Nursing Care Plan for Elderly
Assessment - Nursing Care Plan for Elderly
a. The identity of the patient
Include name, age, sex, religion, education, nation, and address.
b. Disorder found in elderly
Swallowing, communication, pain and others.
c. Mood, consciousness
Hostility, sleep disturbances, and others.
d. History of major problems
Ever stroke, cough, dementia, fractures.
e. Questionable health habits
Smoking, alcohol, and others.
f. Assessment system
Assessment system implemented in sequence starting from system requirements to the musculoskeletal system.
g. History of treatment
Well before the illness, drugs in drinking, both from a doctor's prescription or purchased free (including herbs).
h. Examination of the function
· Activities of daily living that require only simple body's ability to function such as sleeping, dressing, bathing.
· Activities of daily living
· In addition to basic skills that require different coordination ability of the muscle, the more nervous as well as various organs of other cognitive abilities.
· The ability of mental and cognitive function, especially regarding the intellect, memory and long memory about things that just happened.
Nursing Diagnosis for Elderly
1. Risk for injury: falls related to increased activity.
2. Acute pain: (headaches / dizziness) associated with fatigue.
3. Activity intolerance related to imbalance of O2 supply: weakness.
4. Risk for infection related to the state of nutrition: state of immunity.
Nursing Interventions for Elderly
1. Risk for injury: falls related to increased activity.
The client does not fall.
1. Explain to the client about the causes of rheumatic pains / aches.
R /: to understand the causes of line / curve.
2. Provide non-pharmacological measures to eliminate fatigue in the legs such as massage.
R / can stimulate pain in the leg.
3. Avoid doing heavy activity.
R / can reduce ached at the foot area.
4. Avoid foods that contain nuts.
R / can prevent arthritis.
5. Teach the foot by not using footwear in the morning.
2. Acute Pain: (headaches / dizziness) related to fatigue.
headaches / dizziness is reduced
Expected outcomes are:
· Headaches / dizziness is reduced.
· Not nervous.
· Not pale.
· Can not sleep.
· No pacing.
1. Explain to the client about the cause of headaches / dizziness.
R /: to understand the cause of headaches / dizziness.
2. Provide a description of the kx about the side effects of taking medications too often.
R /: understand the side effects of medication.
3. Give nonfarmakologi action to eliminate the headaches, such as a cold compress on the forehead, back and neck massage, a quiet, dim the lights, relaxation techniques.
R /: relieve headaches.
4. Give analgesics as indicated.
R /: to help relieve headaches.
3. Activity intolerance related to imbalance of O2 supply: weakness.
· Able to do the activity.
· Not tired.
· Do not bother.
· Vital signs are normal.
1. Review of daily activities.
2. Teach for leg exercises every hour / ROM.
3. Teach ± sit 3-5 minutes before standing and walking.
4. Increased frequency of activity and distance gradually.
5. Risk for infection related to the state of nutrition: state of immunity.
· There was no infection.
· Normal body temperature (36-370C).
· There is no redness, irritation around the wound.
· Normal leucocytes (10,000 m 4500-I)
1. Teach to minimize contact and pathogens.
2. Explain the need to maintain hygiene
(For example: Shower every day, oral care).
3. Examine the mouth and throat with signs of infection.
4. Teach drinking 200cc/hari.
5. Strive to improve nutrition, diit enough.
6. Provision of adequate vitamins and minerals.
About Elderly Assisted Care
Assisted care for the elderly is mainly geared toward people in assisted living facilities, nursing homes or continuing care retirement communities. Such care is also available for those people living independently, but who need assistance with limited or long-term care for certain tasks. Assistance for seniors might be anything from supervision of prescribed medication to personal care services by trained professionals, who usually work with health care or service providers on the elderly person's behalf.
o For many years, care for the elderly was usually aimed at those people who needed 24-hour assistance. But the concept has evolved over the past 20 years, as alternative measures began offering a wide variety of settings and services. These include at-home and out-of-the-home programs. Organizations have been formed to help lead seniors through the proper channels for their health concerns. One such group, the Consumer Consortium of Assisted Living (CCAL), was established in 1995 as a national education and advocacy association for support of quality care. It provides information on resources for the elderly in need.
o The definition of assisted care for the elderly varies from state to state and can include terms such as residential care, assisted care facilities, personal care, board and care, adult foster care, retirement residences, supported care and enhanced care. Licensing agencies in each state usually define the care terms and what each type of care is needed for the elderly.
o Assisted living facilities help with such activities of daily living (ADL) as eating, bathing, dressing, housekeeping and providing medications. Nursing homes are designed for the elderly who are not able to care for themselves. Continuing care retirement communities are for those who want to live independently with a wide range of services available. Independent living assistance is for people who want to stay in their home, but need some services.
o The goal of elderly assisted care is to provide a certain level of care and service while fostering independence and dignity for individuals. The costs and adverse consequences are greatly lessened by keeping senior citizens away from round-the-clock assistance as much as possible. There are more than a million elderly adults with disabilities who reside in assisted living facilities, in addition to people who live in their own homes but also need assistance. The number is expected to climb dramatically because of the aging population.
o Seniors themselves, health-care providers and loved ones can all play roles in deciding which type of care is needed. Expense can be a key factor. A long-term nursing care program may be expensive, but also the most cost-effective in the long run because there may be no increase in monthly payments. An inexpensive plan may include specific amounts of care, but additional care later on may prove to be expensive. Consulting with a financial planner can help in making decisions about assisted care.
Preventing Falls in the Elderly Long Term Care Facilities
The elderly long-term care
population is at increase risk for falls and fall related injuries. The implementation
of a fall prevention program is important for ensuring resident safety.
Systematically assessing residents’ risk for falls and implementing appropriate
fall prevention interventions can reduce the number of falls in the elderly
long-term care residents. The article reviews a clinical practice guideline
recommendation for implementation of a fall prevention program. Risk factors
affecting falls in the elderly residing in long-term care are examined.
Strategies for implementing a fall prevention program are discussed, including
barriers to implementation.
