Patients’ perceptions and preferences of participation in nursing care

Abstract

The aim of this study was to investigate patients’ perceptions and preferences of their participation in nursing care during hospitalisation in Greece. The sample consisted of medical and surgical patients (n = 300). A questionnaire was developed to measure patients’ perception of participation, including an open question and the control preference scale. Descriptive and inferential statistics were used for quantitative data analysis and content analysis for qualitative data. Participation was described as ‘information receiving and responsibility’ and ‘ability to influence’. One-third of the respondents preferred a collaborative role with the nurses, while 77.2% rationalised patient participation with the themes ‘strengthening patient’s role’, ‘improve hospitalisation’ and ‘collaborative relationship’. The meaning of participation seems to support shared information, patient responsibility and motivation during nursing care. Patients were aware of the positive effects of their involvement in care and were willing to assume, at least to some extent, an active role in their own care. Changes in nursing care organisation, nurses’ communication skills and additional educational strategies need to be developed and implemented in clinical practice to optimise patient participation.

Keywords

Greece nursing care patient participation patients’ perceptions role preference triangulation

Literature review

Modern health care policy emphasises the importance of an approach that promotes patients’ right to participate in care aspects and thus patients’ participation has been encouraged in health care arenas over the past decades (Thompson, 2007). Participation is an essential component of patient-centred care (Thorarinsdottir and Kristjansson, 2014) and an important outcome in measuring the quality of the provided care (Larsson and Larsson, 2002). Nevertheless, the concept of patient participation remains a complex issue, causing widespread debate among health care providers and services consumers (Sahlsten et al., 2008; Thompson, 2007).

In nursing literature the concept of patient participation is widely used and an increasing number of studies have documented patient participation in everyday practice (Kolovos et al., 2012), indicating that paternalism in health care provision is questioned. The attributes of the concept have been defined by Sahlsten et al. (2008) and include an established relationship between the nurse and the patient, the surrendering of some power or control by the nurse, shared information and knowledge, and an active engagement of the patient in intellectual and/or physical activities. Moreover, Eldh et al. (2006) stressed the importance of an interaction between the patient and the health care provider based on respect, empathy and recognition of the patient as an individual as well as a partner, while Tutton (2005) described participation as a dynamic process between the two parties.

In a nurse-led clinic patients experienced participation as taking responsibility, obtaining knowledge and being treated as individuals, while nurses experienced participation as patients’ receiving information and knowledge that enabled them to manage their situation (Eldh et al., 2006). Doherty and Doherty (2005), in their study, found that 20% of the patients chose an active role in decision-making and 40% a collaborative one based on their choices from the autonomy preference index. Participation involves several dimensions (Kolovos et al., 2012) and has been described in different contexts and situations of care (Bangsbo et al., 2014; Frank et al., 2011; Heggland et al., 2013; Helgesen et al., 2010; Latimar et al., 2014).

Strategies to optimise patients’ active participation in nursing care decisions have also been proposed (Sahlsten et al., 2009). The fact that the extent of participation varies considerably depending on the care setting (Aasen et al., 2012; Bramberg et al., 2010; Heggland et al., 2013), the patients’ own characteristics, health status, needs and desires (Malmgren et al., 2014; Say et al., 2006), as well as the staff’s attitudes and competences (Bramberg et al., 2010; Soleimani et al., 2010), confirms that participation is a complex and multifaceted concept. Patient participation remains a critical issue for the nursing profession; yet participation only becomes possible when nursing staff offer individuals support and facilitation, adopt a collaborative approach in health care delivery and balance the asymmetry in the nurse–patient relationship.

Considering the focus on patients’ rights for participation over the past decades, there is a need to address its applicability based on patients’ descriptions and preferences in diverse care settings in order to provide guidance to nursing practice. Research on patients’ understanding of their participation is of great importance, because participation leads to better treatment outcomes, increases motivation and improves satisfaction with received care (Sahlsten et al., 2008; Sainio et al., 2001b). By understanding the patient’s point of view, nurses should be able to adopt an appropriate communication style and implement strategies that help patients to participate effectively in their own care according to their individual needs, desires and capabilities.

