Patient Participation in Nursing Care on Medical Wards: An

Integrative Review

Author
Tobiano, Georgia, Marshall, Andrea, Bucknall, Tracey, Chaboyer, Wendy

Published
2015

Journal Title
International Journal of Nursing Studies

Version
Accepted Manuscript (AM)

DOI
https://doi.org/10.1016/j.ijnurstu.2015.02.010

Copyright Statement
© 2015, Elsevier. Licensed under the Creative Commons Attribution-NonCommercial-
NoDerivatives 4.0 International (http://creativecommons.org/licenses/by-nc-nd/4.0/) which
permits unrestricted, non-commercial use, distribution and reproduction in any medium,
providing that the work is properly cited.

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 Patient Participation in Nursing Care on Medical Wards: An Integrative Review

Title Page

Name: Georgia Tobiano

Job title: PhD Candidate
Highest academic and professional qualification: BN (Hons), RN
Institution (and corresponding author’s address): Centre for Health Practice Innovation,
Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Parklands
Drive, Queensland, 4222, Australia
Address for corresponding author:
Phone number for corresponding author: +61402 869 972
Email for corresponding author: g.tobiano@griffith.edu.au

Name: Andrea Marshall

Job title: Professor of Acute and Complex Care Nursing ab
Highest academic and professional qualification: PhD, RN
Institution: National Centre of Research Excellence in Nursing Interventions for Hospitalised
Patients, Centre for Health Practice Innovation, Menzies Health Institute Queensland, Griffith
University, Queensland, Australiaa and Gold Coast Health, Queensland, Australiab

Name: Tracey Bucknall

Job title: Professora and Foundational Chair in Nursingb
Highest academic and professional qualification: PhD, RN
Institution: Centre for Quality and Patient Safety, School of Nursing and Midwifery, Deakin
University, Victoria, Australiaa and Alfred Health, Victoria, Australiab

Name: Wendy Chaboyer

Job title: Professor and Director
Highest academic and professional qualification: PhD, RN
Institution: National Centre of Research Excellence in Nursing Interventions for Hospitalised
Patients, Centre for Health Practice Innovation, Menzies Health Institute Queensland, Griffith
University, Queensland, Australia

1
 Patient Participation in Nursing Care on Medical Wards: An Integrative Review

Abstract

Background

Patient participation is a way for patients to engage in their nursing care. In view of the

possible link between patient participation and safety, there is a need for an updated review to

assess patient participation in nursing care.

Objectives

To investigate patients’ and nurses’ perceptions of and behaviours towards patient

participation in nursing care in the context of hospital medical wards.

Design

Integrative review.

Data sources

Three search strategies were employed in August 2013; a computerised database search of

Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Medline and

PsychINFO; reference lists were hand-searched; and forward citation searching was

executed.

Review methods

After reviewing the studies, extracting study data and completing summary tables the

methodological quality was assessed using the Mixed-Methods Assessment Tool by two

reviewers. Reviewers met then to discuss discrepancies as well as the overall strengths and

limitations of the studies. Discrepancies were overcome through consensus or a third

reviewer adjudicated the issue. Within and across study analysis and synthesis of the findings

sections was undertaken using thematic synthesis.

2
Results

Eight studies met inclusion criteria. Four themes were identified - enacting participation,

challenges to participation, promoting participation and types of participation. Most studies

included were conducted in Europe. The majority of studies used qualitative methodologies,

with all studies sampling patients; nurses were included in three studies. Data were largely

collected using self-reported perceptions; two studies included observational data.

Methodological issues included a lack of reflexivity, un-validated data collection tools,

sampling issues and low response rates.

Conclusions

On medical wards, patients and nurses desire, perceive or enact patient participation

passively. Challenging factors for patient participation include patients’ willingness, nurses’

approach and confusion around expectations and roles. Information sharing was identified as

an activity that promotes patient participation, suggesting nurses encourage active

communication with patients in practice. Involving patients in assessment and care planning

may also enhance patient participation. For education, enhancing nurses understanding of the

attributes of patient participation, as well as patient-centred care approaches may be

beneficial for medical ward nurses. From here, researchers need to examine ways to

overcome the barriers to patient participation; further nurse participants and observational

data is required on medical wards.

Key words

Communication; consumer participation; cooperative behaviour; nurse-patient relations;

patient-centered care; patient engagement; patient involvement; patient participation; shared

decision-making; review.

3
 Patient Participation in Nursing Care on Medical Wards: An Integrative Review

Introduction

Hospitals may not be the safest place with approximately 1 in 10 patients

experiencing an adverse event (de Vries et al., 2008). In 2014, a Canadian study found 1 in 7

patients hospitalised on medical wards had an adverse event (D'Amour et al., 2014).

Internationally, patient-centred care is advocated as an approach to reduce adverse events in

hospitals (Australian Comission on Safety and Quality in Health Care (ACSQHC), 2011),

with governing bodies such as the National Institute for Health and Care Excellence (NICE)

(2012), American Hospital Association (AHA) (2014) and ACSQHC (2014) developing

resources to enhance practices of patient-centred care in hospitals. Patient participation is a

key concept of patient-centred care (Kitson et al., 2013) and has been suggested as a way for

patients to ensure safety, owing to their prominence in their own care (Koutantji et al., 2005).

Background

Patient participation is a diverse term encompassing a large range of activities. The

various terminology used synonymously with participation included engagement,

involvement (Gallivan et al., 2012), collaboration, and cooperation while patients are

described as clients, consumers and users (Langton et al., 2003). The activity ‘decision-

making’ has been promoted as a way for patients to be involved in healthcare, which reflects

patients’ rights (Entwistle, 2000). However, nursing activities that patients may engage in are

diverse, including handover (Chaboyer et al., 2008), medication rounds (Bolster and Manias,

2010), nursing care planning (Kolovos et al., 2014) and managing own care (Sørensen et al.,

2013).

4
 The definition of patient participation lacks consensus (Longtin et al., 2010). Recent

definitions of patient participation highlight nurses’ requirement to enact patient-centred

qualities such as respect and empowerment, and to involve patients in all elements of their

care (University of Gothenburg Centre for Person-centred Care (GPCC), 2014). For example,

Sahlsten et al.’s (2008) concept analysis provides insights into the phenomenon of patient

participation. Although the concepts are tentative, Sahlsten et al.’s (2008) analysis

incorporates various researchers’ attempts to provide clarity around ‘patient participation’.

With features of the concept recognisable in recent research (Eldh et al., 2010, Soleimani et

al., 2010), this definition seems appropriate and this review may contribute to maturity of the

concept. According to Sahlsten et al (2008), patient participation in nursing care is

characterised by four defining attributes including a strong existing nurse-patient relationship,

relinquishing of power by nurses, mutual exchange of information and knowledge between

patient and nurse, and collaboration in intellectual and/or physical activities; this latter

attribute being dependent on the presence of the first three.

Research to date shows apparent benefits for patients who participate in their care.

Patient participation in enhancing safety practices in hospital is a convincing concept (Coulter

and Ellins, 2007, Longtin et al., 2010), especially when patients self-manage medications

(Hall et al., 2010). One recent US study found the risk of experiencing an adverse event was

half as likely, when patient participation was implemented (Weingart et al., 2011). However

further evidence of the effectiveness of patient participation in safety activities is required

(Berger et al., 2013, Schwappach, 2010).

Patient participation also benefits the patient in other ways including enhancing

patient knowledge (Coulter and Ellins, 2007) and sense of control (Dudas et al., 2013,

Hӧglund et al., 2010). Patient-centred approaches, inclusive of patient participation, also

improve patient satisfaction (Dwamena et al., 2012) and perceived quality of care (Slatore,

5
2010, Weingart et al., 2011). Finally, involving patients in their care can improve condition

(Coulter and Ellins, 2007), specifically patients’ function in activities of daily living (Ekman

et al., 2012). The potential positive outcomes of patient participation suggest encouraging

patient participation in nursing care, may benefit the patient.