Preventing Falls in the Elderly Long Term Care Facilities
Falls pose a serious risk for the elderly living in long-term care facilities. An average nursing home with 100 beds reports 100 to 200 falls annually (George, 2000). Falls can cause serious injuries and accidental death, and in older people. Prevention of falls in the elderly living in long-term care facilities is very important, and requires several different approaches to deal with the unique factors which may predispose the elderly to this type of injury. This paper reviews the major risk factors of falls and current clinical guidelines in fall prevention for elderly populations living in long-term care facilities. The authors also propose key features and critical aspects of successful fall prevention programs based upon a synthesis of the literature from 1996-2009.
Significance of the Problem
A fall is defined as a sudden, unintentional change in position, which results in an individual either hitting the ground or another object below his or starting point (George, 2000). The American Medical Directors Association (AMDA) (2005) reports that falls are a significant cause of injury and death in the elderly living in long-term care facilities, and according to the Agency for Healthcare Research and Quality (AHRQ) (2009), falls are the leading cause of fatal and nonfatal injuries among Americans aged 65 and older, resulting in more than two million emergency room visits. The AHRQ (2009) also found that one in ten of these emergency room visits were related to injuries from falls, with a rise in visits as patients become older. Moreover, approximately 1,800 older adults living in long term care facilities die each year from fall-related injuries and many of these falls go unreported (Center for Disease Control [CDC] 2009).
What Influences this Issue?
The elderly in long-term care facilities are predisposed to falling and may fall for a variety of reasons. Predisposing factors include, unsteady gait and balance, weak muscles, poor vision, medications, and dementia. In addition, other factors such as poor lighting, loose rugs, poorly fitting shoes, floor clutter, and beds or toilets without handrails, also may cause falls (Jenson, Lundin-Olsson, Nyberg & Gustafson, 2002). Furthermore, medical conditions such as low blood pressure, stroke, Parkinson’s disease, arthritis, Meniere's disease (affects the middle ear - causes vertigo), poorly controlled diabetes, poorly controlled epilepsy, brain disorders and thyroid problem increase the elderly client’s risk for falls (Osteoporosis-Info.com, 2009).
Review of the
A study conducted by Neyens, et al (2009) evaluated the effectiveness of a multi-factorial intervention on the incidence of falls in psycho-geriatric nursing home patients. The study was conducted on one psycho-geriatric ward in 12 nursing homes in The Netherlands. Six nursing homes were allocated to the intervention group and six to the control group. The study reported that multi-factorial interventions to prevent falls that includes a general medical assessment focusing on falls; a specific fall risk evaluation tool; assessing fall history, medication intake, and mobility; and the use of assistive and protective aids have significantly reduced the incidence of falls. The researchers concluded that fall prevention targeted at psycho-geriatric patients in a nursing home setting is both possible and effective in reducing falls among those at the highest risk.
Kato, et al. (2008) conducted a study to develop a fall prevention program for elderly patients in long-term care facilities who are at risk for falls by increasing the care giving skills and the motivation of the staff members. Exercise program consisting of a warm-up, static stretching, muscle strengthening in the lower extremities, toe exercises, proprioceptive neuromuscular facilitation, and cool-down were used to increase motivation and increase the care-giving skills. The results of the study concluded that the fall prevention program helped to reduce injuries from 41.9% to 9.7% among the elderly participants while increasing the emotional support and self-efficacy among the staff members. Empowerment was considered a driving force for change. The fall prevention program demonstrated to be acceptable for use among elderly individuals in a long-term care facility.
A study conducted by Sherrington, Whitney, Lord, Herbert, Cumming, & Close (2008) examined the effects of exercise on fall prevention in the elderly worldwide. This systematic review of 44 trials with 9,603 participants revealed that the pooled estimate of the effect of exercise was that it reduced the rate of falling by 17%. The researchers concluded that this review provides strong evidence that exercise programs can reduce fall rates in older people. The sample size and astute methodology of this study provides confidence that these findings and may be generalizable to the larger population of elderly in long-term care facilities.
A study conducted by Wiens (2001) examined the role of the pharmacist in falls prevention in the elderly. The report concluded that the incidence and risks for falls could be decreased through interventions that include medication review with appropriate modifications to the elderly client’s medication regimen. Wiens explained that while there is not strong evidence for a pharmacist independently intervening to reduce falls, there is support for a pharmacist participating on a multidisciplinary team to review medications, provide appropriate suggestions to reduce high-risk medications, and provide education to the patient and the health care.
Hartikainem, Lonnroos & Louhivuori (2007) conducted a study to determine whether medication was a risk factor for falls. The study concluded that central nervous system drugs, especially psychotropics, seemed to be associated with an increased risk for falls. The researchers found that older adults taking more than three or four medications were at increased risk of recurrent falls. However, the studies included in the meta-analyses had minimal adjustment for confounding factors such as an underlying indication for drug use, dosage, or duration of pharmacotherapy.
Koski, Luukinen, Laippala & Kivela (1996) conducted a study to determine the physiological factors and medications predicting injurious falls among the elderly population in a rural home-dwelling population. The study showed some physiological factors and the use of some medications to be important risk factors. According to the study, lower-extremity muscle weakness, peripheral neuropathy, lower pulmonary capacity, difficulties in gait and use of long acting benzodiazepines and cardiovascular medications were the most important risk factors for injurious falls. The researchers found that the majority of injurious falls occurred when walking or taking a seat. Thus, training of lower extremities and supervised walking could be an effective nursing intervention for elderly clients.
a Fall Prevention Program
Implementing a best practice fall prevention program has proven to be successful in reducing falls in elderly long-term care patients. It is common knowledge that fall prevention is crucial for this population. Best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation (National Guideline Clearinghouse, 2009).
A fall prevention program should initially be piloted on one unit where it is likely to succeed before introducing it to the entire facility. A pilot study can reveal deficiencies in the project that can be addressed before time and resources are expended on a larger scale. Piloting on a unit will also allow closer monitoring of the results for evaluation before finalizing plans for program implementation.
Clinical Practice Guidelines
Clinical practice guideline recommendations important to the successful implementation of a fall prevention program are included in the best practices guideline published in the National Guideline Clearinghouse (2009). The guidelines are as follows:
Assessment: The clinical guidelines recommend assessing fall risks on admission and after a fall. Knowing who is at risks for falls is important in deciding who needs to be in the fall prevention program. Assessing after a fall is important when looking at root cause and interventions to preventing future falls. This is also important in determining if the current fall prevention intervention is effective.
