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Patients and nurses negotiated home care interactions within 6 interpersonal contexts
  1. Chantal D Caron, RN, PhD
  1. Assistant Professor, Department of Nursing
 Université de Sherbrooke
 Researcher, Research Centre on Aging
 Sherbrooke, Québec, Canada
    • nurse-patient relations
    • negotiating
    • home care services
    • community health nursing

    
 
 QUESTIONS: In home care nurse-patient interactions, what are the interpersonal contexts and social acts through which negotiation occurs? What are the outcomes of unsuccessful and successful negotiation?

    Design

    Qualitative ethology for video based research.

    Setting

    A large metropolitan home healthcare agency in the western US.

    Participants

    10 nurse-patient dyads (3 home care nurses and 8 patients; 2 patients were each paired with 2 nurses). Patients were 25–86 years of age and required home care for acute and chronic conditions. Exclusion criterion was inability to communicate verbally because of cognitive or physical impairment. {The 3 home care nurses, who were case managers and had ≥6 years of home care experience, were peer nominated as expert practitioners.}*

    Methods

    31 routine home care visits were videotaped (19 hours of videotape). Nurses and patients participated in separate semistructured interviews before and after the videotaped sessions. The unit of analysis was the communication strategy (verbal or non-verbal action). Data analysis was cyclical, recursive, and verified with colleagues and a conversational analyst.

    Main findings

    Caregiving activities occurred in a complex environment of interpersonal considerations. 6 interpersonal contexts characterised the goals that patients and nurses worked towards by negotiating their needs and expectations. (1) Negotiating territoriality referred to negotiation of shared space in the patient’s home to facilitate caregiving. (2) Negotiating shared perceptions of the situation aimed at creating consensus in perceptions of a patient’s wellbeing and progress. (3) Establishing an amicable working relationship involved the development of a friendly collaboration, whereby both nurses and patients recognised the individuality of the other beyond immediate caregiving activities. This occurred by volunteering information, sharing stories, and keeping track of events in each other’s lives. (4) In synchronising role expectations, nurses and patients recognised each other’s particular expertise. Role boundaries were negotiated, which determined relative autonomy, collaboration, or dependence in caregiving activities. Negotiating pain management was an important aspect of role synchronisation, as nurses helped patients find ways to express and manage pain. (5) Negotiating knowledge involved obtaining and providing information within an interpersonal context. Nurses and patients had to find appropriate ways to offer new information without imposing or demeaning, affirm correct knowledge, and identify and supplant incorrect information. (6) Sensitivity to taboo topics referred to the context in which nurses and patients could address sensitive topics such as pain tolerance, private habits, and personal fears. Communication patterns related to such topics tended to be hesitant and indirect. In responding to patient questions, nurses tried to find a balance between accuracy and specificity and tact, often resorting to euphemisms and other indirect strategies.

    Conclusion

    6 interpersonal contexts characterised the goals that patients and home care nurses worked towards by negotiating their needs and expectations: territoriality, shared perceptions of the situation, an amicable working relationship, role synchronisation, knowledge, and taboo topics.

    Commentary

    Although building and maintaining relationships with clients is at the heart of nursing practice, few studies have explored nurse-patient interactions and how these interactions influence the outcome of care. This dearth of studies may be attributed to the fact that relationships are complex and difficult to study. Spiers provides a rich resource for nurses working in home care. Home care is a unique workplace setting because nurses enter the worlds of their patients. Nurses must find a balance between a professional presentation of self and a friendly attitude. In her study, Spiers exposes this complexity, raising pertinent issues and bringing a new and fresh view of nurse-client communication.

    The study has strong methodological underpinnings. The originality of the research relates to the use of videotaping in a natural setting, which is a powerful research method to analyse and explain social interactions. The level of complexity involved in analysing videotapes and the infrequent use of this method by researchers contribute to the uniqueness of these findings. The sampling strategy was carefully planned, and the rationale for selection of participants was well described. The methodological approach for analysing data was described in detail and provides evidence for rigour in the analysis process. It would have been interesting to have more extensive explanation and demonstration of how the multiple data sources (individual interviews with nurses and patients, videotaping, and observation) were integrated into the overall analysis. Most of the findings were based on analysis of discourse utterance. The findings had few indications of how non-verbal communication contributed to the interpersonal contexts of negotiating care.

    The findings of this study are relevant to community based nurses, particularly because both nurse and patient perspectives are presented. The findings can help nurses to better understand how relationships with patients are constructed. Furthermore, the findings shed light on invisible aspects of interactions between nurses and clients and can sensitise nurses by explicating the role of inter-relationships in nursing activities.