Previous reviews

There are several reviews on patient participation in care, with a particular focus on

patient safety (Berger et al., 2013, Hall et al., 2010, Peat et al., 2010). A recent review by

Vaismoradi et al. (2014) examined patient participation in safety in nursing care, however,

only one review has explicitly investigated patient participation in general nursing care

(Cahill, 1998). Cahill’s (1998) review was conducted over 15 years ago and it is likely that

approaches to patient participation have evolved since this time, particularly in relation to the

strong recent focus on patient safety. In this early review (Cahill, 1998), the researcher’s

attempt to understand patient participation in nursing care was hindered by a lack of available

research, consequently studies relating to doctors/medical care were also included. Overall,

the review by Cahill (1998) was inconclusive and the need for further research to evaluate

patients’ and nurses’ perspectives and behaviours towards patient participation, especially

utilising qualitative or mixed method approaches, was identified. In light of previous reviews,

the aim of this integrative review was to investigate patients’ and nurses’ perceptions of, and

behaviours towards, patient participation in nursing care.

Methods

An integrative review was conducted as it allowed qualitative and quantitative

methodologies to be synthesized; ensuring a variety of sources of patients’ and nurses’

perspectives and behaviours were included. This review was guided by Whittemore and

Knafl’s (2005) integrative review framework to enhance rigor.

6
Sample and inclusion/exclusion criteria

Inclusion/exclusion criteria were based on the concepts studied, target population,

health care problem and sampling frame (Whittemore and Knafl, 2005). Included studies had

to meet the following inclusion criteria. First, the sample had to include either adult patients

or nurses in medical units of hospitals. Because medical patients tend to have multiple co-

morbidities and chronic conditions, a focus on this group was to capture patients who have

more opportunity to participate in nursing care because of their ‘exposure’. Additionally, it is

likely that other patient populations, such as surgical, mental health or rehabilitation patients

would have different experiences, making pooling of findings from these disparate

populations less meaningful and not applicable to the clinical context. Second, studies also

had to have an explicit focus on participation in either intellectual or physical activities and

include either perceptions or actual behaviours. Only the fourth attribute, mutual engagement

in physical and/or intellectual activities, was included as its success hinges on the remaining

attributes. Further, this attribute identifies kinds of perceived and enacted participation that

can occur. Finally, only empirical, full-text studies, published in English were included.

Studies published between 1999-2013 were included to capture those published after Cahill’s

(1998) review. Studies that included areas other than medical wards, or other health

professional in addition to nurses, were subsequently excluded if they did not report findings

for the subsample of medical patients and/or nurses.

Literature search

In August 2013, three search strategies were employed to enhance the quality of this

review (Whittemore and Knafl, 2005), with search strategy one informing search two and

three. With the assistance of a health librarian, a computerised database search of the

Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library,

7
Medline and PsycINFO was performed due to their comprehensiveness and appropriateness

for the topic. The first strategy was guided by three elements of the SPIDER tool;

phenomenon of interest, sample and evaluation. This tool assists in creating sound search

strategies, particularly when anticipating retrieval of qualitative and mixed-methods studies

(Cooke et al., 2012). Step 1 focused on the phenomenon of interest, terms used

synonymously for patient participation were searched (Table 1). The sample was identified in

step 2 and 4, being hospitalised, adult patients and nurses. In step 2 methods of evaluation,

including perceptions and behaviours, were linked to medical subject heading (MeSH) terms.

Consistent with integrative review there were no restrictions on research designs or study

types. To meet inclusion criteria, restrictions were placed on language and years published.

The second search strategy involved hand-searching reference lists of retrieved articles to

find relevant literature not previously identified. Third, the citations of retrieved articles were

searched using Scopus to identify subsequent articles.

Table 1 here

Search outcome

The combined search strategies resulted in eight articles meeting the inclusion criteria

(Figure 1). One author undertook the search, and two researchers determined the eligibility of

studies for inclusion.

Figure 1 here

Data extraction and evaluation

To provide an overview, data were extracted relating to approach, context, sample and

key findings. Quality scores were calculated using the Mixed Methods Assessment Tool

(MMAT) (Table 2). The MMAT was used to concurrently evaluate the quality of various

methodologies and has established validity and reliability (Pace et al., 2010, Pace et al., 2012,

8
Pluye et al., 2009). Studies were assessed against the appropriate MMAT criteria based on

the methodology used, and were assigned quality scores ranging from (*) representing one

criteria met through to (****) representing all criteria (Pluye et al., 2011). Two researchers

independently appraised each article and then discussed their MMAT scores and the overall

strengths and limitations of the study. All researchers participated in the review process.

Discrepancies were resolved through discussion and reference to the MMAT tutorial (Pluye

et al., 2011). A third reviewer was available to adjudicate however this was not required.

Quality scores were not used to exclude studies as all studies met at least two criteria, but

instead highlighted the potential contribution of each study to the overall findings.

Data analysis

Thematic synthesis was used for analysing and synthesising the findings of the

included studies, using Thomas and Harden’s (2008) work as a guide. First, the researcher

became immersed in the data by reading and re-reading the sections labelled “results” or

“findings” of each article, maintaining notes of possible patterns and decisions throughout the

thematic analysis and synthesis. Second, the findings or results sections were analysed

inductively. Line by line coding using words was undertaken, with analysis occurring within

and across studies. NVivo 10 software (QSR International) was used to assist with data

management. Next, inductive codes were grouped into hierarchies of categories and sub-

categories, producing largely descriptive categories. Finally, the categories were searched for

the latent themes that went beyond the original content of the studies to provide a meta-

synthesis.

Findings were also coded deductively, using Soleimani et al.’s (2010) core category

“convergence of caring agents” as a framework to uncover the types of participation reported.

This core category included four subcategories, which represented levels of participation:

9
adhering, involving, sharing and true participation (Soleimani et al., 2010). Each study was

assessed against the four subcategories to find which level of participation was achieved. The

subcategory adhering, portrayed patient passivity, whereby patients trusted nurses and

followed their instructions with little engagement (Soleimani et al., 2010). When patients

adhered, nurses were in control, displaying task-orientated behaviour and not encouraging

patient interaction (Soleimani et al., 2010). The next subcategory, involving, was

characterised by information-seeking behaviours by patients, which was encouraged by

nurses (Soleimani et al., 2010). The subcategory entitled sharing, was described as patients

contributing to physical cares and nurses promoting patients to take on this responsibility,

within nursing legislation (Soleimani et al., 2010). Patients and nurses were both eager to

participate when the final subcategory, true participation, was achieved. True participation

included patients undertaking self-care, managing their care, sharing their views and making

decisions (Soleimani et al., 2010). At this level of participation, nurses valued the illness

knowledge that patients shared (Soleimani et al., 2010).

Findings

A summary of the eight studies meeting the inclusion criteria for the integrative review are

presented in Table 2. Despite three studies employing quantitative methodologies, the

findings produced were easily understood in a descriptive manner and results and graphs

were transformed into words and descriptions (Sandelowski et al., 2006). This enabled

comparison of the quantitative and qualitative findings (Sandelowski et al., 2006, Voils et al.,

2008), with both complementing each other and contributing to a rich description of patient

participation in the medical context.

Table 2 here.

10
 The research context can be seen in Table 2, with six of the eight studies being

conducted in European hospitals, predominately in Sweden; the remaining two studies were

undertaken in Australia and Iran. Attempts to enhance credibility through investigating

different settings were noted with most researchers studying more than one medical ward.

Contextual descriptions tended to be generic, explaining countries position towards patient

participation rather than thick contextual descriptions about the ward and hospital that related

that patient participation.

In terms of sample (Table 2), all studies explored patients’ perceptions of patient

participation; only three studies included nurses as study participants (Florin et al., 2006,

Lomborg and Kirkevold, 2008, Soleimani et al., 2010). The patient population across the

studies had an average age ranging from 50-68 years and a variety of medical conditions. The

average age of nurses ranged from 31-34 years and the average experience varied

considerably, ranging from 1.5 years to 10 years. Transferability was addressed with five of

the eight studies identifying types of medical conditions of patient participants. Only three

research teams (Florin et al., 2008, Florin et al., 2006, Lomborg and Kirkevold, 2008)

explicitly reported wellness of the patient, which may be important for patient participation.