Exercise: While this is not recommended as a stand alone intervention, the clinical guidelines recommend that nurses use strength training exercise as a component of a fall intervention program.
Multi-factorial: It is important when developing a fall prevention program to look at the predisposing and precipitating factors that affect a patient’s or resident’s fall risk. Implementing a variety of fall prevention interventions based upon known risk factors for falls the elderly can help in reducing future falls.
Medications: The clinical guideline recommends that nurses consult with the health care team and conduct periodic medication reviews to prevent falls among elderly in long term care settings. Clients taking benzodiazepine, tricyclic antidepressant, selective serotonin-uptake inhibitors, trazadone, or more than five medications should be identified as high risk for falls. Medication review should be conducted periodically throughout the institutional stay. Most elderly long-term care residents are on multiple medications, sometimes referred to as “polypharmacy”, which places them at increased risk for falls.
Client Education: The clinical guidelines recommend educating patients that have been determined to be at increased risk for falls. Educating the patient on falls and fall prevention interventions increases safety awareness and reduces the fear of falling. When developing educational materials for this population, the nurse educator should consider factors affecting the aging process, and utilize methods consistent with adult learning principles.
Environment: The clinical guideline recommends that nurses should include environmental modification as a component of fall prevention strategies. Examining the environment for wet areas, clutter, poor lighting, and other environmental factors can reduce the risk of falling in nursing home patients.
Strategies that can be used to facilitate incorporating the recommendations into clinical practice based upon guidelines of the National Guidelines Clearinghouse, 2009:
1. Establish a fall committee. The members should be committed to leading the initiative. Assign someone to document and track activities and timelines.
2. Assign a dedicated clinical resource nurse who will provide support, clinical expertise, mentorship, and leadership. The individual should also have good interpersonal, facilitation, and project management skills.
3. Develop or implement new
assessment tools and intervention products.
4. Plan and provide interactive educational sessions and in-service staff as necessary on an ongoing basis.
5. Promote and support successful implementation on each unit. Celebrate and acknowledge a job well done.
Resources Needed for Implementation
Implementation of the fall prevention program will require time, money and a collaborative effort from the staff. A change agent is helpful to launch a new program but the change must be carried out as a team/facility wide effort. There needs to be administrative and staff support for successful implementation and maintenance of the program (National Guideline Clearinghouse, 2009).
Cost of Implementation
The cost associated with implementing the fall prevention program would include the costs of risk management, time in the form of documentation and monitoring, any additional supplies and/or equipment, and staff training (National Guideline Clearinghouse, 2009). However, since fall-related injuries among older adults are associated with substantial economic costs which are typically much greater than the cost to implement an evidence-based fall prevention program, the benefits accrued from the implementation of such a program underscore the critical need to implement fall prevention programs in long-term care facilities (CDC, 2008).
Establishing Team Players
An interdisciplinary team structure is recommended to plan the fall prevention program, including assessment of nursing home readiness, development of clinical pathways and provision of education to both providers and patient on fall prevention. Members of this fall prevention team should include (National Guideline Clearinghouse, 2009):
· Physicians, preferably focused on a geriatric case;
· Nurses or nurse practitioners, preferably geriatric based;
· Social worker;
· Physical therapy;
· Administrators or managers.
Potential Barriers to Success
There may be some barriers to implementation a fall prevention program because human beings by nature may not like change. Staff may see this as additional work even when they understand the benefits of the program. However, the education of staff, patients, and families about fall risk and the fall prevention program should help to reduce these barriers over time.
1. Nurses should be educated in the use of a fall risk assessment tool, and should be able to describe the rationale for completing a fall assessment on admission, as well as after a fall. Staff should be familiar with different fall prevention interventions that are appropriate for each patient/resident based upon the result of the fall risk assessment.
2. Staff should be educated about predisposing and precipitating factors for falls and related prevention strategies and interventions. This will support them in understanding that fall prevention requires a multi-disciplinary approach. Staff needs to understand the different interventions available to them, in order to apply them when caring for patients.
3. Nurses should be educated about medications that increase the risk for falls in the elderly. In collaboration with the healthcare team, nurses should be able to conduct periodic reviews for elderly patients in their care.
4. Staff should understand and be able to implement environmental modifications as a component of fall prevention strategies.
It is very important to establish a baseline before the implementation of a fall prevention program. Determination of a current baseline for the incidence of falls in a healthcare facility, including any historical trends, is important to evaluate whether the falls prevention attempts are making any difference. Having baseline data and information should support staff buy-in for the fall prevention program. Ongoing data collection will provide concrete feedback on the impact of the interventions in preventing falls (Registered Nurses Association of Ontario [RNAO] 2005).
Falls can be measured in different ways; therefore it is important to ensure that a consistent definition for falls is utilized by staff to support accurate data. On admission, the following baseline data should be collected from the patient/resident (RNAO, 2005):
· Living arrangements before admission;
· Admission diagnostic category;
· Medical history (stroke, Parkinson’s disease, cancer, congestive heart failure, osteoporosis or fracture related to a fall);
· Cognitive impairment (mini-mental state examination);
· Functional dependency.
Risk management data will include the following information (RNAO, 2005).
· All residents who come to rest inadvertently on the ground or floor or other lower level;
· Falls may be observed or unobserved – it is important to collect both but to distinguish between the two;
· A history of falling (repeated falls) puts a resident at higher risk and therefore, collecting all falls per resident is important;
· It is also important to collect falls with or without injury;
· It is also important to distinguish the severity of the fall. There are no standards to this; however, minor injury would include scrapes, bruises; moderate may include gashes, sprains; severe may include fracture, and even death.
The primary desired outcome for a falls prevention project is to reduce falls among the elderly. The process outcome should include an interdisciplinary approach to fall prevention and management; increased availability of experts in fall prevention and management; and systematic program deployment and evaluation. Desirable patient outcomes would include increased knowledge about falls; increased strength, balance, and mobility; increased functional independence with use of exercise and assistive/adaptive devices as needed; increased confidence in abilities; and reduced severity of fall-related injuries.
The evaluation component is necessary to determine if the program is satisfactorily achieving what it was designed to achieve (McNamara, 1998). Evaluations produce data that can verify if a program is effective. The evaluation for this program should be outcomes based, in order to identify the benefits to the clients. The clients in this case include the patients or residents, and nursing home staff and administration.
