an elaborate understanding of participation. They tended to stress practical examples of participation rather than stating the reasons why it should be encouraged. Informants recognized the need to involve patients in decisions about their discharge from hospital. However, they viewed elderly patients as being both passive and reluctant to participate in decision making. Several reasons were given for this which were seen as resulting from patient rather than nursing behaviour. Part two of this article will appear in Vol 5(17): 26 September.

Individual vs collective activity: a primary nursing paradox

Primary nursing has been proclaimed as a way of providing nursing care that benefits both the patient and the nurse. This article supports this view; however, a pragmatic approach is taken to identify some of the paradoxes and contradictions that may be encountered. These include: conflicts of loyalty; planning psychological care; empowerment of patients; empowerment of nurses; and competition. By using examples from practice the issues surrounding these concepts are explored, examining the impact both on practice and on nursing as an occupation. Nurses must address these paradoxes if they are to prevent conflict and frustration. The future goal of fully implementing primary nursing will, however, provide great opportunity and potential for improving patient care.

Ethical and practical problems of early anti-cancer drug trials: a review of the literature

Early clinical trials for new anti-cancer drug treatments typically use patients with cancer as research subjects. This paper identifies some of the ethical and practical concerns that arise from the recruitment of a vulnerable group of patients and their exposure to a drug of unknown risk or benefit. This review discusses the ethical principles related to recruitment and informed consent in cancer trials, and indicates that there is a lack of consensus concerning the requirements, process and practice of informed consent. It is suggested that, as yet, little is known about patients' decision making framework in this situation, and the need for further work that concentrates on the patient's point of view is highlighted. The paper concludes by discussing some of the difficulties associated with obtaining patients' opinions, and suggests that the use of a qualitative approach may overcome some of these problems.

Children in intensive care: can nurse-parent partnership enable the child and family to cope more effectively?

The admission of a child to an intensive care unit (ICU) causes extreme distress and is likely to throw the family unit into turmoil (Hazinski 1992). The effects of hospitalisation on the child are well known (Rutter 1981), as are stressors which affect the parents' functional ability at a time of extreme stress (Rushton 1990). This paper examines the conflict caused for the whole family by a child's admission to ICU and how nurses can minimise these effects. In particular, it includes investigation of the use of a nurse-parent partnership which, it is argued, will enable the child and family to cope more effectively with the experience of intensive care admission.

Creating consensus about nursing outcomes. I. An exploration of focus group methodology

The aim of this study is to explore a method for achieving consensus about nursing outcomes between patients, nurses and health professionals. Focus group work as a research tool is described and reviewed. Problems of recruiting and facilitating such groups are highlighted. The relationship between focus groups and consensus is discussed. It is concluded that focus group work is not without problems, yet means of incorporating patient views into health services need to be developed.

Parent participation: a concept analysis

Parent participation has become a central tenet of paediatric nursing in the United Kingdom. The purpose of this paper is to explore the meaning of parent participation, to clarify the concept to benefit children and their families, and to increase understanding among practitioners. The concept analysis utilized was directed by Rodgers' "evolutionary approach' that views concept development as an ongoing dynamic process. A review of British literature and research studies indicated that parent participation is a complex and multi-dimensional concept. In the evolution of parent participation, the terminology changed from "parental involvement' to "partnership in care', to "care-by-parent' and finally to "family-centred care'. The analysis reveals a lack of coherence in the descriptions, with the terminology changing but the underlying theme remaining parent participation. Parent participation can be conceptualized as a composite of attributes that relate to the family, the nurse and their relationships. Those attributes include: negotiation, control, willingness, competence and autonomy. The concept of family-centred care is gradually assuming importance in the literature. This acknowledgement of the family is long overdue. However the concept remains poorly defined and urgent clarification is needed in this area. To adopt a family-centred care approach, a radical paradigm shift is required.

Self-care: the application of a ward philosophy

The purposes of this study were twofold. The first was to determine the rationale behind the adoption of a self-care approach to nursing. The second, to determine how a self-care philosophy is applied in practice. The study was carried out from a phenomenological perspective, as it facilitated an understanding of nursing practice from the practitioners' perspective. The adoption of a self-care philosophy and approach to caring, appears to have evolved through patients need. This finding has implications for all practitioners.

Staff perspectives on the role of the nurse in rehabilitation wards for elderly people

The increasing demand for cost-effective and efficient health care may create a demand for more demonstrably effective hospital-based rehabilitation services, with the explicit goal of enabling patients to return home after short admissions; thus rehabilitation is centre stage. This paper reports the findings from a study of the rehabilitation of elderly people in hospital; in particular it focuses on an aspect of the process of care: namely staff perceptions of rehabilitation work, with particular emphasis on the role of the nurse. A conversational style of interviewing was used with 56 staff respondents from two rehabilitation wards for elderly people. Findings suggest that therapists are often seen as experts, and nursing is viewed as separate from rehabilitation, and hence nurses are an under-utilized resource in this field. It is suggested that there is a need to examine further the reality of multidisciplinary teamwork in rehabilitation, particularly with respect to maximizing the potential contribution of nurses, with the end goal of improving patient outcomes.