The methodological quality of qualitative studies ranged from moderate (**) to high

(****) (Table 2). The most common critique of qualitative pieces was the researchers not

addressing their influence on data collection, seemingly important as these researchers had

nursing qualifications. Two of the research teams undertook observations; however, the

researchers failed to explicitly detail strategies for acknowledging their assumptions

(Lomborg and Kirkevold, 2008, Soleimani et al., 2010), whereby methods of self-reflection

would have enhanced rigor during data collection (Polit and Beck, 2008). A further example

was Doherty and Doherty’s (2005) interpretive phenomenology, with the methodology

encompassing identification of pre-understandings, which was not addressed.

11
 Shown in Table 2, the methodological quality of quantitative pieces was moderate

(**) due to data collection tools, sampling and response rates. In the studies reviewed data

collection tools were modified and not validated (Florin et al., 2008, Florin et al., 2006). One

study used a tool that had been validated in a different population but not in the in the

diagnostic group reported (Vestala and Frisman, 2013). Sampling issues included unclear

descriptions of randomisation (Vestala and Frisman, 2013) and non-independent data with

repeated measures for some nurses (Florin et al., 2006). Small response rates reduced

methodological quality (Florin et al., 2008, Florin et al., 2006).

Meta-synthesis

Three themes were discovered inductively in the data, which provided clarity on the

way participation was enacted, the challenges facing participation and the way participation

was promoted on medical wards. The final theme, types of participation, was found

deductively.

Enacting participation

The theme enacting participation, described the variety of verbal and physical forms

of participation in nursing care that were practiced on medical wards. Verbal participation

activities studied included rounds, handovers, and information sharing encounters regarding

treatment and disease. Decision-making with nurses was researched in a broad and

sometimes an un-specified range of activities, relating to a variety of patient needs and

nursing care. Some specific areas of patient participation in decision-making explored

included documentation, medication administration and meals. Medication administration

and hygiene were examined as aspects of physical participation.

Challenges to participation

12
 The second theme, challenges to participation, illustrated that patient participation

was hard to achieve, with many issues uncovered. Patients’ capabilities were one factor that

presented a challenge to achieving patient participation. In particular physical forms of

participation, in the Iranian and Danish medical wards, seemed to be hindered by patients’

capabilities and condition. The more unskilled and/or unwell the patient the less physical

participation occurred.

Patient preferences were not fixed, presenting another challenge for patient

participation. Participation in decision-making appeared to be influenced by preference rather

than capabilities, with patients choosing to be active, collaborative or passive. On the whole,

most patients admired roles where they were largely passive or collaborative with the nurses,

rather than more active roles where choices were determined by the patient. Despite this,

preferences for verbal participation did vary between contexts, with Swedish patients

preferring more passive involvement, whereas, British and Australian patients chose a more

active role.

While patients’ desire for patient participation could vary depending on their

capability and preference, nurses tended to express a desire for a more patient-inclusive

approach for all forms of patient participation. The incongruence between patient and nurse

expectations for patient participation was apparent. Patients and nurses expectations and

desires for patient participation were often not met and in some instances, patients reported

undertaking more or less participation than wanted.

Patients’ expectations were confounded by confusion on how patient participation

should be enacted. Patients’ perceptions revealed that some participation activities were

viewed as the nurse’s duty and patients were unsure of the level of participation they were

expected to undertake. Some patients were not aware that decision-making was a nursing

role, meaning patients could not foresee decision-making with nurses as an area in which

13
they could participate. Overall, patients’ lack of clarity on enacting patient participation

tended to entrench a passive approach.

A key challenge to effective patient participation was the manner of the nurse.

Patients’ confidence to participate was diminished when nurses displayed behaviours that

were unsupportive of patient participation. Noticeably, when nurses appeared busy or task-

orientated in nature, patient participation was difficult to achieve. Participation was also a

challenge when nurses did not verbally engage, making patients feel uninformed or ignored,

or when nurses did not show respectful communication towards patients; with condescending

or de-personalised language being barriers.

Nurses’ manner towards communication meant some nurses failed to keep themselves

informed. Both nurses and patients believed that nurses did not always know the patient when

they came on shift. Nurses undertook activities without consulting patients and were not kept

abreast of patients’ willingness or expectations; this often placed nurses in an instructive and

assuming role and, in some instances, nurses wrongly judged patients’ willingness and

expectations for patient participation. When nurses were viewed by patients as not attempting

to understand their situation, patients simply complied with nurses or felt negative emotions

such as fear and unhappiness. Overall, there were many patient and nurse related challenges

to participation encountered on medical wards.

Promoting participation

Promoting participation, the third theme, portrays information-sharing as a facilitator

to patient participation. Patients participated by gaining information from nurses, which made

them feel included and informed. Patient participation in information sharing was

characterised by patients asking questions, clarifying nurses’ information or contributing to

decision-making. Accordingly, patients appreciated their shared knowledge being respected

by nursing staff. Information exchanges between patients and nurses were viewed by patients

14
as a way of enhancing assessment of their capabilities and preferences and making nurse

expectations explicit, with bedside handover viewed as a facilitator to information exchanges.

Vital to the success of involving patients in information sharing was the manner in

which nurses portrayed themselves. When nurses displayed actions that were inviting,

supporting and encouraging, patients’ eagerness to participate in information exchanges was

enhanced. Further patient participation was boosted when nurses displayed respect through

genuine engagement in dialogue, which was spoken in non-clinical language and

acknowledging the patient as a person.

Types of participation

According to Soleimani et al.’s (2010) core category “convergence of the caring

agents” there are four types of participation; adhering, involvement, sharing and true

participation, each study was assessed to find the extent that these types of participation were

found. Table three shows all but one study identified patients adhering to nurses’ instruction

rather than participation, with the majority of patients expressing a desire for adherent

behaviour (Florin et al., 2008, Florin et al., 2006), or simply adhering to nurses regardless of

their desire (Larsson et al., 2011, Lomborg and Kirkevold, 2008). Almost every study showed

some elements of true partnerships with patients (Doherty and Doherty, 2005, Vestala and

Frisman, 2013) and nurses (Florin et al., 2008, Lomborg and Kirkevold, 2008) expressing

desires for patient involvement in decision-making, but this did not reflect how decision-

making was (Lomborg and Kirkevold, 2008) or may have been practiced (Doherty and

Doherty, 2005, Florin et al., 2006). Another feature of true participation encountered was

patients sharing information that was valued by nurses (Larsson et al., 2011, McMurray et al.,

2011). However, all elements of true partnership was only demonstrated in Soleimani et al.’s

(2010) study, where patients were supported by nurses and used all their capabilities to take

15
control of their care. Overall, adherent forms of participation were most easily achieved on

medical wards.

Table 3 here

Discussion

The findings of this integrative review demonstrate that participation is commonly

practiced in an adherent way on medical wards, which may be attributed to challenging and

promoting factors. The challenges and promoters identified in our review resonate with

Sahlsten et al.’s (2008) concept analysis. By discussing the challenges found in this review in

relation to Sahlsten et al.’s (2008) four defining attributes, ways to improve patient

participation in medical wards may be identified.

Active mutual engagement in intellectual and/or physical activities

Our review suggests that a challenge to participation was patients’ willingness, which

is required for achieving patient participation in intellectual or physical activities (Sahlsten et

al., 2008). Willingness was influenced by patient preference and condition in this review. In

terms of patient preference, the importance of nurses acknowledging desires for decision-

making was highlighted and is a well-accepted factor in the success of shared decision-

making (Coulter and Ellins, 2007, Longtin et al., 2010, Rise et al., 2013). Patients’ condition

also influenced willingness to participate, as exemplified in Soleimani et al.’s (2010) study,

with previous research also suggesting when patients are unwell their willingness to

participate diminishes (Davis et al., 2007, Vaismoradi et al., 2014).

Given the variability of patient willingness, our review and Sahlsten et al.’s (2008)

findings advocate the practice of nursing assessment prior to patient participation. Previous

research indicates that nurses understand the value of involving patients in intentional

assessments to achieve patient participation (Jewel, 1994, Sahlsten et al., 2005). Despite this

16
recognition, this review suggests assessment of patient capability for patient participation is

not easily operationalised or recognised in current medical ward nursing practice.

Questionnaire findings from Finnish nurses working in a geriatric hospital, implied only 56%

of nurses took patients’ assessment of their functional ability into account, with nurses

tending to pursue family members’ assessments rather than patients (Eloranta et al., 2014).