Data analysis regarding fall prevention should include the quality management department, because the department will be able to put a review process in place to analyze reported fall event information on a routine basis for learning and improvement opportunities. Use of an incident report form for falls that is specifically designed to collect data based on evidence about factors contributing to fall occurrences is important in a fall prevention program. For example, data collected might include time of day, location, activity, orthostasis, and incontinence. From the analysis of the data, one can determine the type of fall, such as accidental, anticipated physiological, unanticipated physiological fall (Morse, 1997) and severity of injury i.e., minor, moderate or major. Analysis of data also enables clinicians, administrators, and risk managers to profile the level of fall risk for their patients, along with actual factors contributing to the falls, including the identification of overall patterns and trends surrounding fall occurrences. Fall rates and the severity of injury to the patient or resident should be considered when analyzing the effectiveness of the fall prevention program.
Dissemination of the Project
Implementation of a falls prevention program should be accomplished by involving the entire organization, and would include the organization and delivery of training and in-services tailored to the learning needs of the staff in healthcare facility. Once patient health and safety outcomes of a fall prevention program are determined and summarized, the overall evaluation and result may be disseminated to the surrounding community, and to healthcare professionals both locally and nationally.
Throughout a fall prevention program, the importance of finding a way to help nursing staff deal with the issue of patient falls is of utmost importance. Ultimately, the authors would like nursing staff to recognize how vital it is to be aware of the possibility of falls among the elderly, and to underscore the nurse’s responsibility to create an environment that will be safe for patients or residents in their care.
Implications for Nursing
If nurse administrators and educators work to increase knowledge about the incidence of falls in the elderly, and assist in the changing of attitudes, perceptions, and behaviors of nursing staff in relation to fall prevention among the elderly in the long-term care setting, they can help to enhance patient safety in their facilities. Through implementation of a fall prevention program nurse administrators and educators can help health care providers gain more confidence in their abilities to work with elderly persons in regard to fall prevention.
The implementation of the program can also assist nursing staff to become more knowledgeable about important fall prevention strategies, and provide them accurate information to share with patients and families. Giving nursing staff the opportunity to achieve excellence by learning ways to reduce the risk of falls in the elderly can effectively provide a means of establishing a safe, high quality care environment.
Fall prevention is an important and timely issue that needs to be address by all healthcare providers, and especially in the care of the elderly in long-term care facilities. Applying clinical practice guideline recommendations for fall prevention is important to the development of a successful fall prevention program. Implementation of this project will have a positive implications for nurses. The program will enhance nurses’ knowledge and boost their confidence in preventing falls among their residents. An effective fall prevention program can reduce falls and fall related injuries in the elderly long-term care residents, in turn supporting increased cost-effectiveness related to prevention of falls-related injury and mortality.
Patients' Perceptions of Nurses' Behaviour That Influence Patient Participation in Nursing Care: A Critical Incident Study
Patient participation is an important basis for nursing care and medical treatment and is a legal right in many Western countries. Studies have established that patients consider participation to be both obvious and important, but there are also findings showing the opposite and patients often prefer a passive recipient role. Knowledge of what may influence patients' participation is thus of great importance. The aim was to identify incidents and nurses' behaviours that influence patients' participation in nursing care based on patients' experiences from inpatient somatic care. The Critical Incident Technique (CIT) was employed. Interviews were performed with patients, recruited from somatic inpatient care at an internal medical clinic in West Sweden. This study provided a picture of incidents, nurses' behaviours that stimulate or inhibit patients' participation, and patient reactions on nurses' behaviours. Incidents took place during medical ward round, nursing ward round, information session, nursing documentation, drug administration, and meal.
Patients’ active participation in their own care is known to increase motivation and adherence to prescriptions, give better treatment results, create greater satisfaction with received care , and reduce stress and anxiety . Patient participation is an important basis for nursing care and medical treatment and it is also a legal right in many Western countries. Studies have established that patients consider participation to be both obvious and important [3, 4], but there are also findings showing the opposite  and patients may prefer a passive recipient role [6, 7]. Knowledge of what may influence patients’ participation is thus of great importance when it comes to meeting their expectations and demands.
Previous research focusing on patient participation from a patient perspective has been performed primarily in medicine and is carried out by physicians [8, 9]. Research on patient participation in nursing care has defined participation in performing clinical or daily living skills . Patient participation has been explored in different situations, for example, discharge planning [11–14] and bedside reporting  in emergency care  and has primarily focused on decision-making in treatment/care (e.g., [17–20]).
Although nursing theories emphasise participation (e.g., ) and studies have explored patient participation in different contexts and situations, there have not been congruence regarding definition, elements, and processes [8, 22, 23]. The lack of clarity is amplified by the use of several terms: patient/client/consumer/user involvement, collaboration, partnership, and influence [8, 17]. However, when the focus is on the patient perspective, the concept of patient participation is commonly used.
Empirical studies have identified conditions for patient participation. Sainio et al.  found that the patient needs to have the intellectual ability to understand and choose between alternatives and make decisions about their own nursing care and the nurse must provide adequate and correct information. Tutton  emphasized the significance of developing a relationship between nurse and patient and the importance of understanding the patient as well as gaining and retaining an emotional connection. According to Sahlsten et al. , a nurse needs to use strategies including building close co-operation with the patient, getting to know the person, and reinforcing self-care capacity.
Factors restricting participation were identified by Wellard et al. : limited communication between nurses and patients, task-oriented nursing labour, and environmental constraints limiting patients’ privacy. Eldh et al.  found nonparticipation; when patients lack an equal relationship, respect, and information. According to Efraimsson et al. , nonparticipation, occurs when professionals are not attuned to the concerns of the patient and individual needs and when they literally silence or disregard the patient’s wishes. Sahlsten et al.  found that a nurse can lack theoretical or practical knowledge required as well as an insight that patient participation requires deliberate and planned interaction between nurse and patient together with adjusted actions within every encounter. Larsson et al.  recently presented barriers for participation from a patient perspective: facing own inability, meeting lack of empathy, meeting a paternalistic attitude, and sensing structural barriers.
While several studies have addressed patient participation, few accounts exist based on patients’ descriptions of decisive incidents that influenced their participation in nursing care. Accordingly, there is a need to explore situations related to critical incidents that influence patient participation. The aim of this study was to identify incidents and nurses’ behaviours that influence patients’ participation in nursing care based on patients’ experiences from inpatient somatic care.