Study aim

The purpose of the current study – which was part of a larger study – was to explore patients’ perceptions and preferences in relation to participation in nursing care.

Methods

Design, setting and participants

A multi-method triangulation study with both a quantitative and qualitative design was conducted. The reason for including both qualitative and quantitative methods was that the measurement of participation is a complex phenomenon and in this way it would be possible to gain a more complete picture of it.

A convenience sample of medical and surgical patients from 23 wards in three general public hospitals in Greece were recruited between April 2009 and September 2010. Inclusion criteria included being an inpatient with a length of hospital stay of at least three days, minimum age 18 years, sufficient knowledge of the Greek language to comprehend and fill in the questionnaire, and that participation in the study would not jeopardise the patients’ health care. The researcher in cooperation with the nursing staff identified the patients who met the inclusion criteria and asked them if they were willing to participate in the study. Written and oral information was given to participants prior to data collection and included information about the purpose of the study, voluntary participation and the right to refuse participation at any time during the research process; it was also stated that refusal to participate would not endanger their care and it was guaranteed that no unauthorised person could have access to the data. The patients who gave their informed consent verbally completed the anonymous questionnaire and returned it to the researcher in a closed envelope. In case the patient asked for help the researcher was available to assist them in completing the questionnaire. Each questionnaire was coded to ensure data confidentiality. The planned sample size from each hospital was 100 patients, 300 in total, which was achieved. Patients were selected according to the criteria mentioned above; all the patients we invited to participate following verbal consent accepted.

Data collection

An anonymous questionnaire was used for data collection and included the following. A self-report structured questionnaire was developed that broadly described the concept of patient participation during hospitalisation. The questionnaire consists of eight items (content of patient participation) and is based on previous studies (Sainio et al., 2001a, 2001b) and an open question, in which participants were asked to complete one of the two aspects of the question ‘I wish/I do not wish to participate and have a choice in issues related to my nursing care, because …’. Respondents rated their level of agreement with each item on a five-point Likert scale, ranging from 1, strongly agree to 5, strongly disagree. Items included in the scale are shown in Table 1. The content validity of the questionnaire was tested with a group of academic and clinical nurses, who judged whether the content of the items covered what was actually believed to be measured. Construct validity was tested by the multifactor technique of factor analysis, which resulted in two factors with an eigenvalue greater than 1.0 accounting for a cumulative of total items variance of 55.3%. There were five items that loaded on factor 1 (with loadings ranging from 0.82 to 0.66 and explained variance 39.4%) and three items that loaded on factor 2 (with loadings ranging from 0.87 to 0.42, explained variance 26.34%) (Kolovos, 2011). Reliability was estimated by using Cronbach’s alpha coefficient and was found to be equal to 0.85 for the ‘content of patient participation’ domain, which is considered good (Polit et al., 2001).

Table 1.

Patients’ perceptions (%) on the content of patient participation.

Perceived meaning of patient participation	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
Asking about his/her health status	37.7	52.3	7.3	2.7	0.0
Asking about possible interventions and their consequences	36.8	50.8	8.4	4.0	0.0
Receiving relevant information	41.3	49.0	7.4	2.3	0.0
Deciding on who would be informed	20.5	50.7	19.8	8.7	0.3
Possibility of alternatives	17.5	49.8	23.2	8.8	0.7
Communicating symptoms	44.6	52.7	15.2	5.4	0.3
Communicating preferences	29.0	50.2	2.7	0.0	0.0
Compliance with the recommendations	45.3	47.3	5.3	1.7	0.3

Moreover, the modified version of the control preference scale (CPS) was used to assess the patients’ preferred role in decision making in nursing care (Florin et al., 2006, 2008). The CPS was developed by Degner and Sloan (1992) and has previously been used in medical decision making. The instrument was translated into Greek and was culturally adapted according to international guidelines (Chen et al., 2003). Participants were asked to select their response on this single-item, five response option, ordinal scale that indicates the degree of control patients preferred to have in decision making in nursing care (Degner and Sloan, 1992). Finally, demographic and hospitalisation characteristics of the patients were asked (10 items).

