Nurse-patient interaction and decision-making in care: patient involvement in community nursing

This paper reports a study to identify the extent to which community nurses incorporate patient involvement in decision-making into their everyday clinical practice.

The complexity underlying the concept of patient participation is not always recognized. It links the notions of 'passive patient' and 'active participant', hence its usage along with those of similar terms such as 'partnership', 'involvement' and 'collaboration' is often ambiguous. The literature on this subject is fairly extensive and often contradictory; it encompasses the participation of potential as well as actual patients. Hierarchical structures have been proposed to offer an understanding of the current nature of patient participation, and these have sometimes linked the level of participation to the quality of the nurse-patient relationship. Much work has been done in the area of cancer care, where it has been noted that the role of 'passive patient' may in itself be a deliberate choice.

The approach was ethnographic and data were collected during 2000 and 2001 by participant observations with 22 nurses and 107 patients; 137 interactions were observed in all. Detailed field notes were kept and then carefully interpreted. The approach to rigour was primarily concerned with ensuring credibility.

The extent to which nurses involved patients in making decisions about their care, and the manner in which this was achieved, varied considerably. Collectively, the behaviour of participants is presented as the 'involving-non-involving continuum', with five typologies of behaviour: 'completely involving'; 'partially involving'; 'forced involving'; 'covert non-involving' and 'overt non-involving'. The findings highlight that caring for people in their own home does not necessarily mean that patients are involved in care and treatment decisions.

This observation study of the extent to which community nurses involved patients in decision-making in nursing care offers some useful insights into one aspect of nursing work. The implications of the study are far-reaching. The findings suggest that it could be important for nurses and their managers to devote more time to relationship-building in nursing practice. They also offer a perspective--the involving-non-involving continuum--that could usefully be incorporated into nurse education at both pre- and postregistration levels.