This study is part of a larger project regarding patient participation in nursing care from the perspective of both patient and nurse. A qualitative approach, using the Critical Incident Technique (CIT), was employed. The CIT is a systematic, inductive, and flexible method where specific descriptions of human behaviour in defined situations are collected . The method is useful in solving practical problems. The central concept in CIT is a critical incident which is a maior event of great importance to the person involved. The incidents are mostly collected in semistructured face-to-face interviews , the most satisfactory data collection method in CIT for insuring that all the necessary details are supplied . The informants are asked to provide descriptions of specific incidents, positive and/or negative, which they perceive as significant. Here, these descriptions were collected within the framework of the interview method in order to generate an adequate depth of response. The number of incidents required depends on the complexity of the problem under investigation. It is usually sufficient to collect a total of 100 incidents for a qualitative analysis .
The participants in this study were recruited from somatic inpatient care. The selection was purposeful. The intention was to have a range of informants able to contribute their experience as patients. The informants were ambulatory patients from three internal medical wards with neither an explicit care philosophy emphasising patient participation, nor a focus on nurse-patient continuity. The wards were focused on (i) stroke, (ii) disorder of kidney and heart, and (iii) lung. All informants were able to communicate in Swedish and had no physical or cognitive deficits hampering the ability to describe their experiences as patients. The time spent on the ward varied from 4 to 19 days. Eight men and nine women participated. Their ages ranged 28–91 years.
2.2. Data Collection
Data were collected by means of semistructured interviews. Nursing care was explained as the interplay with Registered Nurses. The interviewer assisted the patients to describe the specific incidents that have influenced their participation in nursing care. The interview guide consisted of the following questions: describe a positive significant incident which was successful for your participation in your own nursing care, and describe a negative significant incident where you felt nonparticipation. After the patient had identified an event, the following questions, earlier used by Kemppainen , were asked: what were the circumstances leading to that event?, exactly what did the nurse do?, how did you respond to the nurse?, and how did the nurse’s actions affect your behaviour?. The same wording in the questions was kept throughout all interviews, as recommended by Flanagan .
The informants were recruited from an internal medical clinic in a central hospital in West Sweden. Written permission was obtained from the head of the clinic. The head nurse of each ward was contacted by telephone and given information. All the nurses on the selected wards were sent written information regarding aim and procedure. The nurses were asked to approach patients the day before an interview was scheduled and ask whether they were interested in participating in the study or not. Verbal and written information was given to those willing to participate. On the morning of a planned interview, written informed consent was obtained. The interviews were held in the patient’s own room or adjacent to the wards in a place where there would be no interruption in order to provide a relaxed environment. Each interview was conducted in an open, friendly atmosphere by the main nurse researcher and lasted between 30 and 60 minutes. Each interview was audio-taped and transcribed verbatim by the main researcher (Inga E. Larsson).
2.3. Ethical Issues and Approval
The ethics of scientific work was followed. Each study participant gave his/her written consent after verbal and written information. The Ethics Committee of Gothenburg approved the study (no. 176-06).
2.4. Data Analysis
The data material was read repeatedly to obtain a sense of the whole. In the data reduction process, the first step was to identify and mark critical incidents. An incident, either negative or positive, was identified as critical if it was related to the aim of the study and based on a detailed and discernible narrative of a course of events with a distinct start and end. In the data material, a total of 105 critical incidents were identified. Each informant provided between two and 31 incidents. In line with the CIT tradition , the classification started with identification and extraction of the incidents. These were analysed, without consideration whether positive or negative, to find similarities. In the second step of analysis, positive and negative incidents were identified as two main areas. Different kinds of nurse behaviours were next identified and classified, followed by patients’ responses of these behaviours. Early in the analysis, the number of nurse behaviours increased rapidly and the last three interviews resulted in no new behaviours. To increase credibility, the classifications were discussed by the researchers (Inga E. Larsson, Monika J. M. Sahlsten) as no coassessor was involved in the coding. In addition, two researchers (Kerstin Segesten, Kaety A. E. Plos) not earlier involved in the study examined the classifications including direct quotations. A few clarifications were then made. This final classification system consisted of two main areas and 16 nurse behaviours allocated to six patient responses.
The incidents arise in everyday situations and illuminate both positive and negative turning points (Table 1). They mirror different situations in encounters between patient and nurse. The most frequently described incidents concern situations during medical ward round where the nurse provides no support for patient input, and examples are also given of no preparation ahead of the round. Other incidents concern situations during nursing ward round describing genuine interest and search for patients’ experience and views but examples are also given of distance with limited support for patient input. Incidents also describe situations during information session where the nurse provides meaningful and sufficient information but there are also descriptions of missing, insufficient, or inadequate information. The incidents concerning nursing documentation include descriptions of no invitation to participate and examples are also given of no recording of the patients’ views. Other incidents concern situations during drug administration where the nurse leaves it to the patient to decide about tablet dosage for pain treatment but there is also examples of when the nurse provides no tablet for sleeping problems as well as routinely interrupts pain treatment infusion with little or none consideration to the individual. The least described type of incidents is meal which include examples of opportunity to choose where and when as well as what to eat and how much.
Table 1: Incidents and turning points based on patients’ narratives of critical incidents.
In the next step of analysis, positive incidents were identified as stimulating patient participation and the negative incidents as inhibiting. In Table 2, an overview of these two main areas along with patients’ responses to nurses’ behaviours are provided. The nurses’ behaviours are illuminated using direct quotations that illustrate the connection with the narratives.
Table 2: An overview of the two main areas along with patients’ responses to nurses’ behaviours, based on patients’ narratives of critical incidents.
3.2. Stimulating Patient Participation
3.2.1. Regarded as a Person
When nurses care about patients and show a genuine interest, they feel treated and accepted as a unique person. The informants emphasised the importance of not being seen solely as an illness or a bed number. Nurses showed that they were accessible: “The nurse was there when I needed it. She was personal towards me, took her time and sat down with me.” The nurse confirmed the patient by showing “that she cared and wanted to get to know me. She could really confirm my feelings, I felt I was believed”. The fact that the nurse listened and asked questions was considered crucial: “She really listened to me and understood my situation. She asked questions to get an overall picture of my condition and find out what I like and want. Questions also mean that I have to reflect all the time. It helps me to understand my thoughts and how I can process different things.”