The questionnaire was pilot tested with 38 participants from one hospital. No changes were made to the questionnaire. Comprehensibility and internal consistency were examined.

Data analysis

Descriptive statistics were used to present demographic and hospitalisation characteristics. For inferential statistics, parametric tests were used due to the size of the study sample (Polit et al., 2001). More specifically, the t-test, one-way analysis of variance and Welch test (in case of unequal variances) were applied to investigate the correlation between the factors that emerged and the characteristics of the study sample. Some background variables were recoded before testing for correlations (the median of 59 years of age was used as the cut-off point, while education level was categorised as higher, medium or lower). The PASW Statistics 18 (SPSS, Chicago, IL, USA) statistical package was used for the statistical analysis. Results were considered statistically significant at P < 0.05.

Content analysis was used to evaluate the answers of the open-ended question. Subjects’ responses formed the unit of analysis. Data were coded through the process of ‘abstraction’ and then categorised and classified into subcategories. These subcategories comply with the rules of exhaustiveness and mutual exclusion. Finally, subcategories were grouped into broad categories/themes, which integrated the individual meanings (Graneheim and Lundman, 2004).

Ethics approval

An institutional ethics approval for the current study was granted from the National Centre for Health Operations (Ministry of Health). Moreover, the board of directors and the scientific committee of each hospital approved the study protocol, while further permission was obtained from the nursing administrators (nursing directors and head nurses).

Results

Patients’ demographic characteristics

The patient sample had a mean age of 55.4 years (SD 17.9), ranging from 18 to 96 years old; 61.3% were men and 38.7% were women; the majority were married (71.3%). Their educational level was generally low (80.0% had less than high school education); 20.0% were educated at technological or university level and only 2.3% of them had postgraduate studies. Almost half of the patients were hospitalised in a medical ward and the rest in a surgical ward; the majority had been acutely admitted to the ward, while 27.5% were planned admissions. The mean length of hospital stay was 6.5 days (SD 5.7, median 5.0) at the time of the study, whereas 72.5% mentioned at least one previous hospitalisation. The majority (67.7%) evaluated their health status as ‘good’ or ‘very good’, while 20 (6.67%) patients rated their health status as ‘bad’ or ‘very bad’. The patients’ subjective health status was found to be independent of the ward of hospitalisation (χ²= 1.06, P = 0.58).

The content of patient participation in care delivery from the patients’ perspective

Item frequencies are shown in Table 1. Factor 1, ‘information receiving and responsibility’, was statistically significantly associated with age (t(289) = −2.933; P = 0.004), education level (F(2, 291) = 4.923; P = 0.008) and hospitalisation (t(291) = 2.017; P = 0.045). Patients with a lower education level, those over 59 years of age and with experience of previous hospitalisation, attributed to the content of patient participation the dimension of ‘information receiving and responsibility’ more often than did those who were better educated, younger and had experienced no previous hospitalisation. Factor 2, ‘ability to influence’, was statistically significantly associated with age (t(289) = −4.219; P < 0.001), marital status (t(269) = −2.627; P = 0.009) and educational level (F(2, 291) = 17.585; P < 0.001) (Table 2).

Table 2.

Content of patient participation: Associations between the factors that emerged and the background characteristics.

