SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCE UNIVERSITY OF GHANA FACTORS INFLUENCING PATIENTS’ WILLINGNESS TO PARTICIPATE IN THEIR NURSING CARE: A STUDY AT THE NSAWAM GOVERNMENT HOSPITAL BY LAARI KANTAM CLETUS 10552545 THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF PHILOSOPHY DEGREE IN NURSING JULY, 2017 i DECLARATION I Laari Kantam Cletus hereby affirm that this thesis is the product of my own research except for references of peoples‘ work and textbooks which I have acknowledged accordingly. This research was carried out under the supervision and guidance of Dr. Kwadwo Ameyaw Korsah and Mrs. Gladys Dzansi, both of the School of Nursing and Midwifery, University of Ghana. This research has not been fully or partly submitted for any other degree, neither has it been submitted concurrently in candidature for any other degree. Laari Kantam Cletus Signature…………………. Date……………………… (Candidate) Dr. Kwadwo Ameyaw Korsah Signature………………… Date……………………… (Supervisor) Mrs. Gladys Dzansi Signature………………... Date…………………….. (Co-Supervisor) i DEDICATION I dedicate this work to my parents and all my friends who have been very instrumental in my upbringing and educational progression. ii ACKNOWLEDGEMENT My heartfelt gratitude and appreciation goes to the respondents of this study for their time and effort in completing the questionnaire. Special thanks also go to the Dean of the School of Nursing, Prof.Ernestina Donkor and my supervisors, Dr. Kwadwo Ameyaw Korsah and Gladys Dzansi (Department of Adult health, School of Nursing; University of Ghana) for their time and patience in providing me with all the necessary guidance and support throughout the period of this work. Many thanks also go to the administrators, staff and Colleagues of the MPhil/MSc class of 2015 for their moral support and assistance especially during my bereavement in the course of this study. My final and profound acknowledgement and appreciation go to my late father (Mr. Kondiang Laari) and my mum (Kondiang Mary) for their unflinching encouragement and commitment towards the course of my education and carrier development. iii LIST OF ABBREVIATIONS ATT: Attitude BI: Behavioural Intentions ID: Identification Number PBC: Perceived Behavioural Control SN: Subjective Norms SPSS: Statistical Package for the Social Sciences TPB: Theory of Planned Behaviour WHO: World Health Organization iv ABSTRACT Background: Patients' participation in their care is an important component in the delivery of quality health care. Patients‘ willingness to participate in their care is assumed to be influenced by attitude, subjective norms and perceived behavioural control. However, there is a paucity of evidences on the relation between patients‘ participation and their behavioural intentions. Aim: The aim of this study was to explore the factors influencing patients‘ willingness to participate in their nursing care. Method: A cross-sectional descriptive study was conducted. Theory of planned behaviour questionnaire was administered to 380 respondents who were conveniently sampled from the Nsawam government hospital, Ghana. Descriptive, correlation and regression analysis were run to categorise and compare data. Results: Majority of respondents (n = 359, 94.5%) participated in their nursing care. Attitude (M = 39.98, SD = 4.38), subjective norms (M = 22.62, SD = 3.28), Perceived Behavioural Control (M = 132.4, SD = 38.11) and Behavioural Intentions (M = 18.07, SD = 2.69) influenced Patients‘ willingness to participate in nursing care. Significant positive relationship was observed between Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions (P<.001). There was also significant positive correlation between Behavioural Intention and actual participation (< .05) and between indirect attitude and actual participation (< .05). 26.240, P<.005). Indirect attitude, religion, sex, direct subjective norms and direct attitude predicted patients‘ participation in nursing care. Conclusion: Patients are willing to participate in their nursing care therefore nurses ought to include patients in their care. Participation in care is influenced by attitudes, societal expectations, values and norms and these must be recognised and integrated in the care of patient. Key words: Attitude, Participation, Subjective norm, Behavioural control, Behavioural Intentions v TABLE OF CONTENTS DECLARATION ............................................................................................................... i DEDICATION .................................................................................................................. ii ACKNOWLEDGEMENT ............................................................................................. iii LIST OF ABBREVIATIONS ........................................................................................ iv ABSTRACT ...................................................................................................................... v TABLE OF CONTENTS ................................................................................................ vi LIST OF TABLES .......................................................................................................... ix LIST OF FIGURES ......................................................................................................... x CHAPTER 1: INTRODUCTION AND BACKGROUND OF THE STUDY ............ 1 1.1 Background .................................................................................................. 1 1.2 Statement of the Problem ............................................................................ 3 1.3 Purpose of the Study .................................................................................... 6 1.4 Objective of the Study ................................................................................. 6 1.5 The specific objectives of the proposed study were: ................................... 6 1.6 Research Questions ...................................................................................... 7 1.7 Significance of the Study ............................................................................. 7 1.8 Organization of the Work ............................................................................ 8 1.9 Operational Definition ................................................................................. 8 CHAPTER 2: LITERATURE REVIEW ..................................................................... 10 2.1 Theoretical Framework .............................................................................. 11 2.2 Theory of Planned Behaviour .................................................................... 12 2.2.1 Attitudes ............................................................................................... 13 2.2.2 Subjective Norms (Normative Beliefs)................................................ 13 2.2.3 Perceived Behavioural Control (Control Beliefs) ................................ 14 2.2.4 Behavioural Intention .......................................................................... 14 2.3 Behaviour ................................................................................................... 15 2.4 The concept of patient participation .......................................................... 16 2.5 Features in Patient Participation ................................................................ 18 vi 2.6 Attitudes in Patient‘s Participation ............................................................ 20 2.7 Subjective Norms in Patient Participation ................................................. 24 2.8 Perceived Behavioural Control in Patient‘s Participation ......................... 26 2.9 Behavioural Intentions in Patient Participation ......................................... 28 2.10 Relationship between Attitude, Subjective Norm, Perceived Behavioural Control and Behavioural Intentions towards patient participation in nursing care ......................................................................................................................... 30 2.11 Relationship between Attitude, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Participation .......................................... 31 2.12 Predictors of Patient Participation in Their Nursing Care ....................... 32 2.13 Summary of Literature review ................................................................. 34 CHAPTER 3: METHODOLOGY ................................................................................ 36 3.1 Research Design ........................................................................................ 36 3.2 Research Settings ....................................................................................... 36 3.3 Target Population ...................................................................................... 37 3.3.1 Inclusion Criteria ................................................................................. 37 3.3.2 Exclusion Criteria ................................................................................ 37 3.4 Sampling Technique and Size ................................................................... 38 3.5 Data Collection Tool ................................................................................. 39 3.6 Data Collection Procedure ......................................................................... 40 3.7 Data Analysis ............................................................................................. 41 3.8 Validity and Reliability of Study ............................................................... 41 3.9 Ethical Consideration ................................................................................ 42 CHAPTER 4: FINDINGS OF THE STUDY ............................................................... 44 4.1 Descriptive Characteristics of Respondents .............................................. 44 4.2 Patients‘ Participation in Nursing Care ..................................................... 45 4.3 Influence of Respondents‘ Attitude in their willingness to participate in their nursing care ...................................................................................................... 46 4.4 Subjective Norms Influencing Patients‘ Willingness to participate in their nursing care ...................................................................................................... 49 4.5 Intentions Influencing Patients‘ Participation in their Nursing Care ........ 52 vii 4.6 Perceived Behavioural Control (PBC) in patient participation in their Nursing Care .................................................................................................... 53 4.7 Relationship between Patients‘ Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions? .......................................... 55 4.8 Correlation Between Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intention and Patient Participation in their Nursing Care. ......................................................................................................................... 