Alarmingly, nurses reportedly practice assessment in a dominant and task-driven way, with

little patient engagement (Barrere, 2007, Casey, 2007, Jones, 2009). Further complicating

assessment, is a patient reluctance to share feelings of wellness (Huby et al., 2004).

Ultimately, assessments with patients can improve communication and patient outcomes

(Morse et al., 1996), and could be one strategy to overcome the challenges associated with

patient willingness and reduce “adhering” practices of patient participation in medical wards.

Similar to Sahlsten et al. (2008), this review recommends undertaking care planning

with patients, including discussion of goals. The planning process may help address

conflicting expectations and role confusion found in this review. Discussing goals and

expectations with patients has been identified by nurses as a strategy to promote patient

participation (Sahlsten et al., 2009). Despite this, addressing patient goals and expectations

appears to be challenging in other hospital settings, with only 20% of hospital nurses

reporting they ask patient expectations (Rozenblum et al., 2011) and 52% of hospital nurses

ensured that patients knew the goal of their care (Eloranta et al., 2014). In hospital settings,

plans are reportedly made away from patients (Wolf et al., 2012), or when patients do

participate in planning nursing care it is a ‘moderate’ amount (Kolovos et al., 2014).

Research suggests patients want to be part of the planning (Larsson et al., 2007, Rise et al.,

2013), showing a thirst for participation. Planning with patients may be one method to

promote more active patient participation on medical wards and achieve patient-centred care

(Rathert et al., 2013); however, it needs to be catered to patients’ willingness.

17
An established relationship

In our review it was evident that many nurses were perceived as ‘busy’ and often did

not know or attempt to build a relationship with patients, an attribute necessary for successful

patient participation (Sahlsten et al., 2008). Pressures on medical wards are common, created

by frantic environments with high workloads and frequent staff rotation (Wolf et al., 2012).

Working in a busy environment (Hӧglund et al., 2010, Penney and Wellard, 2007) and

discontinuity of care (Larsson et al., 2011, Sahlsten et al., 2005) have been shown to impede

co-operative relationships for participation in hospitals. In light of these pressures, our

findings highlight the importance of the manner displayed by nurses. Nurses need to be aware

that appearing task-orientated (Wellard et al., 2003) or bound by routine (Sahlsten et al.,

2005) can thwart participatory relationships, as patients become adherent in an attempt not to

disturb nurses (Foss, 2011). Ultimately, nurses need to engage and build relationships with

patients to increase patient participation in medical wards; however, this is a true challenge

due to pressures experienced in current hospital environments. Further research investigating

ways to overcome these issues and enhance patient participation would be beneficial.

A surrendering of some power and control by the nurse

The high degree of adherence and numerous challenges discovered in this review

suggests not all nurses were keen to surrender power, which is a pre-requisite for patient

participation (Sahlsten et al., 2008). Controlling nurse manners identified in our review

included being disrespectful or unengaging towards patients, thus impeding patient

participation. Previous research strongly suggests that authoritative nurse behaviours such as

these hinder patient participation (Aasen et al., 2012, Henderson, 2003), perhaps reflecting

increases in the challenges and ‘adhering’ behaviour of patients found in our review. On the

other hand, we found when nurses were respectful and encouraging, patient participation was

18
promoted, especially in information-sharing. Previous studies conducted with patients

(Larsson et al., 2007, Latimer et al., 2013) and nurses (Sahlsten et al., 2009) also identify

supportive nurse manners as an enhancer of patient participation. In practice, medical ward

nurses need to be aware of the effect their approach can have on patient participation.

Shared information and knowledge

Successful patient participation is characterised by shared information and knowledge

(Sahlsten et al., 2008) which was an area of true participation more easily achieved by

patients and nurses in this review. Patients (Eldh et al., 2006, Larsson et al., 2007) and nurses

(Kolovos et al., 2014, Sahlsten et al., 2005) recognise the importance of information-sharing,

viewing it as a condition for patient participation. Consistent with this review and previous

research, participation in information sharing can make patients feel respected (Rise et al.,

2013) and involved (Lu et al., 2013). Other benefits of information-sharing include patient

empowerment (Nygårdh et al., 2012) and enhanced knowledge, which is a contributor to

enhanced patient participation (Davis et al., 2007, Vaismoradi et al., 2014), especially in

decision-making (Joseph-Williams et al., 2014, Sainio et al., 2001). Interestingly, bedside

handover was found to facilitate information-sharing in this review. Creating formal times for

information-sharing, like bedside handover, can provide ease for patients to contribute

(Chaboyer et al., 2008) and nurses to inform and update (Jeffs et al., 2014), which were

communications valued in this review. Enacting information encounters like bedside

handover may assist in achieving all attributes of patient participation, with improved

assessment (Jeffs et al., 2014), planning (Kassean and Jagoo, 2004), knowledge of the patient

(Chaboyer et al., 2010, Liu et al., 2012) and nurse (Anderson and Mangino, 2006, Wildner

and Ferri, 2012), and greater patient empowerment (Lu et al., 2013) linked to bedside

handover.

19
 This review contains several limitations. The inclusion of medical wards only may

have restricted the findings; however, it provides a context-specific understanding of patient

participation that will enhance transferability to similar clinical contexts. The researchers

strategically designed and undertook a search strategy, specific to the aims of this study, yet

there is always the possibility that some eligible articles may have been missed. This was an

interpretive piece, which some may think results in a potential bias. But through the use of

journaling ideas, feelings, and decisions, and frequent research team meetings, the

researchers undertaking analysis attempted to stay true to the data and acknowledge biases.

This study is also limited by the methodological quality of some articles included, however,

limitations of the included studies have been acknowledged and made explicit through quality

scores, allowing readers to take this into consideration. Overall, by following each step in

Whittemore and Knafl’s (2005) framework the rigour of this integrative review has been

enhanced.

Conclusion

Although the benefits of patient participation are promising, patient participation is

not easily achieved on medical wards. By overcoming various barriers, patients and nurses

can potentially reap the benefits of active patient participation and create safety cultures in

hospitals. This review illustrates information-sharing as a way to enhance patients’

participation, which is one strategy to improve communication safety (Peat et al., 2010).

Further, information sharing appears to benefit the patient by improving patient experience

through making patients feel engaged, informed and respected. Information sharing was

captured in two types of participation; “involvement in information sharing” and “true

participation”. Achieving these types of participation that promote information sharing is

valued by patients and can help foster the unique engagement that occurs between patient and

nurse, allowing both to achieve nursing care together.

20
 There are implications for patient participation in practice, education and research to

address the challenges encountered on medical wards. Patients should be encouraged to

actively participate in assessment and care planning. Further, nurses may benefit from

reflecting on their views on patient-centred care, and how these impact on patients’

engagement (McCormack and McCance, 2006). Information-sharing activities, such as

bedside handover, should be promoted on medical wards to enhance patient participation.

Gaining a better understanding of the core attributes of patient participation may help nurses

implement targeted strategies to promote participation. Further education for nurses on

patient-centred approaches to care and interpersonal skills may be required to enhance patient

participation on medical wards (McCormack and McCance, 2006). More research is needed

to find ways to overcome barriers to patient participation. The research conducted in medical

wards has been largely self-reported by patients, further research with nurses using

observational data may help inform strategies to enhance patient participation. Thus,

enhancing patient participation may be approached as a practice improvement, educational or

research activity.

21
 List of References

Aasen, E.M., Kvangarsnes, M., Heggen, K., 2012. Perceptions of patient participation amongst

elderly patients with end-stage renal disease in a dialysis unit. Scandinavian Journal of Caring

Sciences 26 (1), 61-69. doi:10.1111/j.1471-6712.2011.00904.x

American Hospital Association (AHA), 2014. Resources: Strategies for leadership: Patient-and

family-centered care, http://www.aha.org/advocacy-issues/quality/strategies-

patientcentered.shtml (accessed 9.5.14).

Anderson, C.D., Mangino, R.R., 2006. Nurse shift report: Who says you can't talk in front of the

patient? Nursing Administration Quarterly 30 (2), 112-122.

Australian Comission on Safety and Quality in Health Care (ACSQHC), 2011. Patient-centred care:

Improving quality and safety through partnerships with patients and consumers. ACSQHC,

Sydney, Australia.