Variable	n	Mean	SD	Test statistic	P value
Factor 1: information receiving and responsibility
Education level
Lower	98	0.255	1.019	F(2, 291) = 4.923	0.008^b
Medium	137	−0.131	0.928
Higher	59	−0.119	1.063
Age
≤59 years old	153	−0.162	1.039	t(289) = −2.933	0.004^a
>59 years old	138	0.179	0.936	t(289) = −2.933	0.004^a
Hospitalisation
Yes	215	0.067	1.005	t(291) = 2.017	0.045^a
No	78	−0.198	0.968	t(291) = 2.017	0.045^a
Factor 2: ability to influence
Marital status
Unmarried	60	−0.302	1.068	t(269) = −2.627	0.009^a
Married	211	0.080	0.972	t(269) = −2.627	0.009^a
Education level
Lower	98	0.439	0.993	F(2, 291) = 17.585	<0.001^b
Medium	137	−0.134	0.927
Higher	59	−0.417	0.918
Age
≤59 years old	153	−0.214	0.936	t(289) = −4.219	<0.001^a
>59 years old	138	0.265	0.998	t(289) = −4.219	<0.001^a

t-test; ^banalysis of variance.

Patients’ preferences in decision making in nursing care

Patients’ preferences for participation in decision making in nursing care are presented in Table 3. According to Degner and Sloan’s (1992) measure for assessing patients’ decisional preferences, 64.0% of the respondents preferred to play a passive role in decision making in nursing care (A and B statements), while only 2.6% of the patients were considered as active (D and E statements). One-third of the respondents (33.3%) preferred to share decision making with their nurses, indicating a collaborative role (statement C).

Table 3.

Frequencies of patients’ role preferences.

Statement	n	%	Role preference
A. I prefer to leave all decisions regarding the treatment to my nurses.	85	28.3	Passive
B. I prefer that my nurses make the final decision about which treatment will be used, but seriously consider my opinion.	107	35.7	Passive
C. I prefer that my nurses and I share responsibility for deciding which treatment is best for me.	100	33.3	Collaborative
D. I prefer to make the final decision about my treatment after seriously considering my nurses’ opinions.	7	2.3	Active
E. I prefer to make the final decision about which treatment I will receive.	1	0.3	Active

In Table 4 it is shown that the preferred role was statistically significantly associated with gender (χ²(1) = 5.54, P = 0.019), age (χ²(1) = 9.61, P = 0.002) and education level (χ²(2) = 10.55, P = 0.005). Because only eight respondents chose the category of active role, that role category was not taken into account in the current analysis. Male patients preferred a more passive role than women. Moreover, a more passive role was preferred by older (>59 years old) and less educated patients compared with younger (≤59 years old) and more educated patients. A collaborative role was more often chosen among younger patients (≤59 years old) with a medium educational level. However, marital status (χ²(1) = 2.10, P = 0.147), type of admission (χ²(1) = 0.28, P = 0.595), hospital stay (χ²(1) = 2.02, P = 0.155), ward of hospitalisation (χ²(1) = 0.69, P = 0.406), previous hospitalisation (χ²(1) = 1.13, P = 0.251) and finally, health status (χ²(3) = 0.683, P = 0.077) did not show any statistically significant relationship with patients’ preferences for participation in decision making in nursing care.

Table 4.

Statistically significant predictors of role preference.

	Role preference		Total	Test statistic	P value
	Passive	Collaborative	Total	Test statistic	P value
Gender
Male	127 (117.7)	52 (61.3)	179	χ²(1) = 5.54	0.019
Female	65 (74.3)	48 (38.7)	113
Total	192	100	292
Age
≤59	86 (98.5)	63 (50.5)	149	χ²(1) = 9.61	0.002
>59	105 (92.5)	35 (47.5)	140
Total	191	98	289
Educational level
Lower	78 (65.8)	22 (34.2)	100	χ²(2) = 10.55	0.005
Medium	80 (90.7)	58 (47.3)	138
Higher	34 (35.5)	20 (18.5)	54
Total	192	100	292

Frequency (expected frequency).

Relation between the content of patient participation and their preferences in decision making in nursing care

Both factors were statistically significantly associated with patients’ preferences in decision making in nursing care (t(284) = 3.772; P < 0.001 for factor 1 and t(240.492) = 2.876; P = 0.004 for factor 2). Patients preferring a more passive role attributed to the content of patient participation the dimension of ‘information receiving and responsibility’ more often than patients preferring a more active role. The same holds true for factor 2.