56 4.9 Predictors of Patients‘ Participation in Their Nursing Care ...................... 57 CHAPTER 5: DISCUSSION OF FINDINGS ............................................................. 61 5.1 Role of Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions in Patients‘ Willingness to Participate in their Nursing Care. ................................................................................................................. 61 5.2 Relationship between Patients‘ Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions. ........................................... 65 5.3 Relationship between Patients‘ Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Actual Participation in Their Nursing Care. ................................................................................................... 67 5.4 What are the Predictors of Patients‘ Willingness to participate in their Nursing Care .................................................................................................... 69 CHAPTER 6: SUMMARY, IMPLICATIONS FOR NURSING, CONCLUSION AND RECOMMENDATIONS ..................................................................................... 73 6.1 Summary of the study ................................................................................ 73 6.2 Limitations of the study ............................................................................. 74 6.3 Implications for Nursing Practice .............................................................. 75 6.4 Implication for Nursing Education ............................................................ 76 6.5 Implication for Future Research ................................................................ 76 6.6 Implications for Nursing Administration/ Policy Makers ......................... 77 6.7 Conclusions of the Study ........................................................................... 78 6.8 Recommendation ....................................................................................... 78 APPENDICES ................................................................................................................ 88 viii LIST OF TABLES Table 3-1 Reliability of test instrument (pre-test) ....................................................... 39 Table 4-1 Socio-demographic characteristics of respondents ..................................... 45 Table 4-2 Direct Attitude and Characteristics ............................................................. 47 Table 4-3 Indirect Attitude and its characteristics ...................................................... 49 Table 4-5 Direct Subjective norm and its Characteristics ........................................... 50 Table 4-7: Indirect Subjective Norm........................................................................ 52 Table 4-9 Intention and its Characteristics.................................................................. 53 Table 4-11 Perceived Behavioural Control ................................................................. 54 Table 4-13 Pearson Moment Correlations Results...................................................... 55 Table 4-14 Spearman‘s Ranked-Order Correlations Results ...................................... 57 Table 4-15Predictors of Patient participation in their nursing care ............................ 59 ix LIST OF FIGURES Figure 2-1 the theory of Planned Behaviour (Ajzen, 1991) ........................................ 15 Figure 4-1 Participation Figure 4-2 Level of Participation .................................... 46 x CHAPTER 1: INTRODUCTION AND BACKGROUND OF THE STUDY 1.1 Background The participation of patients in their care is an important component in the delivery of quality health care services (Dzomeku, 2013). It enhances a congenial and participatory environment that allows for trusted and transparent exchange of information necessary for the Patient‘s recovery or positive prognosis that results in higher productivity among citizens (Ofosu-Kwarteng, 2012). It also results in increased patient satisfaction with the nursing care administered, enhance the quality of life of patients and improve patients self-care ability (Suhonen et al., 2012). It is worth noting also that the nurse is in the centre of every health care service, therefore, for a health care to be adjudged best or quality will depend largely on how the nurse engages the patient in the care process (Eldh, Ehnfors, & Ekman, 2006; Florin, Ehrenberg, & Ehnfors, 2008). Patient participation refers to the rights, responsibilities and benefits of patients to have a central role in issues relating to their nursing care activities, including involvement, decisions making concerning their own care, knowledge of their disease condition and the treatment regimens (Tobiano, Bucknall, Marshall, Guinane, & Chaboyer, 2015) . It also includes collaborating with nurses to decide on the best nursing care for each patient situation (Kolovos, Kaitelidou, Lemonidou, Sachlas, & Sourtzi, 2015). In clinical practice, participation of patients in the nursing care rendered is based on perceived expectations which are critical to the wellbeing and satisfaction of both the patient and the healthcare team (Gyasi, Tagoe-Darko, & Mensah, 2013). It is important therefore, to direct and focus all nursing care activities towards the clinical needs and expectation of the individual patient (Thórarinsdóttir & Kristjánsson, 2014). 1 The concept and level of patient participation in their nursing care varies from country to country and from patient to patient with most patients requiring active participation ((Darko, 2005; Donkor & Andrews, 2011; Kolovos et al., 2015; Sahlsten, Larsson, Sjöström, & Plos, 2009; Tobiano, Bucknall, et al., 2015). In countries such as the United Kingdom for instance, the concept of patient participation is well established (Mockford, Staniszewska, Griffiths, & Herron-Marx, 2011), while in other settings such as Ghana there is dearth of evidence or information on the role of patients in improving quality and safety of health care services (Rachel E Davis, Rosamond Jacklin, Nick Sevdalis, & Charles A Vincent, 2007; Korsah, 2011). Other review of studies on patients‘ participation in Africa for instance, have revealed a gap in patient participatory research suggesting a little focus on patients‘ participatory approaches (Shumba, Atukunda, & Memiah, 2013). Despite the desire by most patients to actively participate in their nursing care services, other patients prefer a paternalistic model of care (passive participation) that allows decisions regarding their treatment and care to the nursing care team (R. E. Davis, R. Jacklin, N. Sevdalis, & C. A. Vincent, 2007). The focus on the individual‘s unique health situation and the possibility to tailor interventions to suite the patient needs would require that the nurse ensure a greater participation of the patient. To ensure greater participation of patients in care will also require getting to know their motivations, health beliefs, values, and preferences as it is fundamental to patient‘s willingness to participate in the nursing care (Epstein & Gramling, 2013). According to health behaviour Theorist (Fishbein & Cappella, 2006), understanding patient‘s health beliefs of patients help to predict their health behaviours such as medication adherence, utilization of health care services, and lifestyle decisions. Different factors may influence patients‘ decision or willingness to participate in the nursing care services. According to David, Anderson, Vincent, Miles and Savdalis, (2011), 2 the ability of the patient to participate in the nursing care activity, the social belief concerning the supposed nursing care activity or normative beliefs and the patient judgment regarding the perceived severity will influence or predict his or her ‗willingness or intentions to participate in the nursing care. Again, in their study to investigate whether patient‘s participation in documentation influenced their participation in the nursing care decision- making, (Vestala & Frisman, 2013) found that majority of patients preferred a collaborative or passive role or non- participation regarding care decision-making, and this was attributed to lack of knowledge regarding their disease conditions and its treatment mode and lack of empowerment. Other studies exploring patient participation have identified the role of significant others in patient decision making, patient attitude, the ability of the patient to participate in the care and the patient intentions to do so as factors mostly influencing their willingness to participate in their nursing care (Davis, 2007; Friesen, 2016; Kolovos, 2015; Norheim, 2012; Sahlsten, 2009;Tobiano, 2015). Individualized and patient centred care nursing is a cornerstone in clinical nursing practice and a fundamental component in patient satisfaction and recovery. It is important therefore to explore further the factors influencing the willingness of patients‘ to participate in their nursing. This will enable nurse practitioners the opportunity to tailor nursing interventions towards the peculiar needs of the patients. 1.2 Statement of the Problem In countries with limited health care and financial resources, quality of medical care is to a large extent dependent upon patients‘ and families‘ personal willingness and capability to engage in their own health care (Labhardt, Schiess, Manga, & Langewitz, 2009). The rise in numbers of patients with chronic ailments and its associated rise in population who have 3 become more aware of their health rights have served as a fundamental reason for the promotion of patient participation in nursing care (Soleimani, Rafii, & Seyedfatemi, 2010). It is also important to note that roles of patients have changed over the past decades from passive recipients of services to active participants (Dzomeku, 2013). Unfortunately, many st nurses of the 21 century according to studies bear the wrong unwritten notion that ‗the patient is ignorant about his or her health problems, rights and the cure needed and that the patient should be submissive and cooperative to the health care provider at all times (Donkor & Andrews, 2011). Studies have shown that different factors influence patient‘s willingness to participate in their nursing care activities. For example, a reviewed study on factors influencing patient willingness to participate in their own care conducted by Angel and Frederiksen, (2015) identified quality of nurse-patient relationship, attitudes of the healthcare worker and the patient, time allocated for care engagement and the patient disease situation as some factors influencing their willingness to participate in their care. An examination of nurses‘ perspective on patient engagement during care in Ghana by Korsah, (2011), also identified lack of engagement of patients in the care process and unfair treatment practices as among factors influencing the willingness of patients to either participate or not participate in their own care. . A similar study on provider perspective in managing patient involvement in diabetes decision making, found factors including the failure of healthcare providers to carry out their responsibility of delivering quality care and to respect patients‘ rights to make decisions as the main factors contributing to patient‘s willingness to participate in their care (Shortus, Kemp, McKenzie, & Harris, 2013). 