Findings with integrated commentary derived from the category of ‘Experience’ follow; specifically, the key properties of: ‘Being a good patient, being a good nurse’, ‘Institutional experiences’ and ‘Expectations about healthcare’. The participants’ own terms are used throughout and quotes reflect similarities and differences in their views. Consistent with writing grounded theory, literature is integrated throughout.
Being a good patient, being a good nurse
Being a ‘good’ patient or nurse emerged from data around performance in healthcare. Whilst participants were reflective about role, they recognised the impact of change and brought that recognition to the role they adopted. They also brought those reflections to the prospect of current relationship development and balance within that relationship.
Participants themselves used the terms ‘good patient’ or ‘good nurse’ and had varying views about what that might mean in healthcare today.
Based on their past experience, two patients considered ‘complying’ with care as an important part of managing their social identity as a ‘good’ patient. They described that in interaction patients and nurses played roles, each facilitating the other in achieving an acceptable balance of compliance and control respectively:
"Patient (P) 9: You don’t ask them … they tell you what’s best. You’re in their hands… I’ve no doubt they discuss you and sort it out between them [practice nurse and GP] it’s important to be a good patient for them."
As counterpoint to this, nurse participants expected the patient to be involved in their care to some extent. The involvement nurses expected from patients ranged from asking questions and seeking information, to engagement in decision-making. The role of patient was an expression of belief systems related to experience of interaction learned in the past, and expressed in the present:
"P4: I was brought up to follow what they told you. You just let them get on with it … they were the experts and of course you wouldn’t dream of saying anything unless you were asked…"
Viewing a patient as participatory means that they take responsibility for their own health and wellbeing whilst living their everyday lives within and out with the context of interaction in the health centre. However, a central question arises: how much do individuals as patients delegate their everyday responsibility and how much do nurses assume it in patient-nurse interaction?
The patient has ‘work to do’ in terms of taking responsibility for their illness, and health professionals may conceptualise this responsibility as acting appropriately
]. Acting appropriately relates to who will do what in respect of patient participation in their own care.
Nurse participants acknowledged understandings from an earlier period in time about how to be a ‘good’ patient held by some older people. Those understandings underpinned the extent to which older patients may or may not participate in their own care. Nurses identified that patients continuing in that mode of understanding created an imbalance of expectations in the patient-nurse relationship. Nurses felt that the impact of such imbalance was in terms of reduced communication and collaboration in patient nurse interaction. In addition for some older patients, contemporary definitions of participation in healthcare have not permeated fully and thus are not fully realised.
It was evident that the adoption of a less active role as a patient continued to be embraced by ten patients and six nurses. Some patients preferred a less active role in their care, which was accepted to a lesser extent by nurses:
"Nurse (N) 16: I know how things have changed. The older generations were brought up to respect authority and do as they were asked with few questions. Some patients are still like that today… despite best efforts"
"N2: It’s quite frustrating really because on one hand you want them to do well, but you do want them to be involved at the same time… you can be too good…"
The feeling of agreement of ten patient participants was ‘leave it to the experts’ the patient should have the option of avoiding involvement in their care in relation to decision-making. ‘Leaving it to the expert’ should be perceived as an alternative mode of action. Nurse participants thought that if a patient is not a ‘good’ one within the parameters of their professional beliefs, the prospect of developing a therapeutic relationship would be affected. Important to resolving this potential conflict is establishing what kind of helping/caring relationship patients and nurses value.
The feeling of agreement that the patient should be active to some extent in interaction with the nurse was mostly expressed by patients who were younger or by those who had had sustained contact with community health services over the years:
"P7: I suppose the whole way of it has changed when you think back over the years… it just happens as time passes. I don’t think you’re aware of it at the time… it’s like everything else… washing machines and colour telly and computers"
Nurse participants also mentioned their experiences of change in a range of ways, including references to the professional and, to a lesser extent, personal:
"N2: I can remember when I first started [nursing] there were so many illnesses they could do nothing about… they didn’t understand them. Think about all those operations for stomach ulcers! We used to keep people in bed for days and convalescence was such a drawn out process. Nursing was such a slog."
"N11: I remember going into hospital when I was child and my parents weren’t even allowed to stay with me. Hospitals were formal places with strict rules and doctors were gods. When I qualified the approach was very much a pathological one… and nursing used a bio-medical approach."