Rationalisation of patient participation

Responses to the open-ended question included rationalisation of the patients’ desires for patient participation and non-participation in their care. Of the respondents, 74.6% gave reasons for patient participation, while 25.3% did not answer the question; of those who answered, 77.2% supported patient participation and 21.9% gave reasons for non-participation. Furthermore, two participants gave both a positive and a negative reason.

Following content analysis, the 273 meaning units were interpreted as 18 subcategories explaining participants’ views for patient participation. Of these, eight subcategories corresponded to the theme ‘strengthening patients’ role’, while a group of meaning units (six subcategories) framed the theme ‘improve hospitalisation’. Finally, four subcategories formed the theme ‘collaborative relationship’ (Table 5). The following are examples of patients’ quotes in each code category.

Table 5.

Patients’ responses analysing through qualitative content analysis.

Subcategories	n	Categories	Meaning units (%)
Responses rationalising patient participation (n = 273)
Informing	62	Strengthening patient’s role	50.2% (n = 137)
Responsibility	18
Action	17
Individualised care	15
Better knowledge	9
Compliance	7
Empowerment	6
Understanding of health status	3
Mood	47	Improve hospitalisation	41.8% (n = 114)
Enhancing treatment	28
Better treatment results	17
Adaptation to hospital environment	10
Safety	9
Satisfaction	3
Improve the relationship with nursing staff	7	Collaborative relationship	8% (n = 22)
Better cooperation with nurses	7
Better communication with staff	4
Facilitating nurses’ tasks	4
Responses rationalising patient non-participation (n = 59)
Expertise	22	Access to necessary information	64.4% (n = 38)
Inadequate information	13
Ignorance	3
Confidence	11	Compromise	25.4% (n = 15)
Care organising	4	Compromise	25.4% (n = 15)
No benefit	4	Consequences for patients	10.1% (n = 6)
Adverse effects	2	Consequences for patients	10.1% (n = 6)

Rationalising patient participation

‘… I want to be informed, I better know my needs’

‘… (patient participation) makes me feel better and more familiar with the setting that is related to my care’

‘… (through participation) I help nurses to take care of me in a better way’.

On the other hand, respondents who were against patient participation identified 59 meaning units, which were interpreted as seven subcategories. Of these, three main categories emerged that documented patients’ perception for non-participation and refer to ‘access to necessary information’, ‘compromise’ and ‘consequences for patients’ (Table 5).

Rationalising patient non-participation

‘… because nurses are aware of, have the necessary knowledge and do the best for their patients’

‘… I feel completely confident and safe with the nursing staff’

‘… depending on the disease, I don’t know much and maybe I do harm to myself. However, wherever I have the knowledge, I may help after being properly informed’.

Discussion

The present study has described participation from the patients’ perspective and provided an understanding of the content of patient participation during nursing care. This is the first study carried out in Greece investigating the concept of patient participation in nursing care in hospital settings. Initiatives to promote patient participation should take into account cultural and individual preferences (Lyttle and Ryan, 2010).

The dimensions describing the concept of patient participation suggest that patients’ need for information remains a major issue in everyday practice and that their ability to influence their own care process constitutes a possibility. In the current study patient participation is advocated on the grounds that it strengthens patients’ roles and leads to improved hospitalisation. In addition, patient participation supports the establishment of a collaborative relationship with the staff, which is necessary for information exchange and the encouragement of self-care management.

Patients understood participation as the process through which they are informed, either by asking questions or by receiving relevant information from the nursing staff, and this is associated with better understanding and increased control over the situation. The provision of information to patients emerged as an essential component of the process of participation in the current study. Provision of information is mentioned as a key parameter of patient participation in the nursing literature (Eldh et al., 2006; Heggland and Hausken, 2013; Höglund et al., 2010; Xi et al., 2012). In a study conducted by Sainio and Lauri (2003), cancer patients participated more in decision making when they had received enough information.