4 Some studies made findings that range from the patient physical condition (S. Angel & K. N. Frederiksen, 2015), cultural and economic factors (Korsah, 2011), demographic features (Dzomeku, 2013) and socio-cultural factors (J. Lindberg, M. Kreuter, C. Taft, & L. Person, 2013). Despite ample statistics to support the usefulness of Patient participation in treatment and its outcomes, overwhelming evidence especially in Africa, including Ghana suggests that nurses do not wholly involve their patients in the care process (Ogutu & Matu, 2010; Korsah, 2011). Recommendations for patient participation includes, building a close co-operation between the nurse and the patient, getting to know the patient better and the need to reinforce patient self - care capacity (Sahlsten et al., 2009). Many factors including an increased awareness about the rights and responsibilities of patients, coupled with the failure of nurses to tailor care towards client‘s specific needs have brought a lot of media outcry especially in Ghana on the need to involve the patient during care (Korsah, 2011). The lack or perceived lack of involvement of clients in care has resulted in common instances as a clinical nurse, to hear patients complain either about a dissatisfactory care received; poor information exchange or perceived neglect or abuse in the hands of nurses. Other example in Ghana where nurses and midwives failed to involve their clients in the care process was reported by the Herald News Paper (March, 2014) of a situation in the Komfo- Anokye Teaching hospital of Ghana where a mother requested to see her baby the morning after she had delivered only to be told her baby had died the previous night and the remains had been conveyed to the morgue. Further checks showed the mother of the baby had not 5 been informed of the death of the baby until the following morning when she requested to have her baby. As a means to improve on nursing care services through patient participation, it is important to identify the factors promoting or serving as barriers to patient participation in their own nursing care. This research is therefore intended to identify the factors influencing patient‘s willingness to participate in their own nursing care. 1.3 Purpose of the Study The purpose of this study was to identify factors influencing the willingness of patients‘ to participate in their nursing care. Identification of these factors which influences the decision of patients to participate in their nursing care will help broaden the understanding of what is required by nurses to put in place to enhance patient participation for a satisfactory health care delivery. 1.4 Objective of the Study The main objective of this study was to identify factors influencing patients‘ willingness to participate in their nursing care. 1.5 Specific objectives of the study: 1. To assess the influence of Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions in patient‘s willingness to participate in their nursing care. 2. To determine the relationship between patients Attitude, Subjective Norms, Perceived Behavioural Controls and Behavioural Intentions. 3. To examine the relationship between patients Attitude, Subjective Norms, Perceived Behavioural Controls, Behavioural Intentions and patient Participation. 4. To determine the predictors of patient‘s participation in their nursing care. 6 1.6 Research Questions The study will address the following questions regarding patient‘s willingness to participate in their own nursing care: 1. Will attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions influence patient‘s willingness to participate in their nursing care? 2. What is the relationship between patient‘s attitude, subjective norms, perceived behavioural control and behavioural intentions? 3. What is the Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intention and Patient Participation in Their Nursing Care? 4. What factors predict patient‘s willingness to participate in their nursing care? 1.7 Significance of the Study Nursing Practice: Findings in this study will accord health professionals (especially nurses) an insightful information on how to effectively involve their patients in their nursing care process. Nursing Education: The study findings will also help educationist in nursing and the health sector in general to draft curriculum that will contain contents that will help the student to appreciate process of involving patients in their nursing care activities. Nursing Administration: Study findings and recommendations will also help nurse managers and health administrators at all levels to put in place measures that will help address issues of patients neglect and other poor nursing care practices. Nursing Research: The findings in this study will also serve as a reference material for researchers who will intend to do further studies in the field of nurse - patient relationship. 7 1.8 Organization of the Work This study is organized into six chapters. Chapter one provides the background of the study. It states the problem of the study, its purpose, the objectives, research questions and significance of the study. Chapter two presents a review of relevant literature pertaining to patient participation in health care. Chapter three contain the research method whiles chapter four will contain the findings of the study. Chapter five will present the discussions of the findings while chapter six will cover discussions of the findings, its nursing implications, limitations, summary, conclusions and recommendations of the study. 1.9 Operational Definition Patient – participation in care: refers to the rights and benefits of patients to have a central position in nursing care decisions, involvement in nursing activities including medication and all activities that is geared towards improving the patient condition. It also includes collaborating with nurses to decide on the best nursing care for the patient situation. Patient: any individual seeking or receiving health care services who have been admitted into the ward Nurse: a person who has undergone at least two years nursing training and is licensed to practice as a nurse in Ghana. Attitude: This is an individual's positive or negative evaluation of participating in their nursing care. Subjective Norm: This refers to the patient perception about participating in their own care, which is influenced by the judgment of significant others such as wife, husband, friends, children etc. Perceived Behavioural Control: Perceived behavioural control reflects the patient‘s beliefs about how easy or difficult it will be to participate in the nursing care being rendered. It also 8 involves perceived factors serving as barriers or promoting the willingness of the patient to participate in their nursing care. Behavioural Intentions: This refers to a person‘s readiness or willingness to participate in his or her own nursing care. 9 CHAPTER 2: LITERATURE REVIEW 2.0. Introduction The review of literature is a summary of relevant scholarly information on the subject under study. It draws on and evaluates a range of different types of sources including academic and professional journal articles, books, and web‐based resources (Rowley & Slack, 2004). It also involves the identification of gaps and analysis of research publications that have information related to the research problem being studied (Seuring & Müller, 2008). The search for literature was conducted electronically for studies and publications related to patient participation from the year 2000 to 2016 using terms such as ―patient participation‖, ―patient engagement‖, ―patient Centeredness‖ and ―patient involvement‖ on PubMed, Science Direct, Google Scholar, CINAHL, HINARI, Medline and EBSCOhost. The study also considered and reviewed other publications and studies which though old but most significant to this study. This chapter presents the conceptual framework, upon which this study is organized, the key variables of the conceptual framework or model and a review of published literature based on the independent variables or objectives of the study. The review of literature has been categorized into the concept of patient participation, background information of the respondents and its influence on patient willingness to participate in their nursing care and the major variables of the Theory of Planned Behaviour which include; Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of respondents; which are the independent variables of the model guiding this study. 10 2.1 Theoretical Framework Different theoretical frameworks that look at factors associated with making decision regarding an activity were explored for their suitability to measure the factors influencing patients‘ willingness to participate in their nursing care. An initial consideration of the Theory of Reasoned Action which measures attitude, subjective norms and behavioural intentions was made. The challenge using this theory was the fact that it did not measure the individual control ability of the behaviour which is important in patient participation in any activity. The second consideration was the Behavioural Model of Physical activity adopted from Vanen Bosch, (2011) which measures the demographic features of the individual (Age, race, ethnicity, employment, education), the clinical factors of the individual (duration, comorbidity, depressive symptoms, severity), socio-cognitive factors (attitude, self-efficacy, benefits, social support) and behaviour. The issue with this model was that its usage was not extensive enough, hence, limited information was found especially regarding arguments scholars would have made concerning the model. A third model that was considered was the ―Core, Care and Cure‖ model developed by Lydia Hall (1960). The challenge with this model was the fact that it did not measure the interrelationship between the various constructs (Core, Care and Cure). This model also measures the nurses‘ aspect of participation instead of the patient perspective, hence, the inability to adopt that model for this study. The fourth model considered for this study was the Theory of Planned Behaviour espoused by Icek Ajzen, (1991). This model measures attitude, subjective norms, perceived behavioural control, behavioural intentions and actual behaviour. The model since its inception has been used extensively in different fields with satisfactory results. It was therefore considered a suitable model to guide this study. 