Patient participation in nurse-patient interactions about medication
The dominant political ideology emphasises the patient as a consumer and partner in health care. Correspondingly, the move towards patient-centred nursing, based on the principles of humanism and individualism, emphasise the central role patients' should play in the nurse-patient encounter. Additionally, changing social and demographic trends highlight the importance of medication as a health care issue. Thus, current health care policy and practice contexts highlight the importance of patients' participation in health care as consumers and partners and, nurses' ability to make an effective contribution to educating patients about medication as part of their role in health education and promotion. However, despite the significance of this context, little is known about the extent and manner of patient participation, or the contribution that nurses make to this important health promotion activity. Therefore the purpose of this study is to extend knowledge in this area by describing and explaining patient participation in medication interactions, as it occurs within the reality of the clinical context. In order to study patient participation in medication interactions in the reality of the clinical context, a case study approach was adopted. Three case sites were sampled and included: 1) an acute medical ward, 2) a community hospital rehabilitation unit, and 3) a community mental health service. Data collection methods employed to explore and describe patient participation in medication interactions included: non-participant observation, audio-recording of nurse-patient interactions, nurse interviews, patient interviews, reflective field notes, focus groups and documentation. The data analysis framework included the use of conversation analysis for nurse-patient interaction data and content analysis for other qualitative data. The findings indicate that patient participation can be understood at least in part by the communicative practices and choices that nurse and patients/clients make. More specifically a range of conversational strategies were employed by nurses to initiate and control conversations and by doing so inhibited patients' participation. However a comparison of findings across sites indicates that there were both differences and similarities in the extent to which nurses facilitated and inhibited patient participation. A number of influencing factors were identified that helped to explain these findings. These include: power, nurses' communicative style, knowledge, skills and experience, patients' age, acuity of illness and level of knowledge, and the organisation and philosophy of care. The findings from the study make a unique contribution to the body of knowledge in a number of ways. First, as the only study to describe patient participation in medication interactions between nurses and patients, it identifies that participation can occur at an interactional level, as well as a more practical level via, for example, the potential to self medicate and independently manage medications. Related to this, it has also contributed to the conceptual clarity and development of the concept of patient participation. This study has highlighted that patient participation may be realised and understood more fundamentally, at the level of the nurse-patient interaction, in contrast to previous research that conceptualises participation as making choices and involvement in decisionmaking. Furthermore, by the successful use of conversation analysis, this study has also advanced knowledge about potential ways to investigate patient participation at the level of nurse-patient discourse. Finally, this study provides a contribution to advancing theoretical explanations of patient participation through the construction of a framework of explanatory factors influencing patient participation. A framework for enabling participation has been developed based on the specific conclusions and principles for action drawn from the findings and from the philosophy of Freire (1972; 1983), which acknowledges an individual's potential to be empowered and assume control. The framework proposes that addressing attitudinal, interactional, relational, educational and contextual issues, might facilitate patient participation. Implications and recommendations reflect the practice and education requirements needed to implement such a framework.