3.2.2. Engaged through Information
When nurses provide information adapted to the patient’s needs, he/she is motivated to actively participate in own care. The nurse gave the necessary explanations: “She made sure I got the information I wanted and needed. It was really good getting it from one and the same nurse. She explained what the illness meant and how it was all connected, for example, why I took this pill and was given that injection. I was given time to think and ask questions, so I know what it is all about.” The nurse also gave written material: “I was given brochures and books to read, which enabled me to form my own opinion and understand better how it is all connected. Then it was easier for us to talk about my illness and what was going to happen next.” It was considered important that the nurse acts as a mediator of contacts: “She helped me so that I got to talk with other patients about their experiences and the treatment I was going to begin on. The nurse also took me on a guided tour to say hello on the ward where I was going to be treated and see how it all works.” The informants also emphasised the importance of the nurse giving tips about self-care: “I was given tips about what to do to make it easier, how to take care of the bandage, give the injections at home, and take care of myself when it comes to food and exercise.”
3.2.3. Acknowledged as Competent
When the nurse starts with and utilizes patients’ own knowledge, they feel as an asset in their cooperation. The nurse discussed and made agreements: “She always included me in discussions because she needs my knowledge, said I was an expert. Nothing was done until we had had a discussion. I was involved and in control.” The nurse also handed over responsibility: “I have been allowed to decide on my pain treatment and I take the pills when I need them. That means I do not have to press the call button as soon as it hurts and then I can wait longer so that I do not get so drugged and constipated.”
3.3. Inhibiting Patient Participation
3.3.1. Abandoned without Backup
When a nurse, who is expected to provide support, seems to view patients in an unreflected way, they feel alone, ignored, and let down. A nurse withdrew from the patient: “I was so unhappy and she just looked at me indifferently. She must have thought that I could do that myself and was just trying to get out of it. You have to dare meet person to person.” A nurse was non-supportive during the medical ward round: “I tried to give my views during the round and didn’t get any help from the nurse. She was silent and didn’t dare back me up in front of the physician. They talked about me, but I wasn’t asked a single question; I felt ignored and upset. It would have been better to have been backed up directly instead of her coming back afterwards and trying to put everything right.”
3.3.2. Belittled Verbally
The way a nurse communicates can make patients feel depreciated. A nurse disparaged a patient with baby talk: “The nurse talked to me like I was a child; that belittles me as a person and gives an impression of insincerity.” A nurse made ironic remarks about an experience: “I was told to point at a ruler and got the answer: my dear, you can’t be in that much pain. If you were, you’d be both in a cold sweat and more affected. Now, you just think about it one more time.”
3.3.3. Ignored without Influence
When a nurse seems to want to exercise control and does not attach any importance to patients’ views, they feel ignored and unable to participate and exert an influence. A nurse made the decisions herself and rejected the patient’s views: “She took control of everything. When I said we should do like this instead, the nurse said: you don’t understand this, what are you making a fuss for. She thought I was trying to correct her.” A nurse answered curtly: “I am inquisitive and the nurse only answered very briefly. I was constantly being told: we’ll have to wait and see what the physician has to say. Surely, it is possible to answer one of my questions reasonably. Maybe she’s not allowed to tell me, but she could at least tell me that.” A nurse neglected making notes in records: “She didn’t write what I has asked to be written in my record. I think that is misconduct. When so many people are involved in my care, what is written down is important and it is often wrong; that scares me. When I read the epicrisis of the nursing care plan, I saw that they had copied the old one. It would have been good if I had been allowed to take part in the planning and evaluated my care.”
This study, based on patients’ experiences from inpatient somatic care, provided a picture of incidents, nurses’ behaviours that stimulate or inhibit patients’ participation and patient reactions on nurses’ behaviours. The patients are in the best position to make the necessary observations and evaluations. A purposeful sample was used in order to obtain a varied picture of critical incidents of significance for patient participation. In this study, 17 inpatients provided a total of 105 critical incidents which, according to Flanagan , may be sufficient for a meaningful analysis. The findings are based on these informants and their ability to describe experiences of patient participation in nursing care. Although a majority of these informants were able to name some of the registered nurses on his/her ward, it is not certain that they in fact were able to distinguish “nursing” from experiences with other care providers.
The sample included informants with different experiences, which increases the possibility of shedding light on the researched question from a variety of perspectives. Various ages, diagnoses, wards, and cultural backgrounds contributed to a rich variation which, taken as a whole, can be regarded as a strength. Actions were taken to enhance credibility in data collection. At the end of each interview, the main conclusions were verbally summarised by the interviewer and the informant supplemented, verified, and further developed the content. When 14 interviews had been conducted, earlier data were replicated and nothing new was added. The interviews were conducted and transcribed verbatim in their entirety by the same person, which enhanced the trustworthiness of the data material collected.
Credibility in the analysis was enhanced by continuously switching between the whole and the parts, and comparing and revising until a final classification emerged from the data material. Rigor was ensured by systematically handling the data, repeatedly reading, identifying, and reflecting on the critical incidents. To increase credibility, two of the authors (Inga E. Larsson and Monika J. M. Sahlsten) discussed the classifications including direct quotations in order to reduce bias which is recommended by Flanagan . Finally, two researchers (Kerstin Segesten and Kaety A. E. Plos) not previously involved in the study reviewed and commented on the classifications, which included citations.
This study is based exclusively on the patients’ experiences. To provide a more complete picture, a future study may include observations of interactions between nurses, physicians, and patients but also interviews afterward to get their perspectives on why they behaved the way they did. Many factors influence each interaction, and asking why could provide more insight and knowledge. Only inpatient somatic care has been highlighted and, obviously, other patients and settings need to be explored.