Two older nurses provided these examples and their reflections characterised considerable changes in healthcare and nursing in the United Kingdom in the last thirty years. Various references were made to changes in nursing itself. These comments related to the professional careers of nurse participants in terms of changing roles and emerging opportunities. N11 and N2 discussed how these issues had been influential in their approach to nursing and patient care and provided different perspectives, principally about how the patient had been regarded:
"N11: I think it has mattered a great deal to me how things have changed. It is important that things have moved on. There is much better understanding of who the patient is rather than just what’s up with them… and only looking at problems."
"N2: When people talk about the good old days they forget just how bad things could be… things like not knowing what was going on or being asked… you certainly were not a client… and as a nurse, the same was true half the time."
Despite the assertions by these nurse participants that things have changed in a range of ways, it could be that they were promoting the ideals or ‘received wisdom’ about contemporary practice and policy, rather than accurately describing the impacts of role change in healthcare in particular what might constitute a good patient or a good nurse.
In terms of today’s emphasis upon involvement, the issue of who defines roles in healthcare interaction is at the heart of how the reality of being a patient or nurse is constructed.
Consistent with grounded theory methodology, unexpected findings emerge. In this instance, meanings and understandings drawn on from beyond NHS settings were found to be important to some patient participants and influential in their performance in healthcare settings. It may be the case that patients, who have felt relatively powerless in other institutions by being unable to exert any control over process, may bring those ‘apprehended’ behaviours to their performance in healthcare [48; 50; 51]. That may mean that their belief in engaging in involvement is reduced. That may mean they are perceived as less interactive by nurses. Four patient participants in particular were observed to await instruction from the nurse; they did not assume it was their turn rather waited until the nurse formally invited them to follow and to then to be seated and, continued to respond to instructions without initiating action themselves for example, rolling a sleeve up.
The four patients referred specifically to experiences they had had in other institutions including the Department of Social Security (DSS) and Social Work Department (SWD).
These specific references were made during interviews and emerged around the issue of knowing what to do as modus operandi when meeting the nurse and in need-care interaction. The patients described the rituals they felt obliged to follow if they were to achieve the purpose of their visit to either DSS or SWD:
"P11: It’s like take a number … like at the counter in Tesco … wait your turn, go where you’re telt [told] … dae what you’re telt … an away."
"P13: You have to just go through the hoops or you’ll get nowhere…they’ve got a way of working … you fit in … get the business done, that’s it"
Participants believed that certain behaviours were appropriate in similar settings, including DSS and the Health Centre. Whilst they identified that systems related to basic organisation were essential, for example to avoid queue jumping, they felt a sense of resignation about going through pre-determined hoops in that what you did and how you did it was not open to negotiation. The participants expressed difficulties with this in a range of ways. In particular, whilst they disliked ‘being a number’ and having to ‘go along with it’, they were resigned to it as appropriate behaviour to adopt to achieve their purpose. Four participants identified that it is reasonable to be asked to ‘sit down there’ or ‘go there’, especially if you were a novice in such a place as the DSS. However, the key issue seemed to be that you would probably be left to pick up clues from others and copy what others did:
"P17: I didn’t have a clue what to do… couldn’t really make head nor tail of it. Eventually I could see some were waiting to have forms checked, some were being called… eventually I worked out that folk at one side were waiting to make inquiries like me… so I moved and sat at the end…"
P17 describes clearly the process of working out what to do in an unfamiliar setting as did others. In order to navigate their way through the unfamiliar, they drew on wider experiences, a process that served them only to a limited extent. The key issue that perplexed them was the lack of signposts that they expected to be there by custom and practice. These signposts were not only the physical, for example, lack of inquiry signs, but also lack of opportunity to interact face to face. The participants noted that there often seemed to be a lack of social engagement with fellow clients and staff in DSS and/or SWD. In effect, the lack of information and supportive actions for example, effective signposts or human communication, hindered individuals’ opportunities to problem solve. The alternative and available action was to be passive and compliant in a process over which they felt they had little control because clues to aid modus operandi were largely concealed. The understandings generated contributed to participants’ beliefs about their competence in institutional settings and the control that could be exerted in settings that they identified as similar, such as the health centre.