Furthermore, in the present study, patients more frequently described participation within the terms of communicating symptoms and preferences as well as greater compliance with the recommendations, which have also been mentioned in previous studies (Eldh et al., 2010; Sainio et al., 2001b). In the current study the content of patient participation seemed to be affected by patients’ demographic characteristics (age, education level, marital status) as well as previous hospitalisation, providing a conceptualisation based on patients’ own experience of the nurse–patient interaction. Older, less educated patients and those having experienced previous hospitalisation were found to support to a greater extent the dimensions of patient participation ‘information receiving and responsibility’ and ‘ability to influence’. This result could suggest that when patients have complex needs or require more attention, the nursing personnel may engage them to a greater extent. This finding is also supported by the study of Frank et al. (2011) in investigating participation in an emergency department. Moreover, the experience of previous hospitalisation seemed to increase patients’ motivation during hospital care. Similarly, in a study conducted by Soleimani et al. (2010) patients with repeated hospitalisations were more willing to be involved in their care. These findings suggest that younger, better educated patients with no previous experience with hospitalisation might have a different perception of what participation means. Further research should include patients more carefully selected in order to work with more homogenous samples.

One-third of the patients supported a shared model according to CPS, indicating that patients prefer to share their needs and expectations with the nursing staff. This finding suggests that there is a possibility that effective communication and interaction with the patients during hospitalisation occurred. These findings are in line with those reported by Sainio et al. (2001b) and Eldh et al. (2010), while the importance of a relationship and interaction between the patient and the nurse have also been cited in the literature (Soleimani et al., 2010; Tutton, 2005). Sainio and Lauri (2003) reported that a good relationship with the staff encouraged greater patient participation in decisions about treatment and nursing care, while Kvangarsnes et al. (2013) also stressed the need for a collaborative inter-professional approach to meeting patients’ wishes for involvement. The majority of the patients in this study chose to adopt a passive role (64%), which is in line with the results of other studies (Doherty and Doherty, 2005; Florin et al., 2006, 2008; Soleimani et al., 2010), even though the organisation of the health care system and the cultural influences differ. The adoption of a passive role is probably associated with the difficulty for patients to clarify the term ‘participation in decision making’ in communication with the nursing staff in a health care system that places more value on medical decision making. Furthermore, the patients’ desire for participation may be restricted to the initial stages of the participation continuum (receiving information, consultation) and may not include control over the ultimate decisions. The majority of the patients actually stated that they preferred a passive role, even though more patients provided a rationale for being involved in their care, which should be attributed to the use of a role label measure, such as the CPS (Florin et al., 2006). This finding is also confirmed in the study by Doherty and Doherty (2005) using the autonomy preference index. This suggests that research into the subject of patient participation should be undertaken with caution when using measures that are likely to elicit misleading results.

Patients’ gender, age and education were all associated with the role preference in the present study. Although the results of relevant studies are contradictory (Doherty and Doherty, 2005; Florin et al., 2006, 2008; Sainio and Lauri 2003), it is confirmed that demographic characteristics significantly determine the patients’ preferred role in decision making and should be taken into account during the planning and implementing of nursing care. The ward of the hospital was not found to influence the preferred role in the present study. In contrast to this, Doherty and Doherty (2005) found that the ward of the hospital differentiated patients’ preferred role, demonstrating that the surgical patients chose a passive role in secondary care in comparison with the medical patients. Differences in nursing curricula and the implementation of a functional model of nursing care in Greek hospitals might explain this finding.

Moreover, the investigation of patients’ preferred role in relation to the actual one is of great importance (Florin et al., 2006; Melnyk and Fineout-Overholt, 2006; Tariman et al., 2010), which is lacking in the current study. Finally, patients who tended to prefer a rather passive role seemed to understand patient participation with the dimension of ‘information receiving and responsibility’ and ‘ability to influence’. It is possible that patients desire involvement in nursing care, but that their experience from the current health care system has been paternalistic and thus their passive preference is the result of such an organisation. These findings underline that paternalism remains a dominant ideology in a hospital setting (Doherty and Doherty, 2005).