The findings reveal incidents that arise in everyday situations on a hospital ward. The incidents pinpoint situations in which nurses may risk to overstep the mark. Medical ward rounds still seem to be an incident not conducted in a democratic fashion. Patients seem to have limited opportunities to actively participate. Weber et al.  states that the rounds serves as a central marketplace for information where the main topic for physicians and nurses is medical information. The patients are only asked in order to reach agreement on decision-making or checking outcomes of treatment. Nursing documentation seems also to be an incident where patients have limited opportunities to exercise influence. The hierarchical nursing classification system carried out in detail may mainly serve organisational and administrative purposes  and therefore disregard the patients. The goal has been to record work done by nurses and to provide evidence for performed interventions. Accordingly, nursing documentation is regarded as a matter for nurses and the fact that patients also have views on its content seems to have been noticed earlier in only two studies of patient participation [4, 28]. Drug administration appears to be an incident where ward policies and protocols seem to be emphasised rather than an individual’s comfort needs. Pain is an individual experience where patient participation is of uttermost importance for the recovering . The most basic nursing care situations such as participation in daily living skills are not described with the exception of meals, indicating that it may be obvious and/or of minor importance.
The findings reveal that stimulating patients’ participation occurred when nurses treated the patient as a valuable coworker. This emphasises the importance of a person-centred care and of achieving a genuine connection and trusting companionship, in line with Tutton  and Sahlsten et al. . Each patient’s own capacity needs to be reinforced in order to optimise participation where patient and nurse share control and responsibility. To achieve this balance, a nurse ought to develop a personal, “ordinary”, and spontaneous approach in nursing practice. Morrison  states that this promotes recovery and makes patients feel good in themselves. Our findings highlight that if patients are to feel regarded as unique persons, it is crucial to break free from preconceptions and assumptions of what their needs are and enter into each patient’s world. Patients need to feel that the nurse understands their situation and unique prerequisites, which is a starting point for being actively involved in one’s own nursing care.
According to the informants, it is important to become motivated and engaged through information. Information constitutes the basis of patient participation . It might be helpful to think of the patient as using and trying to implement evidence-based practice, as pointed to by Edwards . Patients need to find acceptable interpretations of what is happening to them, which is essential for participation. Patients collect information and take action according to their own assessment of credibility and trustworthiness of information given . If different nurses appear to provide contradictory information or opinions, the patient could be confused as it means that the starting point for coping and action strategies keeps changing. Consequently, information needs to be adequate, individually adjusted, coordinated, and univocal. To meet the patients’ needs, nurses have to use pedagogical strategies that promote learning such as focusing on the patient’s process of reflection. This implies in-depth questions to induce patients to be self-reflective in order to utilise their own full potential in line with Sahlsten et al. .
The findings suggest that a patient, who is acknowledged as competent, presupposes stimulation and encouragement as a successful doer and owner of knowledge, in line with Hughes  and Tutton . Patients’ desire to do as much as they can by themselves may be seen as a basic human characteristic. Consequently, it is only the patient who can decide what is in his/her own best interest and nurses are then engaged in supporting. If possibilities to choose and make decisions are maximised, this may result in increased motivation to take responsibility, and exert influence and control [36, 39]. According to the informants, this leads to a sense of independence, which increases well-being, but a nurse then needs to relinquish some control, rather than exerting it.
The findings reveal that inhibiting patients’ participation occurred when nurses treated patients so they felt neglected and as a helpless object of a nurse’s actions. This seems to indicate that a person-centred approach is devalued in favour of a task-centred one. It also indicates a maintained traditional power imbalance where a nurse is in control. This prevents companionship, which is essential for patient participation. A nurse might have a limited understanding of professional nursing care and focus on tasks, which could result in the patient easily becoming a passive object .
When patients perceive themselves as being abandoned without backup, this indicates that nurses may use a protective mechanism to screen off emotional or advocacy aspects of their work. This may be due to working under time pressure or an idea that connecting with the patient is risky in a professional relationship. The patient is left abandoned and lonely. A patient needs genuine understanding and support. Nurses may need both practical and personal support to reduce a use of blocking behaviours to be able to work in a more responsive and effective way. In order to continuously develop self-awareness and critical monitoring skills, a professional nurse can participate in, for example, clinical nursing group supervision. This may increase nurses’ ability to reflect and develop their behaviour in patient encounters.
To provide sufficient support during medical ward rounds was surprisingly an expectation on nurses by all informants. In order to optimise patient participation, nurses need courage to back up patients to reach self-advocacy and also to be sufficiently confident to question procedures, which are to the patient’s disadvantage. However, nurses can see themselves as, and acts as, an intermediary with the physician. The rounds are then perceived as “his show” which may lead to hesitation to interfere. Rounds have long been criticised for taking place with little or no patient input. Patients rarely get explanations or are encouraged to ask questions , an outdated routine that does not satisfy the demands of patients today. If medical ward rounds should continue in its present shape, patients need information regarding its actual aim, which seems to be to, as physician, get a face on the patient for whom the care planning is done .
When patients feel belittled verbally, a nurse may exercise the power of language or behave as a parent figure, also pointed to by Hewison . This reinforces a patient’s vulnerability and inhibits open communication and cooperation. The nurse disparages the patient in order to be in charge and sets the parameters for what is acceptable. McCabe  claims that professional nurses need to be aware of the impact the way they choose to communicate has on their patients. Communication is a powerful tool that mediates ideas, attitudes, and information, but it can also reinforce nurses’ authority and hinder or exclude patients so they become increasingly dependent according to Kettunen et al.  or result in reluctance.
Being ignored without influence mirrors nonrespect and no recognition of patients’ requests and their right to participate. By recording the patients’ views, things they regard as important will be revealed and made visible, also pointed to by Kärkkäinen and Eriksson . This presupposes that the recorder knows the patient, which perhaps was not the case here. When a nurse neglects the importance of written documentation, the informants here felt that they were exposed to risks. Records can be used as working documents for both parties which may improve the content. We recommend that a nurse provide a notebook and encourage patients to keep their own notes. This could support them to remember, prepare for meetings for example, rounds, and ask questions. It can also help patients to participate and take a higher degree of control in their own care.
When nurses have a bossy or patronising attitude, this reflects a belief that it is the nurse who knows best what is in the patient’s interest. This results in the patient being excluded, in line with Henderson . The level of control that nurses themselves have over their practice has been shown to affect the level of active patient participation . If nurses perceive themselves as diminished and not seen, they may repress patients. Empowering the patient can only be accomplished if nurses themselves are empowered .