Beliefs about parameters of control were related to the individual’s experiences and beliefs about how to navigate in an institutional setting. These beliefs were influenced by interpretations of how to behave conventionally, ‘going through the hoops’
as the participant put it. Berger and Luckmann
] propose that individuals navigate in the social world by identifying and typifying recognisable patterns of activity. By this process, individuals can predict how their activities will be evaluated and reacted to by others. Berger and Luckmann argue that: ‘The social reality of everyday life is thus apprehended in a continuum of typifications, which are progressively anonymous as they are removed from the ‘here and now’, of the ‘face-to-face situation’. Although the health centre environment was identified as more facilitative than other contexts in terms of interaction, how individuals have ‘apprehended’ interaction in other contexts may be transferred and contribute to the complexity of performance in patient-nurse interaction as exemplified by P13:
"P13: These places have their way of working … the same way more or less… you just settle yourself down to it and let them get on with it. Aye, best way"
The experiences identified by patient participants who had had considerable experience in other institutions (DSS and SWD) support this argument.
Patient participants described that at times their sense of self was undermined. One patient participant used the term ‘diminished’ in relation to being a number [P11] ‘like at the counter in Tesco’.
The sense of being undermined or diminished was particularly true of those who described the encounters significant to them out with the health centre. The significance of these encounters was both the link between the reason for the visit, for example seeking welfare/benefits, and the effect the adherent navigation processes had on them. The demands and challenges of organisational structures and processes compromised their sense of self-determination, including in interaction in healthcare and thus for patient-nurse relationship development.
Expectations about healthcare
Participants’ expectations related to healthcare were sometimes those of uncertainty and they brought that to their performance in situated interaction. They connected their experiences in healthcare in the past to experiences in the present day as an interdependency linked to their performance. In doing so they referred to changes in healthcare, nursing and the roles of patients and nurses.
The inclusion of psychosocial aspects in assessment was the prevalent feature included by nurses in their conceptualisation of delivering nursing care. Their conceptualisation related well to patients’ identification of nursing as being more than giving physical care. Whilst four nurse participants expanded on issues of development and change, as shown in previous examples, the points they raised were also identified to some extent by the other nurses.
These views suggest that the approach to caring by nurses may be different from that expected by patients. Those patients are likely to be older and familiar with traditional bio-medical models of care.
In the terms of the nurses cited whose approach to care went beyond bio-medical matters, a tension between their approach and patients’ understanding of nursing and healthcare emerges:
"P11: I haven’t seen the doctor for years… I didn’t even realise they had practice nurses… took me a while to understand what her drift was [role and approach]. I suppose I thought the doc would give me some tablets and keep an eye on it [hypertension] … but she [the nurse] asks me all sorts about lifestyle and all that. She does more than just check it like I thought she would… she takes her time… very good"
In need-care interactions, nurses’ interpretation of nursing ‘the whole person’ commonly prevailed over patients with expectations of a bio-medical approach to caring. The accomplishment of nurse participants seemed to be to win patients over to their approach to caring, rather than it being explained and agreement established. In other words, patients generally ‘caught the drift’ through co-operating in patient-nurse interactions as P11 did. Importantly, ‘really’ being listened to was identified as critical in the consultation process as eight patient identified explicitly:
"P4: She’s a genuine lassie… puts up with my stories and moans and groans… she doesn’t make me feel like a silly old fool"
"P8: We work things out… even if it’s a daft thing. I like the way they remember you… and relax you really"
As in these examples, it was important to patients to feel that they could express themselves without pressure and in comfort, and nurses welcomed that. Interestingly, the two patients just cited [P4 and P8] identified that it is important that, in addition to listening, nurses also accepted that patients needed to tell their story without feeling ‘silly’ or ‘daft’. In terms of confidence and trust, this related to patients’ concerns about preservation of integrity and the importance placed upon behaving appropriately and being accepted:
"N9: above all, patients just need to feel that they can just talk; it’s about them … how things get sorted out, wee things and feelings get picked up"
The motivator to overcoming any uncertainly was the development through interaction of the patient-nurse relationship (which was valued highly where it existed). Nurse participants recognised that a patient’s emphasis upon the ‘expert’ ‘knowing best’ created an imbalance in their relationship.