11 2.2 Theory of Planned Behaviour The theoretical framework underpinning this study is the theory of plan behaviour (TPB). The Theory of planned behaviour was espoused by Icek Ajzen, (1985, 1987) through his article "From intentions to actions‖. It was developed from the ‗Theory of Reasoned Actions‘, which was proposed by (Ajzen & Fishbein, 1980). According to the theory of reasoned action, if people evaluated the suggested behaviour as positive (attitude), and if they think their significant others want them to perform the behaviour (Subjective Norms), this results in a higher intention (Behavioural Intentions) and they are more likely to do so. The theory of planned behaviour came about as a result of arguments that ensued about the correlation between attitudes and subjective norms to behavioural intention, and subsequently to behaviour. While some research findings showed a perfect correlation between these variables (Sheppard, Hartwick, & Warshaw, 1988), other scholars opine that behavioural intentions does not always lead to actual behaviour due to situational limitations; therefore, behavioural intention cannot be the exclusive determinant of behaviour where an individual's control over the behaviour is incomplete. Ajzen therefore, introduced the theory of planned behaviour by adding a new component, "perceived behavioural control‖, which originated from the Self-Efficacy Theory espoused by (Bandura, 1977). Ajzen upon considering the arguments regarding volitional actions extended the theory of Reasoned Action to include non-volitional behaviours that predict behavioural intention and actual behaviour. The Theory of Planned Behaviour has been used in many studies and in different fields to predict behaviour or an action. For instance, in the field of nursing it was successfully used by Ko et al., (2004) predict the intentions of nurses to care for patients suffering from Severe Acute Respiratory Syndrome (SARS). The model was further used in the field of health to examine health professional student‘s intention in relation to medication safety and collaborative practice (Lapkin, Levett-Jones, & Gilligan, 2015). In the field of 12 social sciences the Theory of Planned Behaviour was used to assess individual‘s attitude, subjective norms, perceived control and intention to use condom during sexual activity (Prati, et. al, 2014). The wide use of the Theory of Planned Behaviour in different fields and the ability of the model to measure non-volitional behaviour made it a better model to be able to predict factors influencing the willingness of patients‘ to participate in their nursing care. The key constructs of the theory are Attitude, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Behaviour 2.2.1 Attitudes This refers to an individual's positive or negative assessment of self-capability to perform a particular behaviour. The concept indicates the extent to which performing the behaviour is positively or negatively valued (Ajzen, 2006). It is determined by the total set of accessible behavioural beliefs linking the behaviour to various outcomes and other attributes. This explains that patients who have positive belief systems regarding the outcome of participating in their own nursing care is most likely to partake in the nursing care activities while patients who have negative belief systems regarding the outcome of their participation in the nursing care activities would most likely not participate in the nursing care activities. 2.2.2 Subjective Norms (Normative Beliefs) This is an individual's perception about the particular behaviour, which is influenced by the judgment of significant others such as, parents, spouse, friends, teachers (Amjad & Wood, 2009). It is a person's perception of the social expectations to adopt a particular behaviour. These expectations are influenced by normative beliefs in association with the person's motivation to comply. Normative beliefs are concerned with the likelihood that important others would approve or disapprove of a behaviour, and motivation to comply is an assessment of how important it is to have approval of important others (Ajzen, 1991).This intimate that a patient willingness to participate in the nursing care being rendered would be 13 influenced by significant others, such as the parents, friends, spouse, teachers and other equally important social relations. 2.2.3 Perceived Behavioural Control (Control Beliefs) This is an individual's beliefs about the presence of factors that may facilitate or hinder performance of the behaviour, (Ajzen, 2001). Perceived behavioural control reflects a person's beliefs about how easy or difficult it will be to perform behaviour (Ajzen, 2006). The salient beliefs underlying the formation of this concept are control beliefs, which involve the person's perceptions of resources versus barriers for engaging in the behaviour. These beliefs are combined with the perceived power of each control factor to facilitate or impede the behaviour to form the overall perceived behavioural control. This construct in the context of patient participation would mean that patients‘ willingness to participate in their nursing care would be influenced by their beliefs about the presence of motivating and hindering factors that may enhance or serve as obstacle for patient participation in their nursing care. 2.2.4 Behavioural Intention This is an indication of an individual's readiness to perform a given behaviour. It is assumed to be an immediate antecedent of behaviour (Ajzen, 2002). Also Ajzen argues that attitude toward behaviour, subjective norm, and perceived behavioural control, with each predictor weighted for its importance in relation to the behaviour and population of interest influence behaviour intention (Ajzen, 2006). This explains the readiness of patients to participate in their own nursing care. Patient‘s readiness or wiliness to participate in the nursing care is based on their attitude towards participation, their subjective norms and perceived behavioural control. 14 2.3 Behaviour This is an individual observable response in a given situation with respect to a given target. According to Ajzen (2001), behaviour is a function of compatible intentions and perceptions of behavioural control in that perceived behavioural control is expected to moderate the effect of intention on behaviour, such that a favourable intention produces the behaviour only when perceived behavioural control is strong. In addition to the preceding factors specific to the three main TPB concepts as discussed above, extraneous factors may influence the beliefs certain individuals hold about a particular behaviour. These distal factors may include demographic characteristics, personality traits, and cultural beliefs (Peters & Templin, 2010). ATTITUDES (Behavioural beliefs X Ou tcome evaluation) SU BJECTIVE NORMS BEHAVIOURAL BEHAVIOUR INTENTIONS (Normative Beliefs X Mot ivation to Comply) PERCEIVED BEHAV IOURAL CONTROL (Control Beliefs X Influence of Control Beliefs) Figure 2.1 the theory of Planned Behaviour (Ajzen, 1991) The Theory of Planned Behaviour (TPB) assumes that an individual‘s attitude, subjective norms, and perceived behavioural control predict the persons‘ intention, while intention along with perceived behavioural control predicts the actual behaviour. The theory further assumes that developing attitude, subjective norm, and perceived behavioural control 15 involves an interaction between the individuals‘ beliefs and the subjective value the person attributes to those beliefs. 2.4 The concept of patient participation The demands for a better health care and treatment outcomes have renewed the calls for a healthcare system cognisant of the rights and responsibilities of the patient. The acceptable approach to healthcare in these clarion calls internationally, is a patient-centered care that recognizes patient participation as a core component in the care system (Kitson, Marshall, Bassett, & Zeitz, 2013). Patient participation in this study therefore, refers to the involvement of the patient and the family or significant others in the decision making, clinical care including control of medication, administration of certain medications, physiotherapy and any other activity that enhances the autonomy of the patient and family regarding their care. Getting the patient to actively participate in their nursing care creates an enabling environment that results in better treatment outcomes, hence, promoting the quality of healthcare delivery (Weingart et al., 2011). Issues concerning concept clarity about participation have resulted in the synonymous use of patient participation with other concepts including engagement and involvement (Barello, Graffigna, Vegni, & Bosio, 2014). To address issues of ambiguity and streamline the meaning of patient participation, a concept analysis conducted by (Sahlsten et al., 2009), recommended the institution of an established cordial relationship between the nurse and the patient, surrendering of some of the powers of care controlled by the nurse with the patient, sharing of important medical information and knowledge with the patient and actively and mutually engaging the patient in intellectual or physical activities. The nature of the relationship established between the nurse and the patient during the period of care will determine to a large extent whether the patient would be willing to participate passively or actively in the nursing care been rendered. 16 It is important to note that improving patient participation in nursing care would require building a strong nurse - patient relationship and connecting and relating with patients as equals and humans with integrity. It is also required of nurses to give the needed respect to their clients and genuinely engage them in the care process; taking into consideration patient‘s experiences, values; preferences and needs (Thórarinsdóttir & Kristjánsson, 2014). The phenomenon of patient participation despite its usefulness to patients healing process and outcomes is complex and difficult to fully achieve (Tobiano, Bucknall, et al., 2015). Several instances and reports have shown that nurses in practice preferably adopt paternalistic stance during care practices that are inimical or not supportive of patient participation in care, thereby resulting in passive participatory modes among patients (Wellard, Lillibridge, Beanland, & Lewis, 2003). Adopting paternalistic model of care does not allow patients the free will to express their desires and to be fully engaged in the nursing care practices rendered, hence, affecting the quality of care been rendered and the overall prognosis or treatment outcomes. According to Heggland and Hausken (2012), different categories and processes of patient participation in decision making towards treatment exist, and they include proper information dissemination, formulation of options for patients to choose from, proper integration of information and control of interactions between health care professionals and patients. This presuppose that once the right information is given to the patient through the right channel with the creation of options or chances for their inputs, they will