Australian Comission on Safety and Quality in Health Care (ACSQHC), 2014. Resources to

implement the NSQHS standards, http://www.safetyandquality.gov.au/our-

work/accreditation-and-the-nsqhs-standards/resources-to-implement-the-nsqhs-standards/#top

(accessed 9.5.14).

Barrere, C.C., 2007. Discourse analysis of nurse-patient communication in a hospital setting:

Implications for staff development. Journal for Nurses in Staff Development 23 (3), 114-122.

doi:10.1097/01.NND.0000277180.47829.8d

Berger, Z., Flickinger, T.E., Pfoh, E., Martinez, K.A., Dy, S.M., 2013. Promoting engagement by

patients and families to reduce adverse events in acute care settings: A systematic review.

BMJ Quality & Safety 23 (7), 548-555. doi:10.1136/bmjqs-2012-001769

Bolster, D., Manias, E., 2010. Person-centred interactions between nurses and patients during

medication activities in an acute hospital setting: Qualitative observation and interview study.

International Journal of Nursing Studies 47 (2), 154-165. doi:10.1016/j.ijnurstu.2009.05.021

Cahill, J., 1998. Patient participation: A review of the literature. Journal Of Clinical Nursing 7 (2),

119-128. doi:10.1046/j.1365-2702.1998.00132.x

22
Casey, D., 2007. Findings from non-participant observational data concerning health promoting

nursing practice in the acute hospital setting focusing on generalist nurses. Journal Of Clinical

Nursing 16 (3), 580-592. doi:10.1111/j.1365-2702.2006.01557.x

Chaboyer, W., McMurray, A., Wallis, M., 2010. Bedside nursing handover: A case study.

International Journal of Nursing Practice 16 (1), 27-34. doi:10.1111/j.1440-

172X.2009.01809.x

Chaboyer, W., McMurray, A., Wallis, M., Chang, H.Y., 2008. Standard Operating Protocol for

Implementing Bedside Handover in Nursing. Griffith University, Australia.

Cooke, A., Smith, D., Booth, A., 2012. Beyond PICO: The SPIDER tool for qualitative evidence

synthesis. Qualitative Health Research 22 (10), 1435-1443. doi:10.1177/1049732312452938

Coulter, A., Ellins, J., 2007. Effectiveness of strategies for informing, educating, and involving

patients. British Medical Journal 335 (7609), 24-27. doi:10.1136/bmj.39246.581169.80

D'Amour, D., Dubois, C.-A., Tchouaket, E., Clarke, S., Blais, R., 2014. The occurrence of adverse

events potentially attributable to nursing care in medical units: Cross sectional record review.

International Journal of Nursing Studies 51 (6), 882-891. doi:10.1016/j.ijnurstu.2013.10.017

Davis, R.E., Jacklin, R., Sevdalis, N., Vincent, C.A., 2007. Patient involvement in patient safety:

What factors influence patient participation and engagement? Health Expectations 10 (3),

259-267. doi:10.1111/j.1369-7625.2007.00450.x

de Vries, E.N., Ramrattan, M.A., Smorenburg, S.M., Gouma, D.J., Boermeester, M.A., 2008. The

incidence and nature of in-hospital adverse events: A systematic review. Quality & Safety In

Health Care 17 (3), 216-223. doi:10.1136/qshc.2007.023622

Doherty, C., Doherty, W., 2005. Patients' preferences for involvement in clinical decision-making

within secondary care and the factors that influence their preferences. Journal of Nursing

Management 13 (2), 119-127. doi:10.1111/j.1365-2934.2004.00498.x

Dudas, K., Olsson, L., Wolf, A., Swedberg, K., Taft, C., Schaufelberger, M., Ekman, I., 2013.

Uncertainty in illness among patients with chronic heart failure is less in person-centred care

than in usual care. European Journal of Cardiovascular Nursing 12 (6), 521-528.

doi:10.1177/1474515112472270

23
Dwamena, F., Holmes-Rovner, M., Gaulden, C.M., Jorgenson, S., Sadigh, G., Sikorskii, A., Lewin,

S., Smith, R.C., Coffey, J., Olomu, A., 2012. Interventions for providers to promote a patient-

centred approach in clinical consultations. The Cochrane Database of Systematic Reviews 12

(12), CD003267. doi:10.1002/14651858.CD003267.pub2.

Ekman, I., Wolf, A., Olsson, L., Taft, C., Dudas, K., Schaufelberger, M., Swedberg, K., 2012. Effects

of person-centred care in patients with chronic heart failure: The PCC-HF study. European

heart journal 33 (9), 1112-1119. doi:10.1093/eurheartj/ehr306

Eldh, A.C., Ekman, I., Ehnfors, M., 2010. A comparison of the concept of patient participation and

patients' descriptions as related to healthcare definitions. International Journal of Nursing

Terminologies and Classifications 21 (1), 21-32. doi:10.1111/j.1744-618X.2009.01141.x

Eldh, A.C., Ekman, I., Ehnfors, M., 2006. Conditions for patient participation and non-participation in

health care. Nursing Ethics 13 (5), 503-514. doi:10.1191/0969733006nej898oa

Eloranta, S., Arve, S., Isoaho, H., Aro, I., Kalam-Salminen, L., Routasalod, P., 2014. Finnish nurses'

perceptions of care of older patients. International Journal of Nursing Practice 20 (2), 204-

211. doi:10.1111/ijn.12137

Entwistle, V.A., 2000. Supporting and resourcing treatment decision-making: Some policy

considerations. Health Expectations 3 (1), 77-85.

Florin, J., Ehrenberg, A., Ehnfors, M., 2008. Clinical decision-making: Predictors of patient

participation in nursing care. Journal of Clinical Nursing 17 (21), 2935-2944.

doi:10.1111/j.1365-2702.2008.02328.x

Florin, J., Ehrenberg, A., Ehnfors, M., 2006. Patient participation in clinical decision-making in

nursing: A comparative study of nurses' and patients' perceptions. Journal of Clinical Nursing

15 (12), 1498-1508. doi:10.1111/j.1365-2702.2005.01464.x

Foss, C., 2011. Elders and patient participation revisited - A discourse analytic approach to older

persons' reflections on patient participation. Journal Of Clinical Nursing 20 (13-14), 2014-

2022. doi:10.1111/j.1365-2702.2010.03505.x

Gallivan, J., Kovacs Burns, K., Bellows, M., Eigenseher, C., 2012. The many faces of patient

engagement. Journal of Participatory Medicine 4, e32.

24
Hall, J., Peat, M., Birks, Y., Golder, S., Entwistle, V., Gilbody, S., Mansell, P., McCaughan, D.,

Sheldon, T., Watt, I., Williams, B., Wright, J., 2010. Effectiveness of interventions designed

to promote patient involvement to enhance safety: A systematic review. Quality & Safety in

Health Care 19 (5), e10. doi:10.1136/qshc.2009.032748

Henderson, S., 2003. Power imbalance between nurses and patients: A potential inhibitor of

partnership in care. Journal Of Clinical Nursing 12 (4), 501-508. doi:10.1046/j.1365-

2702.2003.00757.x

Huby, G., Stewart, J., Tierney, A., Rogers, W., 2004. Planning older people's discharge from acute

hospital care: Linking risk management and patient participation in decision-making. Health,

Risk & Society 6 (2), 115-132. doi:10.1080/1369857042000219797

Hӧglund, A.T., Winblad, U., Arnetz, B., Arnetz, J.E., 2010. Patient participation during

hospitalization for myocardial infarction: Perceptions among patients and personnel.

Scandinavian Journal of Caring Sciences 24 (3), 482-489. doi:10.1111/j.1471-

6712.2009.00738.x

Jeffs, L., Beswick, S., Acott, A., Simpson, E., Cardoso, R., Campbell, H., Irwin, T., 2014. Patients'

views on bedside nursing handover: Creating a space to connect. Journal of Nursing Care

Quality 29 (2), 149-154. doi:10.1097/NCQ.0000000000000035

Jewel, S.E., 1994. Patient participation: What does it mean to nurses? Journal of Advanced Nursing

19 (3), 433-438. doi:10.1111/j.1365-2648.1994.tb01104.x

Jones, A., 2009. Creating history: Documents and patient participation in nurse-patient interviews.

