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Creating and establishing a positive care relationship between nurses, patients and relatives: An ethnographic study of encounters at a department of medicine for older people
Jönköping University, School of Health and Welfare, HHJ. ADULT.
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background and aim: Numerous encounters take place in the healthcare sector every day. Although the encounters should be conducted in a safe and respectful manner, an increased number of complaints about communication and interaction have been reported to the Health and Social Care Inspectorate. When a nurse, patient and relative meet in a so-called triad encounter, the focus is on creating and establishing a care relationship with the facilitated by communication and interaction. Thus, if communication and interaction fail in these encounters there is a risk that the care relationship will be bad and the patient's needs not fulfilled, which can lead to poorly prepared patients with difficulties participating in their own care. The overall aim of this thesis was to explore and describe the care relationship, communication, content and social interaction in the triad encounter between nurses, patients and relatives at a department of medicine for older people.

Methods: The four studies were designed using a qualitative, ethnographic approach guided by Vygotsky’s sociocultural and Goffman’s interactional perspective. Participatory observations (n=40) and informal field conversations (n=120) with patients, relatives and nurses were carried out (October 2015-September 2016) at the same time as field notes were written. Studies I, II and III were underpinned by an ethnographic analysis, while in study in IV, a thematic analysis with an abductive approach was conducted.

Results: The result of study I, identified a process where patients, relatives and nurses used different strategies for navigating before, during and after a triad encounter. The process was based on the following categories: orienting in time and space, contributing to a care relationship and forming a new point of view. Study II, showed how nurses communicated, using four different voices which reinforced by body language, which formed patterns that constituted approaches that changed depending on the situation and orientation: a medical voice, a nursing voice, a pedagogical voice and a power voice. Study III, emphasized three categories of content of the communication exchanges: medical content focusing on the patient’s medical condition; personal content focusing on the patient’s life story; and explanatory content characterized by nurses attempting to increase the patient’s and relative’s knowledge about the patient’s health and nursing needs. Study IV showed that, to create social interaction, the nurses employed greetings, small talk and bodily expressions. Patients accepted the invitation with body language, while relatives employed various strategies to receive an invitation. Nurses led the conversation, patients followed and described their health problem through gestures, while relatives captured the moment to receive and give information. Nurses summarized using ritual language, patients expressed gratitude’s through verbal and non-verbal expressions and relatives verbally clarified the agreements. The synthesis of the four results showed a model with the four activities as puzzle pieces: navigating through different perspectives, being involved in the communication, being attentive to social interaction and explaining the relevant content. When the institutional environment is such that the asymmetry between the nurse, patient and relative is limited, and the norms and routines promote communication between them, it is more likely that the puzzle pieces fit together and an opportunity arises to create and establish a positive care relationship in the triad encounters.

Conclusion: The nurses' role as a professional is crucial, as they start, lead and end the encounter. If nurses minimize the asymmetry and combine the medical, personal and pedagogical questions, an opportunity arises for creating and establishing a positive care relationship that enables the patients to become more active and relatives more visible. This can contribute to strengthening the patient’s position in the healthcare system and increasing patient safety.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2020. , p. 94
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 103
Keywords [en]
Care relationship, communication, ethnographic approach, nurses, interactional perspective, older patients, relatives, social interaction, sociocultural perspective, triad encounter
National Category
Nursing
Identifiers
URN: urn:nbn:se:hj:diva-48136ISBN: 978-91-88669-02-5 (print)OAI: oai:DiVA.org:hj-48136DiVA, id: diva2:1423792
Public defence
2020-05-29, Albert aula F105, University West, Trollhättan, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2020-04-15 Created: 2020-04-15 Last updated: 2020-04-15Bibliographically approved
List of papers
1. Striving to establish a care relationship—Mission possible or impossible?—Triad encounters between patients, relatives and nurses
Open this publication in new window or tab >>Striving to establish a care relationship—Mission possible or impossible?—Triad encounters between patients, relatives and nurses
2019 (English)In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 22, no 6, p. 1304-1313Article in journal (Refereed) Published
Abstract [en]

Background

When patients, relatives and nurses meet, they form a triad that can ensure a good care relationship. However, hospital environments are often stressful and limited time can negatively affect the care relationship, thus decreasing patient satisfaction.

Objective

To explain the care relationship in triad encounters between patients, relatives and nurses at a department of medicine for older people.

Design

A qualitative explorative study with an ethnographic approach guided by a sociocultural perspective.

Method

Participatory observations and informal field conversations with patients, relatives and nurses were carried out from October 2015-September 2016 and analysed together with field notes using ethnographic analysis.

Result

The result identifies a process where patients, relatives and nurses use different strategies for navigating before, during and after a triad encounter. The process is based on the following categories: orienting in time and space, contributing to a care relationship and forming a new point of view.