be encouraged to actively participate in their nursing care. It is also important to adopt strategies to optimize or get patients to wilfully involve in the nursing care being rendered to them. These can be enhanced by always building closer co-operation with the patient, giving them courage to be inquisitive about what is being done to them and creating friendly nurse-patient engagement situations that would open up the 17 patient to wilfully be engaged. Other forms would include the need to know the patient better by using stimulating questions, listening carefully to the patient, reinforcing self-care capacity by encouraging accountability and focusing on goal attainment (Monika & Sahlsten, 2009). Understanding what influences patients willingness to want to be involved in their care is a fundamental factor in achieving quality health care delivery that is satisfactory to both the patient and the health care worker especially the nurse. This will give an understanding as to what influences a patient to be actively or passively involved in the care they receive. It will help nurses as well to develop different strategic measures that will help promote patient participation in their nursing care. 2.5 Features in Patient Participation An individual‘s demographic characteristics including age, sex, marital status, employment status and educational level influences decision towards seeking health care or participating in health care services rendered (Mackenzie, Gekoski, & Knox, 2006). According to Longtin et al., (2010) patient-related factors including their socio-demographic features, lack of acceptance of the new patient role, lack of medical knowledge, lack of confidence and comorbidity significantly influences the willingness of a patient to be involved in healthcare practices. The study further revealed healthcare workers- related factors including; patients desire to maintain control of their care, lack of time, personal beliefs, type of illness, and social status of the patient and their ethnic origins. A review study of published articles on patient participation in decision making in health care also found among other things patient related-factors, including their demographic characteristics, personal characteristics of the individual patient, their level of acculturation, cultural knowledge, belief systems of the patient including values and practices concerning healthcare, their physical ability and cognitive and emotional relation with others including 18 cultural appropriateness and competency of the system and organization as determinants in decision making (Vahdat, Hamzehgardeshi, Hessam, & Hamzehgardeshi, 2014). Additionally, quantitative cross-sectional comparative study of newly discharged patients from a university hospital in Sweden, employing a sample comprising of 140 patients records (n = 140), Nurse-patient dyads (n = 80), and patients discharged from hospital care (n = 428), with the aim of examining clinical decision making in nursing in inpatient nursing care found that; nurses perceived patients to prefer more active roles in clinical decisions compared with the patient‘s own preference which is mostly passive. The study explained that factors predicting the choice of either passive or active participation among patients were patient‘s gender, educational level, living condition and occupational status. The study further to predict that 53% of female senior citizens with at least a high school degree who lived alone preferred active roles in clinical decision-making while 8% of working cohabiting males with less than a high school degree preferred active participatory roles in clinical decision making in nursing care activities (Florin et al., 2008). A further qualitative descriptive study conducted by Dyrstad, Testad and Storm ( 2015) with the objective of identifying the factors that influence participation of patients by examining health care workers views on participation of patients during the admission of older patients through the emergency department using a sample size of 27 health workers revealed that weakness or frailty and how old the patient was influenced their decision in participating in the nursing care being rendered including daily care process and performance of some activities such as medical examination. A descriptive cross sectional survey conducted to identify and classify the various factors indicative of in-patients satisfaction and dissatisfaction at the Kwame Nkrumah University of Science and Technology (KNUST) hospital found that, elderly clients were more satisfied with nursing care rendered than the young ones. The findings suggest that the 19 elderly were satisfied with the nursing care rendered because most elderly people are passive in participation during care than the young ones and therefore meticulously follow instructions from the nurses and doctors taking care of them. It also found that well-educated people were dissatisfied with the care service rendered as compared to the less educated respondents. The explaining was that, well-educated people are critical of their rights and the responsibilities of the nurses towards them (Dzomeku, 2013). 2.6 Attitudes in Patient’s Participation Attitude as explained by the Theory of Planned Behaviour is an individual's good or bad judgement of ones-performance of a particular activity. The assumption therefore is that; patients who have positive belief systems regarding the outcome of participating in their nursing care will partake in the care activities while patients who have negative belief or perception regarding the outcome of participation will rescind participation (Knabe, 2012); Ajzen, 2011). According to Arnetz and Zhdanova (2015), nurses believe positively about the need for patients to be involved in all nursing care activities rendered them, interestingly, the behaviour and attitudes of nurses were not reflective of their clinical behaviour and quest to have patients involved. Circumstances according to the study where nurses created environment congenial for patient‘s involvement were when nurses perceived patient involvement to be less of a hindrance in their routine nursing work. Moreover, a good patient-centred working environment characterized by motivational behaviour exhibited by the nurses created an environment conducive for patient participation. Once the environment for participation was available and the activity required for participation was judged by the patient as positive, he or she participated in the nursing care. It is important as health care givers to find ways of inducing patients to be involved or to participate in their nursing care. To achieve this will involve creating avenues of trusting 20 relationship with the patient by developing positive encounters with the patient at all times and empowering them to take central role in the care system. Patients level of trust in their providers and the provider‘s positive attitudes towards the patients are an important factor in patients‘ willingness to communicate or participate in their care (Flink et al., 2012). A positive nurse-patient relationship creates a good outlook of general care been rendered and this positively influences the decision of the patient to participate in the nursing care been rendered. Furtherance to ensuring a good nurse-patient relationship that creates an enabling environment for participation, it is important to understand the views or perspective of the nurses on patients need for participation. For instance, a qualitative grounded theory study conducted with the aim of investigating providers perspectives or views on managing patient involvement in diabetes decision making regarding their care found that; in situations where the nurses saw it as a conflict between their responsibility to deliver care and the need for them to respect the patients‘ rights to make decisions regarding their care, patients right were either not adhered to or the core responsibility of the nurse to render best care were not adhered to, and this affected the overall uptake of the nursing care that was rendered (Shortus et al., 2013). Again, a quantitative descriptive design study conducted in Saudi Arabia using a sample size of 468 healthcare workers recruited from eight intensive care units, with the objective of describing healthcare providers‘ attitudes to family involvement during routine care and family presence during resuscitation or other invasive procedures in adult intensive care units found that; healthcare providers had positive attitudes towards family involvement during routine care, but negative attitudes towards family presence during resuscitation or other invasive procedures. Staff indicated a need to develop written guidelines and policies, 21 as well as educational programmes that will further enhance their understanding of the concept of patient participation (Abbas, Virginia, Anthony & Rosemary, 2013). Additionally, a mixed method study conducted in Queensland, Australia, with the aim of exploring what constitutes nurse–patient interactions found friendly and informative Nurse–Patient interactive sessions. On the contrary, limited opportunities created by nurses to develop closeness with patients that would have given patients the chance to be involved in the care were also found. The study revealed that patients were mostly satisfied with the care where it involved cordial interactive sessions but dissatisfied when they perceived that nurses were not readily available to respond to their specific needs or requests (Henderson et al., 2007). A further integrative mixed method literature review of published study conducted by (Sanne Angel & Kirsten Norup Frederiksen, 2015) on patient participation with the aim of identifying how empirical studies have addressed the issues of challenges in achieving patient participation in nursing care, concluded that; the nurse – patient relationship, the nurse‘s attitude, the patient physical situation, time available for engaging patients and knowledge of patients on the need to participate were key in achieving patient participation. On nurse- patient relationship, the study identified the seeming dominant role of the health professional in the relationship as a factor for the low level of patient involvement in their care. It revealed that, instances where the nurses dominated the care relationship, the patient influence was limited. The study further revealed the importance of sharing information between the patient and the nurse as it is important for participatory processes. It recognized the need to share information in a humane and mutual manner. In addition, the study asserted that nurses did not want to enter into a cordial relationship with patients especially when time spent between them was limited. The study further asserted the influence of the disease situation of the patient in the participatory care as weaker patients failed to participate in the nursing care. 22 The attitude of nurses was also found to be significant in the patient