Sociology of Health & Illness 31 (6), 907-923. doi:10.1111/j.1467-9566.2009.01190.x

Joseph-Williams, N., Elwyn, G., Edwards, A., 2014. Knowledge is not power for patients: A

systematic review and thematic synthesis of patient-reported barriers and facilitators to shared

decision making. Patient Education and Counseling 94 (3), 291-309.

doi:10.1016/j.pec.2013.10.031

Kassean, H.K., Jagoo, Z.B., 2004. Managing change in the nursing handover from traditional to

bedside handover - A case study from Mauritius. BioMed Central Nursing 4 (1).

doi:10.1186/1472-6955-4-1

25
Kitson, A., Marshall, A., Bassett, K., Zeitz, K., 2013. What are the core elements of patient-centred

care? A narrative review and synthesis of the literature from health policy, medicine and

nursing. Journal of Advanced Nursing 69 (1), 4-15. doi:10.1111/j.1365-2648.2012.06064.x

Kolovos, P., Kaitelidou, D., Lemonidou, C., Sachlas, A., Sourtzi, P., 2014. Patient participation in

decision making during nursing care in Greece - A comparative study. Nursing Forum.

Advance online publication. doi:10.1111/nuf.12089

Kolovos, P., Kaitelidou, D., Lemonidou, C., Sachlas, A., Zyga, S., Sourtzi, P., 2014. Patient

participation in hospital care: Nursing staffs' point of view. International Journal of Nursing

Practice. Advance online publication. doi:10.1111/ijn.12242

Koutantji, M., Davis, R., Vincent, C., Coulter, A., 2005. The patient's role in patient safety: Engaging

patients, their representatives, and health professionals. Clinical Risk 11 (3), 99-104.

Langton, H., Barnes, M., Haslehurst, S., Rimmer, J., Turton, P., 2003. Collaboration, user

involvement and education: A systematic review of the literature and report of an educational

initiative. European Journal of Oncology Nursing 7 (4), 242-252. doi:10.1016/S1462-

3889(03)00033-4

Larsson, I.E., Sahlsten, M.J.M., Segesten, K., Plos, K.A.E., 2011. Patients' perceptions of nurses'

behaviour that influence patient participation in nursing care: A critical incident study.

Nursing Research and Practice 2011. doi:10.1155/2011/534060

Larsson, I.E., Sahlsten, M.J.M., Segesten, K., Plos, K.A.E., 2011. Patients’ perceptions of barriers for

participation in nursing care. Scandinavian Journal of Caring Sciences 25 (3), 575-582.

doi:10.1111/j.1471-6712.2010.00866.x

Larsson, I.E., Sahlsten, M.J.M., Sjöström, B., Lindencrona, C.S.C., Plos, K.A.E., 2007. Patient

participation in nursing care from a patient perspective: A grounded theory study.

Scandinavian Journal of Caring Sciences 21 (3), 313-320. doi:10.1111/j.1471-

6712.2007.00471.x

Latimer, S., Chaboyer, W., Gillespie, B., 2013. Patient participation in pressure injury prevention:

Giving patient's a voice. Scandinavian Journal of Caring Sciences 28 (4), 648-656.

doi:10.1111/scs.12088

26
Liu, W., Manias, E., Gerdtz, M., 2012. Medication communication between nurses and patients

during nursing handovers on medical wards: A critical ethnographic study. International

Journal of Nursing Studies 49 (8), 941-952. doi:10.1016/j.ijnurstu.2012.02.008

Lomborg, K., Kirkevold, M., 2008. Achieving therapeutic clarity in assisted personal body care:

Professional challenges in interactions with severely ill COPD patients. Journal Of Clinical

Nursing 17 (16), 2155-2163. doi:10.1111/j.1365-2702.2006.01710.x

Longtin, Y., Sax, H., Leape, L.L., Sheridan, S.E., Donaldson, L., Pittet, D., 2010. Patient

participation: Current knowledge and applicability to patient safety. Mayo Clinic Proceedings

85 (1), 53-62. doi:10.4065/mcp.2009.0248

Lu, S., Kerr, D., McKinlay, L., 2013. Bedside nursing handover: Patients' opinions. International

Journal of Nursing Practice 20 (5), 451-459. doi:10.1111/ijn.12158

McCormack, B., McCance, T.V., 2006. Development of a framework for person-centred nursing.

Journal of Advanced Nursing 56 (5), 472-479. doi:10.1111/j.1365-2648.2006.04042.x

McMurray, A., Chaboyer, W., Wallis, M., Johnson, J., Gehrke, T., 2011. Patients’ perspectives of

bedside nursing handover. Collegian 18 (1), 19-26. doi:10.1016/j.colegn.2010.04.004

National Institute for Health and Care Excellence (NICE), 2012. Quality standard for patient

experience in adult NHS services http://publications.nice.org.uk/quality-standard-for-patient-

experience-in-adult-nhs-services-qs15 (accessed 9.5.14).

Nygårdh, A., Malm, D., Wikby, K., Ahlström, G., 2012. The experience of empowerment in the

patient-staff encounter: The patient´s perspective. Journal Of Clinical Nursing 21 (5-6), 897 -

904. doi:10.1111/j.1365-2702.2011.03901.x

Pace, R., Pluye, P., Bartlett, G., Macaulay, A., Salsberg, J., Jagosh, J., Seller, R., 2010. Reliability of a

tool for concomitantly appraising the methodological quality of qualitative, quantitative and

mixed methods research: A pilot study. 38th Annual Meeting of the North American Primary

Care Research Group (NAPCRG), Seattle, USA.,

http://mixedmethodsappraisaltoolpublic.pbworks.com/f/Pace-Pluye-et-al-final-poster-2010-

10-29.pdf (accessed 2.8.13).

27
Pace, R., Pluye, P., Bartlett, G., Macaulay, A., Salsberg, J., Jagosh, J., Seller, R., 2012. Testing the

reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic

mixed studies review. International Journal of Nursing Studies 49 (1), 47-53.

doi:10.1016/j.ijnurstu.2011.07.002

Pearson, A., 2004. Balancing the evidence: Incorporating the synthesis of qualitative data into

systematic reviews. JBI Reports 2 (2), 45-64. doi:10.1111/j.1479-6988.2004.00008.x

Peat, M., Entwistle, V., Hall, J., Birks, Y., Golder, S., 2010. Scoping review and approach to appraisal

of interventions intended to involve patients in patient safety. Journal of Health Services

Research & Policy 15 (1), 17-25. doi:10.1258/jhsrp.2009.009040

Penney, W., Wellard, S.J., 2007. Hearing what older consumers say about participation in their care.

International Journal of Nursing Practice 13 (1), 61-68. doi:10.1111/j.1440-

172X.2006.00608.x

Pluye, P., Gagnon, M.P., Griffiths, F., Johnson-Lafleur, J., 2009. A scoring system for appraising

mixed methods research, and concomitantly appraising qualitative, quantitative and mixed

methods primary studies in mixed studies reviews. International Journal of Nursing Studies

46 (4), 529-546. doi:10.1016/j.ijnurstu.2009.01.009

Pluye, P., Robert, E., Cargo, M., Bartlett, G., O'Cathain, A., Griffiths, F., Boardman, F., Gagnon,

M.P., Rousseau, M.C., 2011. Proposal: A mixed methods appraisal tool for systematic mixed

studies reviews, http://mixedmethodsappraisaltoolpublic.pbworks.com (accessed 1.8.13).

Polit, D.F., Beck, C.T., 2008. Nursing research: Generating and assessing evidence for nursing

practice Lippincott Williams & Wilkins, Philadelphia, Pennsylvania.