Our findings seem to support better patient cooperation with the nursing staff and increased confidence and responsibility for the patient, which, finally, stresses an improvement in the nurse–patient relationship and interaction. In addition, a shift towards a more patient-centred model of the care provided appears. In Greece, as in other countries, the systematic and comprehensive education of nursing personnel in regard to the principles of ethics during the past years may have contributed to this trend. Further research with a larger population sample and broader range of care needs would permit more valid results. Nurses are in a position to support and facilitate participation through organisational and social changes, dialogue and effective interaction on the one hand (Aasen et al., 2012; Bangsbo et al., 2014; Riva et al., 2014), and on the other patients seem to assert participation as a right as well as an individual need in the care encounter. It is a challenge for nurses to guide and individually educate patients according to their wishes and capabilities in relation to participation in care aspects (Lindberg et al., 2013).

The most important limitation of the current study is that the sample was not representative of the larger study population because it was a convenience sample derived only from three hospitals. It should also be pointed out that in the literature there is not an accepted definition of the concept of patient participation, which is a fundamental problem in both measuring and comparing the results from different environments (care and/or cultural). Finally, the study was limited to the secondary level of care, although patient participation takes place at all levels and spectrums of nursing care. However, the results of the current study offer insights into the development of nursing practice. It is important for nursing staff to understand what patient participation means to patients and to recognise how patients want to take part in decision making in nursing care.

Conclusions

The meaning of patient participation during nursing care from a patient’s point of view seems to support shared information, patient responsibility and motivation in the care process, which are all prerequisites for genuine participation. The perceptions of patients suggest that the establishment of a collaborative relationship between the patient and the nurses might be possible in a hospital setting in Greece, although patients’ preferences related to control over decision making lend support to a paternalistic model. Furthermore, the study has demonstrated that patients are aware of the positive effects of their involvement in care and are willing to undertake, at least to some extent, an active role.

The findings of the current study could be used to formulate guidelines for quality provision of care by enhancing patient participation according to patients' wishes, while highlighting the need to stimulate changes in nursing care organisation (such as primary nursing). A thorough assessment of patients’ assumptions and preferences for participation has a great value in the delivery of high quality care (Florin et al., 2006). Moreover, nurses’ communication skills and additional educational strategies need to be developed and implemented in clinical practice to optimise patient participation. Finally, these findings form the basis for further research in primary and secondary care as well as in aspects of nursing practice such as bedside reporting, decision making, compliance with the recommendations, performing daily living skills, the discharge process and rehabilitation.

Key points for policy, practice and/or research

Patient participation remains a complex issue, causing widespread debate among health care providers and service consumers.

In the current study patient participation from a patient’s point of view seems to support shared information, patient responsibility and motivation in the care process.

Patients are aware of the positive effects of their involvement in care and are willing to undertake, at least to some extent, an active role.

Changes in nursing care organisation, nurses’ communication skills and additional educational strategies need to be developed and implemented in clinical practice to optimise patient participation.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Petros Kolovos is Teaching Staff in Clinical Nursing, Department of Nursing, University of Peloponnese, Sparta, Greece.

Daphne Kaitelidou is Assistant Professor, Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece.

Chrysoula Lemonidou is Professor, Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece. Her research interests focus mainly on the area of ethics, clinical nursing problems, health care of chronic patients and patient education.

Athanasios Sachlas is Statistician, Department of Nursing, University of Peloponnese, Sparta, Greece. His research interests include the development and application of stochastic models for process monitoring and the application of statistics on health sciences.

Panayota Sourtzi is Professor in Occupational Health Nursing, Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece. Her research interests include health promotion for adults and older persons, occupational and environmental health, patient education and health care of vulnerable populations.

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