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 QUESTIONS: In home care nurse-patient interactions, what are the interpersonal contexts and social acts through which negotiation occurs? What are the outcomes of unsuccessful and successful negotiation?

    Design

    Qualitative ethology for video based research.

    Setting

    A large metropolitan home healthcare agency in the western US.

    Participants

    10 nurse-patient dyads (3 home care nurses and 8 patients; 2 patients were each paired with 2 nurses). Patients were 25–86 years of age and required home care for acute and chronic conditions. Exclusion criterion was inability to communicate verbally because of cognitive or physical impairment. {The 3 home care nurses, who were case managers and had ≥6 years of home care experience, were peer nominated as expert practitioners.}*

    Methods

    31 routine home care visits were videotaped (19 hours of videotape). Nurses and patients participated in separate semistructured interviews before and after the videotaped sessions. The unit of analysis was the communication strategy (verbal or non-verbal action). Data analysis was cyclical, recursive, and verified with colleagues and a conversational analyst.

    Main findings

    Caregiving activities occurred in a complex environment of interpersonal considerations. 6 interpersonal contexts characterised the goals that patients and nurses worked towards by negotiating their needs and expectations. (1) Negotiating territoriality referred to negotiation of shared space in the patient’s home to facilitate caregiving. (2) Negotiating shared perceptions of the situation aimed at creating consensus in perceptions of a patient’s wellbeing and progress. (3) Establishing an amicable working relationship involved the development of a friendly collaboration, whereby both nurses and patients recognised the individuality of the other beyond immediate caregiving activities. This occurred by volunteering information, sharing stories, and keeping track of events in each other’s lives. (4) In synchronising role expectations, nurses and patients recognised each other’s particular expertise. Role boundaries were negotiated, which determined relative autonomy, collaboration, or dependence in caregiving activities. Negotiating pain management was an important aspect of role synchronisation, as nurses helped patients find ways to express and manage pain. (5) Negotiating knowledge involved obtaining and providing information within an interpersonal context. Nurses and patients had to find appropriate ways to offer new information without imposing or demeaning, affirm correct knowledge, and identify and supplant incorrect information. (6) Sensitivity to taboo topics referred to the context in which nurses and patients could address sensitive topics such as pain tolerance, private habits, and personal fears. Communication patterns related to such topics tended to be hesitant and indirect. In responding to patient questions, nurses tried to find a balance between accuracy and specificity and tact, often resorting to euphemisms and other indirect strategies.

    Conclusion

    6 interpersonal contexts characterised the goals that patients and home care nurses worked towards by negotiating their needs and expectations: territoriality, shared perceptions of the situation, an amicable working relationship, role synchronisation, knowledge, and taboo topics.

    Commentary

    Although building and maintaining relationships with clients is at the heart of nursing practice, few studies have explored nurse-patient interactions and how these interactions influence the outcome of care. This dearth of studies may be attributed to the fact that relationships are complex and difficult to study. Spiers provides a rich resource for nurses working in home care. Home care is a unique workplace setting because nurses enter the worlds of their patients. Nurses must find a balance between a professional presentation of self and a friendly attitude. In her study, Spiers exposes this complexity, raising pertinent issues and bringing a new and fresh view of nurse-client communication.

    The study has strong methodological underpinnings. The originality of the research relates to the use of videotaping in a natural setting, which is a powerful research method to analyse and explain social interactions. The level of complexity involved in analysing videotapes and the infrequent use of this method by researchers contribute to the uniqueness of these findings. The sampling strategy was carefully planned, and the rationale for selection of participants was well described. The methodological approach for analysing data was described in detail and provides evidence for rigour in the analysis process. It would have been interesting to have more extensive explanation and demonstration of how the multiple data sources (individual interviews with nurses and patients, videotaping, and observation) were integrated into the overall analysis. Most of the findings were based on analysis of discourse utterance. The findings had few indications of how non-verbal communication contributed to the interpersonal contexts of negotiating care.

    The findings of this study are relevant to community based nurses, particularly because both nurse and patient perspectives are presented. The findings can help nurses to better understand how relationships with patients are constructed. Furthermore, the findings shed light on invisible aspects of interactions between nurses and clients and can sensitise nurses by explicating the role of inter-relationships in nursing activities.

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    Footnotes

    • * Information provided by author.

    • Source of funding: no external funding.

    • For correspondence: Dr J A Spiers, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. jude.spiers{at}ualberta.ca

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