Treatment decision making in women newly diagnosed with breast cancer

The purpose of this study was to explore the hypothesis that women with breast cancer had specific preferences about the degree of control they wanted over treatment decision making. One hundred fifty women, newly diagnosed with breast cancer, were interviewed and their preferences for participation in treatment decision making were established using a measurement tool designed to elicit decision-making preferences (Degner LF, Sloan JF. Decision making during serious illness: What role do patients really want to play? J Clin Epidemiol 1992;45:944-50). Two hundred women with benign breast disease served as a descriptive comparison group. Unfolding theory (Coombs CH. A theory of data. New York: John Wiley & Sons, 1964) provided a means of analyzing the data so that the degree of control preferred by each woman could be established. The majority of the newly diagnosed women preferred to play a passive role in treatment decision making, leaving the decision-making responsibility to their physician, whereas the benign control group preferred a collaborative role in which joint decisions could be made between the patient and the physician. The implications of the results for patient participation are discussed.

Parent participation. 2: Findings and their implications for practice

A qualitative exploratory study was undertaken to examine parents' views and experiences of participation in the care of their child in hospital and to identify factors that inhibit or facilitate participation. Parents of children aged 2-5 years of age were interviewed within 2 months of discharge, using tape-recorded, semi-structured interviews. The findings demonstrate that parents clearly wish to participate in their children's care at a level of their own choosing. However, they preferred professionals to be responsible for their children's clinical care, while they continue to be responsible for the children's normal day-to-day care. Problems were identified in the area of relationships between parents and professionals, centred on communication and the continuing paternalistic nature of these relationships. Parents of children who experienced single, short hospital admissions found involvement in their children's care particularly difficult. Guidelines were developed from the results, to facilitate parent participation in the care of children in this age group.

Self-management of chronic illness: implications for nursing

Health problems and disease have changed during the last century with an increase in the numbers of people with chronic illness. Literature reveals the role of patients changing from passive to active participation in care management. A study of factors influencing self-management using both quantitative and qualitative methods was carried out. Selected results, with the major focus on the qualitative data, are presented to support discussion of a number of issues related to self-management of diabetes. However, many of the implications of the results also apply to those with chronic illness.

Preoperative visiting from the perspective of the theatre nurse

Many issues surround the concept of preoperative visiting. This article explores these issues in the light of recent research findings which question the benefits of using 'psychological' techniques to reduce preoperative anxiety, and examines the strategies in current use.

Partnership in care: parents' views of participation in their hospitalized child's care

This paper describes parents' experiences of participation in their hospitalized child's care on a general surgical paediatric ward. The findings indicate that parents chose to participate because of concern for the child's emotional welfare. Influencing factors included sense of parental duty, past experiences with hospitals, and concern for consistency of care. Parents' readiness to care was encouraged by a supportive family network, support from other parents, familiarity and experience with care. Parents were willing to adapt their parenting skills in order to be able to care for their child at home and were willing to perform more care provided it did not cause pain for the child, had the nurses' approval and increased their confidence and competence as carers. Lack of information, non-negotiation of roles, inadequate facilities, feelings of anxiety and loneliness were the difficulties parents experienced.

Patient autonomy and the politics of professional relationships

Debate in the health care professions about the politics of interpersonal relationships between professionals and their patients or clients is increasingly organized around proxy measures of the quality of professional services such as patient satisfaction, or the extent to which the provision of care avoids routines and is genuinely individualized. This paper explores some of the problems which arise from this in relation to patients' autonomy and nurses' authority.

Service quality in hospital care: the development of an in-patient questionnaire

Describes the development of a multi-item scale for assessing in-patient perceptions of service quality in an NHS or NHS Trust hospital. Presents evidence of the high reliability of the scale and its factor structure. Five intangible factors emerge: empathy, relationship of mutual respect, dignity, understanding of illness and religious needs, along with two tangible factors: food and physical environment. Results in a trial hospital indicate that patients' perceptions meet or exceed expectations in respect of four of the seven factors and 22 of the 49 individual variables. Of concern, however, while possibly not generalizable, must be the unfulfilled expectations in respect of the factors "relationship of mutual respect" and "understanding of illness" and the individual variables relating to the various communications between doctors and patients. Not unexpectedly, dissatisfaction is also expressed with the physical environment. Argues that the situation can only be remedied, usually, by a large injection of cash--an unlikely scenario.

Assessing mental competence of patients and relatives

This paper presents a discussion on the assessment of mental competence of patients and relatives in the health care setting. Their decision-making ability is explored with particular reference to the giving of consent for nursing intervention and medical treatment. It is suggested that, in addition to obvious psychological or neurological disorders, decision-making ability will be influenced by psychological stress and the ability to communicate effectively. It highlights the ambiguity of mental competence assessment and concludes that such assessments will, to a greater or lesser extent, be subject to value-laden judgement.