Rathert, C., Wyrwich, M.D., Boren, S.A., 2013. Patient-centered care and outcomes: A systematic

review of the literature. Medical Care Research and Review 70 (4), 351-379.

doi:10.1177/1077558712465774

Rise, M.B., Solbjør, M., Lara, M.C., Westerlund, H., Grimstad, H., Steinsbekk, A., 2013. Same

description, different values. How service users and providers define patient and public

involvement in health care. Health Expectations 16 (3), 266-276. doi:10.1111/j.1369-

7625.2011.00713.x

28
Rozenblum, R., Lisby, M., Hockey, P.M., Levtizion-Korach, O., Salzberg, C.A., Lipsitz, S., Bates,

D.W., 2011. Uncovering the blind spot of patient satisfaction: An international survey. BMJ

Quality and Safety 20 (11), 959-965. doi:10.1136/bmjqs-2011-000306

Sahlsten, M.J.M., Larsson, I.E., Lindencrona, C.S.C., Plos, K.A.E., 2005. Patient participation in

nursing care: An interpretation by Swedish registered nurses. Journal Of Clinical Nursing 14

(1), 35-42. doi:10.1111/j.1365-2702.2004.00957.x

Sahlsten, M.J.M., Larsson, I.E., Plos, K.A.E., Lindencrona, C.S.C., 2005. Hindrance for patient

participation in nursing care. Scandinavian Journal of Caring Sciences 19 (3), 223-229.

doi:10.1111/j.1471-6712.2005.00336.x

Sahlsten, M.J.M., Larsson, I.E., Sjöström, B., Plos, K.A.E., 2008. An analysis of the concept of

patient participation. Nursing Forum 43 (1), 2-11. doi:10.1111/j.1744-6198.2008.00090.x

Sahlsten, M.J.M., Larsson, I.E., Sjöström, B., Plos, K.A.E., 2009. Nurse strategies for optimising

patient participation in nursing care. Scandinavian Journal of Caring Sciences 23 (3), 490-

497. doi:10.1111/j.1471-6712.2008.00649.x

Sainio, C., Lauri, S., Eriksson, E., 2001. Cancer patients' views and experiences of participation in

care and decision making. Nursing Ethics 8 (2), 97-113. doi:10.1191/096973301677733388

Sandelowski, M., Voils, C.I., Barroso, J., 2006. Defining and designing mixed research synthesis

studies. Research in the Schools 13 (1), 29-44.

Schwappach, D., 2010. Review: Engaging patients as vigilant partners in safety: A systematic review.

Medical Care Research and Review 67 (2), 119-148. doi:10.1177/1077558709342254

Slatore, C.G., 2010. Patient-clinician communication: Associations with important health outcomes

among veterans with COPD. Chest 138 (3), 628-634. doi:10.1378/chest.09-2328

Soleimani, M., Rafii, F., Seyedfatemi, N., 2010. Participation of patients with chronic illness in

nursing care: An Iranian perspective. Nursing & Health Sciences 12 (3), 345-351.

doi:10.1111/j.1442-2018.2010.00536.x

Sørensen, D., Frederiksen, K., Groefte, T., Lomborg, K., 2013. Nurse-patient collaboration: A

grounded theory study of patients with chronic obstructive pulmonary disease on non-

29
 invasive ventilation. International Journal of Nursing Studies 50 (1), 26-33.

doi:10.1016/j.ijnurstu.2012.08.013

Thomas, J., Harden, A., 2008. Methods for the thematic synthesis of qualitative research in systematic

reviews. BioMed Central medical research methodology 8 (1), 45-45. doi:10.1186/1471-

2288-8-45

University of Gothenburg Centre for Person-centred Care (GPCC), 2014. Person-centred care,

http://gpcc.gu.se/digitalAssets/1477/1477256_eng-broschyr_gpcc_147x147_web.pdf

(accessed 11.12.14).

Vaismoradi, M., Jordan, S., Kangasniemi, M., 2014. Patient participation in patient safety and nursing

input – A systematic review. Journal Of Clinical Nursing. Advance online publication.

doi:10.1111/jocn.12664

Vestala, H., Frisman, G.H., 2013. Can participation in documentation influence experiences of

involvement in care decision-making? The Open Nursing Journal 7 (1), 66-72.

doi:10.2174/1874434620130516002

Voils, C.I., Sandelowski, M., Barroso, J., Hasselblad, V., 2008. Making sense of qualitative and

quantitative findings in mixed research synthesis studies. Field Methods 20 (1), 3-25.

doi:10.1177/1525822x07307463

Weingart, S.N., Zhu, J., Chiappetta, L., Stuver, S.O., Schneider, E.C., Epstein, A.M., David-Kasdan,

J.A., Annas, C.L., Fowler, F.J., Jr., Weissman, J.S., 2011. Hospitalized patients' participation

and its impact on quality of care and patient safety. International Journal for Quality in Health

Care 23 (3), 269-277. doi:10.1093/intqhc/mzr002

Wellard, S., Lillibridge, J., Beanland, C., Lewis, M., 2003. Consumer participation in acute care

settings: an Australian experience. International Journal of Nursing Practice 9 (4), 255-260.

doi:10.1046/j.1440-172X.2003.00429.x

Whittemore, R., Knafl, K., 2005. The integrative review: Updated methodology. Journal of Advanced

Nursing 52 (5), 546-553. doi:10.1111/j.1365-2648.2005.03621.x

30
Wildner, J., Ferri, P., 2012. Patient participation in change-of-shift procedures: The implementation of

the bedside handover for the improvement of nursing quality in an Italian hospice. Journal of

Hospice and Palliative Nursing 14 (3), 216-224. doi:10.1097/NJH.0b013e318243251f

Wolf, A., Ekman, I., Dellenborg, L., 2012. Everyday practices at the medical ward: A 16-month

ethnographic field study. BioMed Central Health Services Research 12 (1), 184-196.

doi:10.1186/1472-6963-12-184

31
 Tables
Table 1
First Search Strategy Utilised via Computerised Databases

Steps CINAHL Cochrane Library Medline PsycINFO

(CINAHL (MeSH terms) (MeSH terms) (Subject
headings) headings)
S1 (MH (MH "Cooperative (MH "Cooperative exp Client
"Consumer Behavior") OR (MH Behavior") OR Participation/
Participation") "Consumer (MH "Consumer
Participation") OR Participation+")
(MH "Patient
Participation")
S2 (MH "Nurses") (MH "Nurses/PX") (MH hospitalized
OR (MH "Staff OR (MH "Nursing "Nurses/PX") OR patients/ or
Nurses") OR Staff+/PX") OR (MH "Nursing exp patients/
(MH "Nursing (MH Nursing Staff, Staff+/PX") OR or nurses/
Staff, Hospital+/PX”) OR (MH
Hospital") OR (MH "Patients/PX") "Patients/PX") OR
(MH OR (MH (MH
"Patients") OR "Inpatients/PX") "Inpatients/PX")
(MH
"Inpatients")
S3 S1 AND S2 S1 AND S2 S1 AND S2 S1 AND S2
S4 Limiters: Date Limiters: Date of Limiters: Date of Limiters: Date
of Publication: Publication: 1999- Publication: 1999- of Publication:
1999-2013; 2013 2013; English 1999-current;
English Language. Narrow English
Language. by subject age: all Language.
Narrow by adult: 19+ years Narrow by
subject age: all subject age:
adult [300]
adulthood
(age 18 yrs
and older)

32
Table 2
Overview of Studies

Study Approach Context Participants Key findings 1 Quality score

Doherty Methodology: Setting: 2 medical wards at 1 Patients (N=10) - The most common preference ***
and Interpretive secondary acute trust Age: Mean=63.5 years for DM with nurses was to
Doherty phenomenology hospital (range=18-78 years) take an active role (4/10),
(2005) 2 Data collection: Geography: England Gender: 60% male followed by collaborative
Semi-structured Nursing care: DM Medical conditions: Not (2/10) and passive (2/10)
interviews and Culture: British National clearly provided, however - 2/10 patients did not perceive
single question Health Service described as Crohn’s disease and that DM was a nursing task
questionnaires paternalistic. However, in diabetes appear to be - Patients older than 60 years
light of the Bristol Royal examples wanted a more active role in
Infirmary inquiry, patients Wellness: Not provided DM with nurses than patients
should be participants in DM younger than 60 years
in British hospitals