Participants revealed how they created and sustained meanings and understandings of healthcare and nursing by talking about their changing expectations and beliefs and relating them to the present day. Meanings emerge in local contexts and situations through interaction with others, and wider historical understandings are drawn upon to do so
]. The emergence of meanings is an achievement in everyday life in which meanings are created and sustained in performance in interaction
For the participants, creating and sustaining meanings and understandings emerged in, and of, interaction as it took place. In the process of creating meaning within interaction, patients and nurses draw upon the past to perform in the present – an evolutionary process in which the past articulates with the present.
In this process, some past meanings are sustained and new meanings are created about how to perform in interaction. Their expectations and beliefs have or are changing as a consequence of their contemporary experiences:
"P9: It’s daft when you think about it… only going to the health centre when you’re ill… it’s no called the illness centre. Years ago health didn’t come into it much at all… as they say; the future of the community depends on health. At least now, things are more open… like mental health. Nurses have much more to do now… they’re trained for it … they work alongside other people like the doctor rather than separate."
Comments such as these represented a largely positive view of changes in community healthcare, and identify what were seen as positive aspects of the evolving role of the nurse and transformation in healthcare:
"N12: I know that some people attending the health centre are quite baffled by who does what now until they get used to it. A lot of that relates to the extended roles we [nurses] have, and the specialist roles that are designed to meet patient’ needs … although I don’t think they always realise that. I suppose it has become very different over the last few years"
Patients have a range of views regarding expertise in the health centre, including confusion about what expertise is and with whom it lies.
These views were explicitly echoed by five patient participants whilst others were won over by the competence of practice nurses:
"P6: I wasn’t sure at first… I was used to the doctor monitoring me. But I got used to the nurse and she knows how to adjust things and we sort them out [blood glucose levels]"
"P13: It’s just that you’re used to something else… the lady doctor always sent for you and checked you over and did the [cervical] smear. The nurse does it now and it’s just the same… no bother. She checks the rest of you out as well so it’s time well spent on yourself eh!"
Some patients stated that they would rather see a doctor in circumstances where a medical condition was subject to regular review, for example, diabetes mellitus:
"P2: I just have more confidence … I prefer medical advice and expertise"
"P7: I don’t doubt her proficiency in lots of ways… I’m used to dealing with the doctor … I just believe the doctor is the best person in my circumstances"
Views such as these do not necessarily express an adherence by patients to a reductionist bio-medical approach, or to hierarchical notions that the services of the doctor are superior to those of nurses. Rather, these views may represent a sense of security generated by familiarity with the doctor as provider of care. In these terms, transformations in health care may result in a sense of insecurity related to expertise for some
Nurse participants did not include the same meanings identified by patient participants in their accounts; however, they did include reference to changes in nursing including their professional contribution:
"N11: before you were the nurse that worked along with the GPs in your district. The patients were his and you assisted with skills with patients with lots of different needs… I would say it was more about tasks though, not nursing skills as we know it today."
"N9: Nowadays we have our own caseloads and take responsibility for managing the patients… it’s a turnaround in the way we practice as nurses working as specialists with our multi-disciplinary colleagues and we do bring lots of experience and training to it [the role]"
The nurses’ layers of experience had accrued over time and were expressed in the style of their professional practice and interaction. Those layers included the encounters and experiences they had had in diverse healthcare settings, especially in acute hospitals.
Changing working practices related to interaction include the idea that a ‘blurring’ process occurs as roles evolve
]. The blurring process is in terms of who does what in a division of ‘caring’ labour as the role and expertise of the nurse extends. The blurring of roles has implications for the patient in terms of understanding interaction with individuals with a range of professional expertise in the health centre.
Roles and professional identities have been redefined in the community practice setting with a movement towards person centred care
]. Expertise has been redistributed with the ‘up skilling’ of nurses leading to more complex patient cases being seen by the GP as s/he determines. GPs and some nurses are higher up the complexity hierarchy which is bio-medically focused. In this way a ‘hierarchy of appropriateness’ emerges for the patient
]. Redistribution of roles and expertise contradicts person centredness in that presenting with a biomedical issue becomes the determining factor as to whether you see a doctor or a nurse as a patient in the health centre
]. For some patients this may mean they may not be able to consult with the healthcare professional of their choice and/or preference. From interviews with patients, it is evident that these arrangements for managing care delivery have not been driven fully by them. Also, it is evident that these arrangements may not be apparent to or easily understood by patients.