participatory process as negative attitude was a hindrance to their participation and the vice versa. The review also identified health professionals were central to whether patients participated or not and therefore served as gate keepers to patient participation. The study further stressed that, instances where patients experienced negative encounters with the nurses; it resulted in feelings of frustrations and anger leading to dissatisfaction among patients. Some studies in the literature related challenges to patient participation on the impact of the organizational structure in the hospital, which gives nurses the power over the patient, especially, instances the nurses had a negative attitude towards patient participation. Similarly, a qualitative study design conducted in Norway using a purposive sampling method to recruit participants of multidisciplinary background in different wards in one nursing home into three focus groups with the objective of identifying staff experiences of factors influencing patient involvement in care revealed that; attitudes and environmental conditions contributed to patient involvement. On staff attitude, the study mentioned values, ability of staff to be able to assess patient well, knowledge level of staff and conflict regarding one‘s role in the care process. It further indicate teamwork, role of next of kin, structural conditions in the care setup and time pressure as factors influencing patient participation in their care. It indicated further that instances where competence-building programs were organized for staffs, their level of consciousness regarding patient involvement was enhanced resulting in change in staff attitudes towards patients. The study recommended the adoption of teamwork, continuity of care, creating time for patients, and cooperating with the next of kin when needing patient participation (Norheim & Vinsnes, 2012). It is important to note that staff of one nursing home was used for this study which limited the experiences to only that setting, therefore employing staff of different nursing homes would have giving opportunity for broader experiences and views regarding patient 23 participation. Focus group interviews may not give chance as well for participants to expose embarrassing and confidential views which might be vital for enhancing patient participation. On the contrary however, some studies have also found that attitude does not play significant role in an individual decision making. For instance, a cross-sectional survey of 512 nursing students to assess their attitude and intention regarding pain management revealed that respondents had a negative attitude and intention towards pain management. The study further indicated that direct control, subjective norms, attitude and indirect control independently predicted nursing student‘s intention to treat patients with pain (Fang, Xu, Lin, Jin, & Yan, 2017). 2.7 Subjective Norms in Patient Participation The Theory of Planned Behaviour explains subjective norm to mean a person‘s perception of a particular activity, which is mostly influenced by significant people close to the individual such as parents, spouse, friends, teachers etc. York, (2017) in a study assessing the perceived barriers to quitting tobacco smoking and participating in a free cessation programme post-discharge among hospitalized smokers established that role of family and other significant others were important in the efforts of the patients to cease smoking. An experimental study also examining the effect of educational programme based on a model for eye care in non-insulin dependent diabetic patients revealed that, subjective norms, attitude and behavioural intention were significant in the experimental group of the study (Hazavehei, Jeihooni, Hasanzadeh, & Amini, 2010). Similarly, Shams-Ghahfarokhi & Khalajabadi- Farahani,( 2016) in their quantitative study to assess correlates and determinants of intention for caesarean section versus vaginal delivery among 400 pregnant women in Iran concluded that subjective norms, role of the physician and body image were contributing factors why pregnant women opted for Caesarean section rather than spontaneous vaginal delivery. 24 A further quantitative descriptive study among nurses and medical staff working in intensive care units aimed at assessing their knowledge, attitudes, beliefs and behaviour intentions in bowel management practices came to conclusions that, subjective norms were a significant factor in bowel management practice. Attitude, intentions and behavioural control were not significant in bowel management practices (Knowles et al., 2015). Again, a narrative literature review of 61 relevant published studies on patient participation conducted by Walsh and Sheridan (2016) focusing on factors which may act to facilitate or deter patient participation in clinical trials in Ireland revealed that primary factor influencing participation in clinical trials amongst patients was related to personal factors and these were collectively related to an individual obtaining a form of personal gain through participation. Secondary factors identified according to the study were cost of treatment, nature of communication, influence of staffs, the research process and demographics (York, 2017). Besides the above, a quantitative study to explore the meaning of patient participation in care, Lindberg, Kreuter, Taft and Person, (2013) using a sample of 10 patients with spinal cord injury affirmed that patient participation in their care was very important for their rehabilitation and recovery especially when nurses were sensitive and responsive to individual patient‘s needs. The study further emphasized the need for nurses to respect and maintain the integrity of patients, involve them in decision-making, share vital information of their care with them, and motivate and encourage them including their significant others in the care. Familiar studies also conducted to assess the role of individual attitude, subjective norms and perceived behavioural Control in disclosure of extra-dyadic involvement found that Subjective norms, Attitude and Perceived behavioural control were significant contributors to an individual decision making process (Seedall, Houghtaling, & Wilkins, 2013). 25 2.8 Perceived Behavioural Control in Patient’s Participation Perceived behavioural control as a construct in TPB reflects a person's beliefs about how easy or difficult it will be to perform behaviour. The important beliefs underlying the formation of this concept are control beliefs, which involve the person's perception of resources versus barriers for engaging in the behaviour. Analysis of data for instance, using a qualitative descriptive design employing a focus group discussion of nurse care coordinators with the objective of describing the features of patients seen by nurse care coordinators to benefit from care coordination and interventions judged by nurse care coordinators to be most effective in the care of patients with complex chronic care needs, found that, limited support from significant others coupled with diverse culture and languages of patients were significant in the care coordination (Vanderboom, Thackeray, & Rhudy, 2015). Another qualitative study conducted by Olaleye and Suddick, (2012) in a university hospital in Nigeria, exploring factors perceived to affect people with stroke in Nigeria from participating in their outpatient physiotherapy exercises identified internal and personal factors, external factors and relational factors. The internal and personal factors comprised of the participant health beliefs, hopes about recovery, mood and state of physical being, self-will, motivation and expectation. The external factors include, structure of the program, context, equipment, information and knowledge. Relational factors includes, support from family, friends and the workplace. A further qualitative study conducted by Sainio et al. (2001), seeking views and experiences of cancer patients in relation to their participation in the treatment and care processes, using 34 cancer patients as a sample for the study, found that, physical factors such as general weakness, poor state of health and lack of confidence among patients were factors likely to inhibit the patient‘s ability to participate in the care process successfully. 26 An additional qualitative study also employing a narrative semi-structured interview of 16 patients as a sample in a primary health care setting, assessing whether patients health situation influenced their participation in daily activity concluded that, the patients‘ health situation influenced their activity in relation to achieved participation, it further revealed that participation was up to the professional, even though the patient more or less asked for it (Haidet, Kroll, & Sharf, 2006). In addition to the above, a qualitative study on nurse patient relationship conducted in Malawi employing a semi-structured in-depth interview of HIV- Infected women about factors affecting their participation in care and treatment outcomes concluded that, lack of knowledge regarding diagnosis and Antiretroviral treatment were hampers to their involvement or participation in the care process. It also revealed further that perceptions regarding healthcare workers dominant posture, fear of disclosing HIV status and the lack of psychological support also affect their participation in the care (Donahue, Dube, Dow, Umar, & Van Rie, 2012). Again in their study of Patients‘ Preference and appraisals for involvement in treatment decisions making, Johanne, Michelle, Marina and Maranne, (2015), interviewed fifty-four (54) veterans receiving Out-Patient mental health care at a US Veterans Affairs Medical Centre, with the aim of investigating patient‘s preferences and appraisals of their involvement in treatment decisions. The study identified the nature patient- provider relationship, fear of being judged by providers, perceived inadequacy and a history of substance abuse as factors influencing patient‘s preferences and willingness to engage in shared decision - making. Finally, an integrative review of published studies on also conducted to assess the determinants of patient participation in medical ward activities found that patients participation in nursing care were mostly influenced by four defining attributes, including; 27 the need for a cordial Nurse–patient relationship, the need for relinquishing of power by nurses, the need for mutual exchange of information between the nurse and the patient, Knowledge gap between the Patient and the Nurse, and the need for collaboration between the nurse and the patient in the nursing care activities (Tobiano, Marshall, Bucknall, & Chaboyer, 2015). 