Conclusion

The result indicates that nurses, who are aware of the process and understand how to navigate between the different perspectives in triad encounters, can acknowledge both the patient's and relatives? stories, thus facilitating their ability to understand the information provided, ensure a quality care relationship and strengthen the patient's position in the health-care setting, therefore making the mission to establish a care relationship possible.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
Keywords
care relationship, ethnography, nurses, older patient, relative, triad encounter
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-46490 (URN)10.1111/hex.12971 (DOI)000503237700013 ()31588667 (PubMedID)2-s2.0-85073923765 (Scopus ID)GOA HHJ 2019 (Local ID)GOA HHJ 2019 (Archive number)GOA HHJ 2019 (OAI)
Available from: 2019-10-07 Created: 2019-10-07 Last updated: 2020-04-15Bibliographically approved
2. Voices used by nurses when communicating with patients and relatives in a department of medicine for older people - An ethnographic study.
Open this publication in new window or tab >>Voices used by nurses when communicating with patients and relatives in a department of medicine for older people - An ethnographic study.
2018 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 27, no 7-8, p. e1640-e1650Article in journal (Refereed) Published
Abstract [en]

AIMS AND OBJECTIVES: To describe how nurses communicate with older patients and their relatives in a department of medicine for older people in western Sweden.

BACKGROUND: Communication is an essential tool for nurses when working with older patients and their relatives, but often patients and relatives experience shortcomings in the communication exchanges. They may not receive information or are not treated in a professional way. Good communication can facilitate the development of a positive meeting and improve the patient's health outcome.

DESIGN: An ethnographic design informed by the sociocultural perspective was applied.

METHODS: Forty participatory observations were conducted and analysed during the period October 2015-September 2016. The observations covered 135 hours of nurse-patient-relative interaction. Field notes were taken, and 40 informal field conversations with nurses and 40 with patients and relatives were carried out. Semistructured follow-up interviews were conducted with five nurses.

RESULTS: In the result, it was found that nurses communicate with four different voices: a medical voice described as being incomplete, task-oriented and with a disease perspective; a nursing voice described as being confirmatory, process-oriented and with a holistic perspective; a pedagogical voice described as being contextualised, comprehension-oriented and with a learning perspective; and a power voice described as being distancing and excluding. The voices can be seen as context-dependent communication approaches. When nurses switch between the voices, this indicates a shift in the orientation or situation.

CONCLUSION: The results indicate that if nurses successfully combine the voices, while limiting the use of the power voice, the communication exchanges can become a more positive experience for all parties involved and a good nurse-patient-relative communication exchange can be achieved.

RELEVANCE TO CLINICAL PRACTICE: Working for improved communication between nurses, patients and relatives is crucial for establishing a positive nurse-patient-relative relationship, which is a basis for improving patient care and healthcare outcomes.

Place, publisher, year, edition, pages
John Wiley & Sons, 2018
Keywords
communication, ethnography, nurses’ voices, older patient, relative, sociocultural perspective
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-39542 (URN)10.1111/jocn.14316 (DOI)000430825100036 ()29493834 (PubMedID)2-s2.0-85045891204 (Scopus ID)
Available from: 2018-05-28 Created: 2018-05-28 Last updated: 2020-04-15Bibliographically approved
3. What are they talking about? Content of the communication exchanges between nurses, patients and relatives in a department of medicine for older people - An ethnographic study.
Open this publication in new window or tab >>What are they talking about? Content of the communication exchanges between nurses, patients and relatives in a department of medicine for older people - An ethnographic study.
2018 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 27, no 7-8, p. e1651-e1659Article in journal (Refereed) Published
Abstract [en]

AIMS AND OBJECTIVES: To explore and describe the content of the communication exchanges between nurses, patients and their relatives in a department of medicine for older people in western Sweden.

BACKGROUND: Information, messages and knowledge are constantly being communicated between nurses, older patients and relatives in the healthcare sector. The quality of communication between them has a major influence on patient outcomes. A prerequisite for good care to be given and received is that there is mutual understanding between the parties involved.

DESIGN: An ethnographic study was informed by a sociocultural perspective.

METHOD: Data were collected through 40 participatory observations of meetings between nurses and older patients and/or relatives which covered 135 hr of nurse-patient-relative interaction, field notes, 40 field conversations with 24 nurses and 40 field conversations with patients (n = 40) and relatives (n = 26). Five semi-structured interviews were conducted with nurses. An ethnographic analysis was performed.

RESULTS: The analysis identified three categories of content of the communication exchanges: medical content focusing on the patient's medical condition, personal content focusing on the patient's life story and explanatory content focusing on the patient's health and nursing needs. The content is influenced by the situation and context.

CONCLUSIONS: Nurses would benefit from more awareness and understanding of the importance of the communication content and of the value of asking the didactic questions (how, when, what and why) to improve the patients' and relatives' understanding of the information exchanges and to increase patient safety.

RELEVANCE TO CLINICAL PRACTICE: Nurses can use the communication content to create conditions enabling them to obtain a holistic view of the patient's life history and to develop an appropriate person-centred care plan.

Place, publisher, year, edition, pages
John Wiley & Sons, 2018
Keywords
communication content, ethnography, nurses, older patient, person-centred care, relative, sociocultural perspective
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-39434 (URN)10.1111/jocn.14315 (DOI)000430825100037 ()29493840 (PubMedID)2-s2.0-85045879016 (Scopus ID)
Available from: 2018-05-28 Created: 2018-05-28 Last updated: 2020-04-15Bibliographically approved
4. What is going on? Social interaction between nurses, older patients and their relatives
Open this publication in new window or tab >>What is going on? Social interaction between nurses, older patients and their relatives
(English)Manuscript (preprint) (Other academic)
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-48135 (URN)
Note

Submitted to journal.

Available from: 2020-04-15 Created: 2020-04-15 Last updated: 2020-04-15Bibliographically approved

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