Florin et Methodology: Setting: 1 infectious diseases Patients (N=76 at first data - Most patients preferred a **
al. (2006) Comparative design ward at 1 regional hospital collection point, N=59 at second passive role in DM (61%) and
Data collection: Geography: Sweden data collection point) never picked the self-
Card sorting Nursing care: DM Age: Mean=59 years determination in DM card
technique (patients Culture: Western countries (range=23-84 years) - Patients younger than 61 years
and nurses) and are promoting PP Gender: 54% male3 preferred a more active role in
questionnaires Medical conditions: DM of physical needs than
based on CPS Gastroenteritis, wound patients older than 61 years
(patients only) infections, pneumonia - Compared with RNs
Wellness: Co-morbidity perceptions of patient
index negatively skewed, preference for DM, patients
median=1 preferred a significantly more
Nurses (N=30) passive role in DM for needs
Age: median= 31 years in general, psychosocial needs
(IQR=28-40 years) and physical needs (<0.001)
Experience: median= 1.5 - Only 29% of patients reported
years (IQR=1.0-4.3years) achieving their desired level
of DM in hospital. The
remaining patients (71%) did
not achieve their desired level

33
Study Approach Context Participants Key findings 1 Quality score

of participation in DM in
hospital, experiencing more or
less participation than desired
Florin et Methodology: Setting: medical wards Patients (N=98) - The most frequent preference **
al. (2008)4 Cross- sectional, (number of wards not Age5: Mean=64 years for DM by medical patients
comparative design provided, does include an (range=18-94 years) was a passive role, followed
Data collection: infectious diseases ward) at Gender5: 60% male by a collaborative role in DM
Questionnaires 1 university hospital and 1 Medical conditions:
regional hospital Cancers, disorders of
Geography: Sweden skeletal system and
Nursing care: DM respiratory diseases
Culture: Swedish Health Wellness5: Co-morbidity
Care Act and the Swedish index negatively skewed,
National Board of Health median=1
and Welfare support PP

Larsson et Methodology: Setting: 3 medical wards at 1 Patients (N= 17) Incidents identified by patients that had ****
al. (2011) Critical incident central hospital Age: Range=28-91 years negative and positive turning points for
technique Geography: Sweden Gender: 47% male participation:
Data collection: Nursing care: General Medical conditions: - Medical ward round
Semi-structured nursing care Medical conditions - Nursing ward round
interviews Culture: The medical wards commonly admitted to the - Information sessions
had no explicit care ward included stroke, - Nursing documentation
philosophy emphasising PP disorders of kidney, heart - Drug administration
and no focus on patient- and lung - Meals
nurse continuity Wellness: Not provided Nurse behaviours that stimulated PP:
- Regarded as a person
- Engaged through information
- Acknowledged as competent
Nurse behaviours that inhibited PP:
- Abandoned without backup
- Belittled verbally
- Ignored without influence

Lomborg Methodology: Setting: 3 respiratory Patients (N=12) Elements required for effective co- **

34
Study Approach Context Participants Key findings 1 Quality score

and Grounded theory diseases wards at 1 Age: 30 years and older operation between patient and nurse
Kirkevold Data collection: university hospital Gender: Not provided and achieving therapeutic clarity
(2008) Semi-structured Geography: Denmark Medical conditions: during assisted personal body care:
interviews, Nursing care: Assisted COPD - Reaching a common
observations and personal body care Wellness: Severe COPD, understanding of the patient’s
questionnaire on Culture: Busy ward where requiring assistance with current condition and stage of
breathlessness washing patients was part of hygiene and continuous illness trajectory
the daily routine. Nurses oxygen support. Two - Negotiating a common scope
struggled to attend and patients waiting for and structuring body care
prioritize personal care confirmation of whether sessions
while trying to accomplish they met criteria for lung - Clarifying roles
other tasks such as clinical transplant.
observations, performing Nurses (N=4)
treatments and patient Age: Not provided
education and working Experience: Not provided
around other health care
professionals.

McMurray Methodology: Setting: 2 medical wards at 1 Patients N=10 Four themes ****
et al. Descriptive case hospital Age: Median=68 years - Acknowledging patients as
(2011) study Geography: Australia (range=52-74 years) partner
Data collection: Nursing care: Bedside Gender: 40% male - Amending inaccuracies
Semi-structured handover Medical conditions: Not - Passive engagement
interviews Culture: In Australia, provided - Handover as interaction
patient-centred approaches Wellness: Not provided
are being discussed as a
strategy to improve national
safety and quality in
hospitals

Soleimani Methodology: Setting: Medical wards Patients (N=9) Core category “convergence of the ***
et al. Grounded theory (number of wards not Age: Mean=50 years caring agents” was generated from 4
(2010) 6 Data collection: provided) at 3 university (range=23-65 years) inter-related subcategories that
Semi-structured teaching hospitals Gender: Not provided emerged as the levels of PP:
interviews and Geography: Iran Medical conditions: - Adhering
observations Nursing care: General Cardiac disorder, diabetes, - Involving
nursing care systemic lupus - Sharing

35
Study Approach Context Participants Key findings 1 Quality score

Culture: Nurses experience erythematous, multiple - True participation

staff shortages and heavy sclerosis and respiratory
workloads. PP was tuberculosis
influenced by a culture Wellness: Not provided
bound by legal Nurses (N=8)
responsibilities and Age: Mean=34 years (26-
managers’ expectations. 47 years)
Care that is task-orientated is Experience: Mean=10
viewed more positively than years (range=2-24 years)
a patient-centred approach.
Wards did not always have
resources to support PP, so
nurses would borrow
facilities from other wards.
Strong family member
presence is common in
Iranian hospitals and
patients of low socio-
economic level are often
admitted to these hospitals

Vestala Methodology: Setting: 1 medical ward at 1 Patients (N= 39) - No significant difference **
and Experimental, hospital Age: Mean=56.8 years between intervention and
Frisman randomised design. Geography: Sweden with a standard deviation control group in regards to
(2013) Intervention: PP in Nursing care: of 20.6 preferred and perceived
nursing Documentation and DM Gender: 51.3% male participation in DM, feelings
documentation Culture: The Swedish Medical conditions: of mastery or self-esteem and
Data collection: National Board of Health Diabetes, inflammatory empowerment.
Questionnaires and Welfare emphasises PP bowel diseases, liver - Significant relationship
in health care disease, coronary artery between well-being and
disease and chronic wanting to be passive in DM
obstructive pulmonary (no clear measurement of
disease well-being provided to
Wellness: 72.% of the interpret this result)
intervention group and - Significant correlation
70.6% of the control group between desiring a certain
felt well or better level of participation in DM

36
Study Approach Context Participants Key findings 1 Quality score

and perceiving that this level

of participation was
undertaken (p<0.001)
- Patients over 65 years
preferred a more passive role
in DM than those younger
than 65 years (p=<0.05)
- Reasons for not participating
in DM: trust in physician and
lack of knowledge regarding
disease
- Patients in the intervention
group who had their chronic
illness for more than 5 years
had greater sense of
empowerment compared to
those who had their illness
less than 5 years (p<0.05)

Note. DM = decision-making. PP = patient participation. 1 Findings reported in the table only relate to data from the subsample of medical patients and nurses. 2 Data from
surgical patients and medical patients where the data referred to DM with doctor excluded. 3 Gender data reported reflects total number of patients recruited (N=80), only 76
patients participated in data collection. 4 Data from surgical, cardiology, orthopaedic and urology wards excluded. 5Sample data of medical patients could not be extracted, the
entire sample is reported. 6 Data collected from family members excluded. Adapted from “Balancing the Evidence: Incorporating the Synthesis of Qualitative Data into
Systematic Reviews,” by A. Pearson, 2004, JBI Reports, 2, p. 63.

37
Table 3

Types of Participation Assessed with Soleimani et al.’s (2010) Grounded Theory Category “Convergence of the
Caring Agents”

Author/Year Adhering Involvement Sharing True

to nurse through physical partnership
instructions informing activities between
patients patient and
nurse
Doherty and - - - P*
Doherty (2005)
Florin et al. (2006) P - - N*
Florin et al. (2008) P - - -
Larsson et al. P P P P*
(2011)
Lomborg and P/N N N N*
Kirkevold (2008)
McMurray et al. P P - P*
(2011)
Soleimani et al. P/N P/N P/N P/N
(2010)
Vestala and P - - P*
Frisman (2013)

Note. Participation desired, perceived or enacted by patient (P), participation desired, perceived or enacted by
nurse (N). Only some elements of “true participation” were desired, perceived or enacted (*).Adapted from
“Participation of Patients with Chronic Illness in Nursing Care: An Iranian Perspective,” by M. Soleimani, F.
Rafii, and N. Seyedfatemi, 2010, Nursing and Health Sciences, 12, p. 347

38