2.9 Behavioural Intentions in Patient Participation Ajzen (2002) explains that intentions are the immediate antecedents of behaviour. These intentions are influenced by an individual‘s attitude towards the behaviour, subjective norm and perceived behavioural control. Studies on patient participation have affirmed intentions influence one‘s behaviour. For instance, a quantitative study conducted in Sweden by Frank, Fridlund, Baigi, & Asp, (2011) with the aim of evaluating patient participation in their care from the perspective of patients who received care in the emergency departments and an assessment of the relationship between participation and demographic information revealed the importance of having time with and sharing rightful information with the patient. The study further indicated that patient participation were mostly low in situations where the patient desired to get their basic needs satisfied. It further revealed that young and well- educated patients fought more to participate in their care but gained less attention than older and less educated patients. Similarly, an exploratory grounded theory study on patient participation conducted by Helgesen, Larsson, and Athlin, (2014) exploring the experiences of nursing personnel with regard to patient participation in special care units for persons with dementia described that Patient participation was an important element of the care given but that, while patient participation had to be adjusted to the individual client needs, it was rather adjusted primarily to suit the nurses‘ needs and ideas about how to carry out the daily care. These actions or denial for involvements were largely informed by the fact that nurses felt clients were not in 28 the right frame of mind to make decisions regarding their participation. The study went on to reveal that the patient physical situation, the nurse ability to get patient involved and the ward context also had a considerable impact on the level of their participation. Findings further stressed that well-educated and committed nurses were more inclined to letting patients participate in decisions than nurses without those properties. A further observatory qualitative study in a home care setting examining factors influencing patient participation using a sample size of 8 nurses in 45 homes revealed that, the competency level of the patient to want to participate in the nursing care their level of desire to want to do plays a very important role in the participatory level of the patients (Schoot et al, 2005). A similar qualitative design study employing six focus group interviews of 38 nursing students from two Universities in South Korea with the aim of examining their clinical experience in relation to compliance with standard precaution revealed that, attitude, subjective norms, perceived behavioural control and behavioural intentions were significant factors that hindered or enhanced their clinical experiences of standard precautionary measures (Kim & Oh, 2015). Similarly, a quantitative cross-sectional design study conducted among patients receiving chemotherapy in a large hospital in Switzerland conducted by David and Martin, (2010), with the aim of predicting chemotherapy patient‘s intention to participate in medical errors prevention. A sample size of 923 patients was included in this study, of which 479 returned the completed questionnaire. The findings show that; attitudes, PBC, and subjective norms explained 62% of the variance in one‘s intention to participate. PBC (B = 0.343), and instrumental attitude (B = 0.281) were found to be the direct strong predictors of patients intentions. The results also show that patients experiential attitude had the smallest effect in predicting one‘s intention to participate (B = 0.178). Subjective norms relating to oncology 29 staffs expectations on the other hand had both a strong direct and indirect effects on patient‘s intention to participate (total effect, 0.38) 2.10 Relationship between Attitude, Subjective Norm, Perceived Behavioural Control and Behavioural Intentions towards patient participation in nursing care The Theory of Planned Behaviour as presented by Fishbein and Ajzen (2011) have revealed in its constructs correlation between attitudes, subjective norms, perceived behavioural control and behavioural intentions. This has been confirmed in other studies. For instance, a quantitative cross-sectional study with the aim of identifying predictors of nurses and midwives intention to provide maternal and child healthcare services to adolescents in South Africa employing a sample of 190 nurses and midwives observed a moderate positive correlation between the family planning attitude of nurses and midwives and family planning norms of nurses and midwives. It further revealed a strong correlation between family planning self-efficacy of nurses and midwives and their intention to provide family planning services (Jonas et al., 2016). Similarly, a Pearson correlation analysis of variables of TPB model adopted by Brosseau & Li, (2005) in their study to assess business owners behavioural intentions towards work place health and safety revealed that, attitude toward safety, subjective norms and perceived behavioural control were significantly correlated with intentions towards safety, with attitude toward safety having the strongest correlation (r =.56, p<0.001). Furthermore, a cross-sectional quantitative study design employing a sample of 104 business students of the Cave Hill campus of the University of West Indies aimed at determining the individual factors that are likely going to influence the investment decisions of potential investors made findings that; attitude, subjective norms and perceived behavioural control were positively and significantly related to intentions to invest by applying for shares from an established company. The study further revealed that subjective 30 norms and perceived behavioural control were significant predictors of ones intentions to invest (Alleyne & Broome, 2011). Attitude and subjective norms were also found to be significantly correlated with behavioural intentions when DeBono and Omoto, (1993) assessed 208 undergraduates students of the university of Minnesota on individual differences in predicting behavioural intentions from attitude and subjective norms. Additionally, two concurrently run quantitative design study among students and community members in south east Queensland, Australia, assessing their willingness to consider donating their organ upon death revealed in the first study that, attitude and subjective norms were the strongest correlates of individual willingness to donate organs upon death. The second study also found out attitude and prototype similarity as the correlates of individual willingness to donate organ part upon death. The two studies further revealed that attitude and subjective norms were significant predictors of individual willingness to donate organs upon death (Hyde & White, 2014). Attitude and subjective norms but not perceived behavioural control was also found to be significantly correlated with behavioural intentions in a cross-sectional correlational study of 165 care givers, to determine the relationship of their beliefs, attitude, subjective norms and perceived behavioural control with intentions to serve sugar-sweetened beverages to Non-Hispanic black preschool children (Tipton, 2014). 2.11 Relationship between Attitude, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Participation Correlation between attitudes, subjective norms, perceived behavioural control and behaviour has been established in numerous studies. For instance, the findings of a quantitative study conducted in Israel by Sasson and Mesch, (2016) examining gender differences in the factors explaining risky behaviour online, involvement in risky behaviour 31 online was associated with perception about their peers, subjective norms, perceived behavioural control and perceived parental norms about online risky behaviour. Besides, a two type mixed method study conducted with the aim of determining whether the Theory of Planned Behaviour would provide a good fit for understanding and predicting motivation to recover from Anorexia Nervosa using a sample of 8 women recovered from Anorexia Nervosa and 67 women suffering from the condition for qualitative and quantitative designs respectively revealed that; Behavioural intentions, Attitude and Perceived behavioural control were positive and suggested TPB and an appropriate model for understanding and predicting motivation in Anorexia Nervosa (Dawson, Mullan, & Sainsbury, 2015). On the contrary, a quantitative study conducted among 238 prostate cancer patients in Netherland by Bert Voerman, (2007) with the aim of determining factors related to their intention to participate and their actual participation in social support groups revealed that, behavioural intention to participate in the social support group was only a predictor to participate when respondents had positive attitude and high perceived control of the activity. It further indicated that high perceived control could predict respondents‘ actual participation in social support groups. 2.12 Predictors of Patient Participation in Their Nursing Care Predicting behaviour or the things which influences behaviour is an important factor in addressing issues related to the behaviour. In their quantitative cross-sectional study to determine the predictors of chemotherapy patients‘ intention to engage in medical errors prevention, Schwappach & Wernli, (2010) identified that Attitude, Subjective norms and Perceived behavioural control explained 62% of intention to engage in medical error monitoring and reporting. The study further indicated that perceived behavioural control, 32 norms related to patient relatives and instrumental attitudes were the strongest (direct) predictors of patients‘ intentions to engage in medical errors prevention. Additionally, a quantitative design study on patient participation conducted in Netherland, with the aim of determining factors related to the patient intention to participate and actual participation in social support groups for prostate cancer patients using a sample of 238 cancer patients revealed that; age of the patient, lack of social support, positive attitude and a high perceived control predicted one‘s intention to participate in a social support group. It further revealed that perceived control and the number of prostate-specific problems did predict the factual participation (Bert Voerman, 2007). A similar study conducted by Leske, Strodl, Xiang-Yu, and Hou, (2017) determining the predictors of dieting and non-dieting approaches among adults living in Australia revealed that attitude and subjective norms significantly predicted dieting intention while dieting intention also significantly predicted dieting behaviour. Also, a quantitative study conducted among 221 Australian students aimed at determining the predictors of people‘s intention to donate their body for medical science and research revealed that, individual‘s attitude, subjective norm and moral norms were the significant predictors of people‘s intention to donate their body for medical science and research (Delaney & White, 2015). Furthermore, a quantitative cross-sectional study employing a