This study, based on patients’ experiences from inpatient somatic care provided a picture of incidents, nurses’ behaviours that stimulate or inhibit patients’ participation and patient reactions on nurses’ behaviours. In order to promote patient participation, nurses need to be aware of the situations where they could overstep the mark and which of their own behaviours lead to promotion or hindrance. Our findings suggest that there is scope for developing nurses’ behaviours in order to activate patients in their own nursing care. The findings may increase understanding of patient participation in nursing practise, education, policymaking, and evaluation. Further verification of the findings is recommended, either by means of replication or other studies in different settings.
2. S. Lauri, “Developing the nursing care of breast cancer patients: an action research approach,” Journal of Clinical Nursing, vol. 7, no. 5, pp. 424–432, 1998. View at Scopus
3. S. Nordgren and B. Fridlund, “Patients' perceptions of self-determination as expressed in the context of care,” Journal of Advanced Nursing, vol. 35, no. 1, pp. 117–125, 2001. View at Publisher · View at Google Scholar · View at Scopus
4. I. E. Larsson, M. J. M. Sahlsten, B. Sjöström, C. S. C. Lindencrona, and K. A. E. Plos, “Patient participation in nursing care from a patient perspective: a grounded theory study,” Scandinavian Journal of Caring Sciences, vol. 21, no. 3, pp. 313–320, 2007. View at Publisher · View at Google Scholar · View at PubMed · View at Scopus
6. J. Sims, “What influences a patient's desire to participate in the management of their hypertension?” Patient Education and Counseling, vol. 38, no. 3, pp. 185–194, 1999. View at Publisher · View at Google Scholar · View at Scopus
7. J. Florin, A. Ehrenberg, and M. Ehnfors, “Clinical decision-making: predictors of patient participation in nursing care,” Journal of Clinical Nursing, vol. 17, no. 21, pp. 2935–2944, 2008. View at Publisher · View at Google Scholar · View at Scopus
8. J. O. Cahill, “Patient participation—a review of the literature,” Journal of Clinical Nursing, vol. 7, no. 2, pp. 119–128, 1998. View at Scopus
9. T. Schoot, I. Proot, R. Ter Meulen, and L. De Witte, “Recognition of client values as a basis for tailored care: the view of Dutch expert patients and family caregivers,” Scandinavian Journal of Caring Sciences, vol. 19, no. 2, pp. 169–176, 2005. View at Publisher · View at Google Scholar · View at PubMed · View at Scopus
10. P. Saunders, “Encouraging patients to take part in their own care,” Nursing times, vol. 91, no. 9, pp. 42–43, 1995. View at Scopus
11. K. Roberts, “Exploring participation: older people on discharge from hospital,” Journal of Advanced Nursing, vol. 40, no. 4, pp. 413–420, 2002. View at Publisher · View at Google Scholar · View at Scopus
12. E. Efraimsson, P. O. Sandman, L. C. Hydén, and B. H. Rasmussen, “Discharge planning: fooling ourselves? Patient participation in conferences,” Journal of Clinical Nursing, vol. 13, no. 5, pp. 562–570, 2004. View at Publisher · View at Google Scholar · View at PubMed · View at Scopus
13. E. Efraimsson, P. O. Sandman, and B. H. Rasmussen, ““They were talking about me”—elderly women's experiences of taking part in a discharge planning conference,” Scandinavian Journal of Caring Sciences, vol. 20, no. 1, pp. 68–78, 2006. View at Publisher · View at Google Scholar · View at PubMed · View at Scopus
19. S. Henderson, “Influences on patient participation and decision-making in care,” Professional Nurse, vol. 17, no. 9, pp. 521–525, 2002. View at Scopus
20. S. Wellard, J. Lillibridge, C. Beanland, and M. Lewis, “Consumer participation in acute care settings: an Australian experience,” International Journal of Nursing Practice, vol. 9, no. 4, pp. 255–260, 2003. View at Scopus
24. E. M. M. Tutton, “Patient participation on a ward for frail older people,” Journal of Advanced Nursing, vol. 50, no. 2, pp. 143–152, 2005. View at Publisher · View at Google Scholar · View at PubMed · View at Scopus
28. I. E. Larsson, M. J. M. Sahlsten, K. Segesten, and K. A. E. Plos, “Patients’ perceptions of barriers for participation in nursing care,” Scandinavian Journal of Caring Sciences. In press. View at Publisher · View at Google Scholar · View at PubMed
29. J. C. Flanagan, “The critical incident technique,” Psychological Bulletin, vol. 51, no. 4, pp. 327–358, 1954. View at Publisher · View at Google Scholar · View at Scopus
31. J. K. Kemppainen, “The critical incident technique and nursing care quality research,” Journal of Advanced Nursing, vol. 32, no. 5, pp. 1264–1271, 2000. View at Scopus
32. H. Weber, M. Stöckli, M. Nübling, and W. A. Langewitz, “Communication during ward rounds in Internal Medicine. An analysis of patient-nurse-physician interactions using RIAS,” Patient Education and Counseling, vol. 67, no. 3, pp. 343–348, 2007. View at Publisher · View at Google Scholar · View at PubMed · View at Scopus
33. O. Kärkkäinen and K. Eriksson, “Recording the content of the caring process,” Journal of Nursing Management, vol. 13, no. 3, pp. 202–208, 2005. View at Publisher · View at Google Scholar · View at PubMed · View at Scopus
34. E. Manias, “Pain and anxiety management in the postoperative gastro-surgical setting,” Journal of Advanced Nursing, vol. 41, no. 6, pp. 585–594, 2003. View at Publisher · View at Google Scholar · View at Scopus
P. Morrison, Understanding the Patients, Baillière Tindall,
38. S. Hughes, “Promoting independence: the nurse as coach,” Nursing Standard, vol. 18, no. 10, pp. 42–44, 2003. View at Scopus
44. T. Kettunen, M. Poskiparta, and P. Karhila, “Speech practices that facilitate patient participation in health counselling—a way to empowerment?” Health Education Journal, vol. 62, no. 4, pp. 326–340, 2003. View at Publisher · View at Google Scholar · View at Scopus
45. S. Henderson, “Power imbalance between nurses and patients: a potential inhibitor of partnership in care,” Journal of Clinical Nursing, vol. 12, no. 4, pp. 501–508, 2003. View at Publisher · View at Google Scholar · View at Scopus
46. D. Allen, “'I'll tell you what suits me best if you don't mind me saying': 'Lay participation' in health-care,” Nursing Inquiry, vol. 7, no. 3, pp. 182–190, 2000. View at Scopus