sample of 86 enrolled nursing students with the aim of exploring their intentions to care for patients with alcohol dependence and its antecedents also showed that, subjective norms and attitude had significant positive effect on one‘s intention to care for the people with alcohol dependence. It however indicated that subjective norm was a stronger predictor of one‘s intention to care than attitude (Talbot, Dorrian, & Chapman, 2015). Other studies employing the theory of planned behaviour have also revealed significant role of attitude, subjective norms and perceived behavioural control in intentions 33 to perform behaviour. For instance, a descriptive cross-sectional survey based on the theory of planned behaviour using a sample of 65 undergraduate pharmacy, nursing and medical students of an Australian university with the aim of examining their intention in relation to medication safety and collaborative practice found that, attitude, subjective norm and perceived behavioural control were the most significant predictors of intention to engage in medication safety and collaborative practice, accounting for about 30%-46% of the variance (Lapkin et al., 2015). In their study to identify the predictors of medical professionals intention to allow family presence during resuscitation, Lai, Aritejo, Tang, Chen, & Chuang, (2017) adopted a cross-sectional survey of 714 medical staff of a medical centre in Taiwan. The results showed that attitude and subjective norms significantly predicted medical staff intention to allow family presence during resuscitation. Furthermore, a study using the theory of planned behaviour to examine the factors associated with the intentions of students from various fields to work with individuals with intellectual disability, employing a sample of 512 respondents showed that, attitude and subjective norms predicted individual‘s intention to work with people with intellectual disability. Subjective norms according to the study was the strongest predictor of intention to care for people with intellectual disability followed by the attitude of students toward working with individuals with intellectual disability (Werner & Grayzman, 2011). 2.13 Summary of Literature review The reviewed literature above focused on factors influencing decision making especially regarding patient participation in their care. The areas reviewed included, attitude, subjective norms, perceived behavioural control and behavioural intentions of patients to participate in their nursing care. The literature revealed a gap on studies regarding patient participation in nursing care and the factors influencing their decision to participate in their 34 care especially in Africa. It also revealed a dearth of information on the concept of patient participatory studies in Ghana, especially about factors influencing their willingness or decisions to participate in their care. The paucity of information on patient participation in Ghana necessitated the need to assess factors influencing patient participation in their own care. Chapter three that follows involves the explanation of the study methods, the design of the study, measurement tools that will be used to gather data, procedures for data gathering, validity and reliability of the study and ethical considerations for the study. 35 CHAPTER 3: METHODOLOGY Chapter three entails design of the study, population sample, sampling size and technique/ procedure, instruments for data collection, validity and reliability of the research instrument, data collection procedures and data analysis techniques. The chapter also addresses issues of ethics and limitations of the study. 3.1 Research Design A quantitative descriptive cross-sectional design was used for this study. Data was routinely collected from respondents between February and April using a modified Theory of Planned Behaviour Questionnaire. The design facilitated the assessing of attitudinal, subjective norms, perceived behavioural controls and behavioural intentions influencing patient participation in their own care. Using inferential statistical measures the relationships between these variables were also examined. Research designs give vivid description and the steps required to follow to achieve the objectives of the research (Fraenkel & Wallen, 2006). This design allows data gathered to be analysed at the same time in one point as compared to other designs which looks at trends of a particular phenomenon and analysis on different periods or points in time. 3.2 Research Settings The research was carried out at the Nsawam Government Hospital of the Eastern region of Ghana. The above setting was selected because of its proximity to the researcher and the fact that this hospital is located in a Cosmopolitan area; hence, patients are of varied socio-demographic backgrounds. The Nsawam Government hospital was established in 1928 by the state and located at Ayigbetown, in the Nsawam Township. The Hospital was moved to its present site on the Nsawam Aburi road where new but largely uncompleted structures had earlier been built. From an initial bed capacity of 50, the 135 bed capacity hospital was formally commissioned 36 nd on 2 February 1982. The bed capacity was reviewed from 135 in 2010 to 159 in 2011. The Hospital serves as the Municipal hospital for the Nsawam/Adoagyiri Municipality with a population of 135,570. The Hospital also serves part of the Suhum Kraboa Coaltar, West Akim, Ewutu Senya, Akuapem South and Ga West Districts. The Hospital have five main wards namely, Male, Female, Kids, Casualty Maternity/Gyaenic and the OPD. 3.3 Target Population The target population in this study was all patients (In-patient) age 18 years and above admitted to the clinical wards of the Nsawam Government hospital. Population of a study involves all the items or people under study (Orodho, 2004). It is also the group of people targeted for the study and from whom data will be collected and any inferences made (Creswell, 2005). 3.3.1 Inclusion Criteria The inclusion criteria for this study were In-patients who have stayed more than twenty four (24) hours in the clinical ward and were of age eighteen (18) years and above and of sound mind and ability. The reason for this criterion was to have respondents who were sufficiently exposed to routine nursing care activities. Eighteen (18) years and above is also considered the legal age per the Ghanaian constitution for any individual to make independent decision regarding health care or consent to any research work which requires their involvement. 3.3.2 Exclusion Criteria The exclusion criterion for participation in this study were patients whose disease situation would not permit them or make it impossible for them to be able to participate. Patients below the age of eighteen (18) years were also excluded from the study as they were 37 presumed to be minors and lack the ability per the Ghanaian constitution to take independent decisions in their health care or consent for research work. 3.4 Sampling Technique and Size The technique used for recruiting respondents for this study was a judgmental Non- probability Quota sampling where the various clinical wards of the hospital were grouped into quotas or segments. Respondents were then judgmentally selected using the eligibility criteria from these quotas. A total of 380 respondents were recruited for the study. This was obtained using Yamane‘s (1967) formula or procedure for calculating sample sizes. Using the total number (N) of patients admitted to the clinical wards of the Nsawam government hospitals where this research was conducted, and an alpha level (e) of 0.05, the sample size was reached at using Yamane‘s (1967) formula; Where: n = required sample size, N = Accessible population (About 300 admissions each month) and e = alpha level. Thus, = n = 2 = 300/1+300(0.05) 300/1+0.75 = 300/1.75 = 171.43 = 172 In order to cater for instances of non-responses to the questionnaire, a 10% of the sample size gotten from the formula above will be added to the sample size. Thus, 10/100×172=17 =172+17= 189 participants. The data gathering process lasted for a period of two months, hence, 2×189 = 378. Therefore, a sample size of 378 respondents plus an additional two (2) was added to make it 380 for this study. 38 3.5 Data Collection Tool The study measured attitude, subjective norms, perceived behavioural control and behavioural intentions as explanatory factors and hence, the independent variable. Participation was treated as the dependent variable or response variable. The assumption was that the independent variables or explanatory factors would be antecedent to the dependent variable or response variable (Tamhane & Dunlop, 2000). Data was collected from respondents using a planned behaviour tool (Appendix D) or questionnaire that was modified from a study entitled, ―Applying the Theory of planned behaviour to a study of online course adoption in public relations education‖ conducted by Knabe (2012). The questionnaire was divided into sections measuring the demographic and social data (section A), Attitude (section B), Subjective norms (section C), Perceived behavioural control (section D) and Behavioural intentions (section E). The validity and reliability levels of the constructs in Knabe (2012) were estimated at; attitudes = 0.78, norms = 0.75, behavioural control = 0.8 and intentions = 0.9 for Cronbach‘s alpha‘s. Table: 3.1: Reliability of test instrument (pre-test) Variable Number of Items Question Cronbach’s alpha Attitude 13 9-12 & 34-36 .74 Subjective Norm 10 13-22 .74 Perceived Control 8 26-33 .72 Behavioural Intention 3 23-25 .76 Pretesting of this tool was done to confirm its suitability for this study. Results of the pre-test results are shown in Table 3-1. 39 3.6 Data Collection Procedure Data collection was started soon after ethical approval (Appendix B) was obtained from the Noguchi Memorial Institute for Medical Research Ethical Review Board of the University of Ghana. Permission was also obtained from the management of the Nsawam Government Hospital where this research was conducted after an introductory letter from the School of Nursing of the University of Ghana was submitted to them (Appendix A). The population for study was divided into three (3) quotas; the Female, Male and Emergency wards. The ward managers were approached formerly after approval from the hospital management was obtained. The purpose of the research was explained to prospective respondents and eligibility ascertained using the information sheet attached to the consent form. Respondents who met inclusion criteria went through the consenting process using consent form (Appendix C). The researcher with two research assistants with qualification of first degrees in psychology he had recruited and trained for this study approached individual patients at the various clinical wards and selected purposively patients who have stayed more than twenty four hours and were been discharged. Those who were literates were given information sheets which contain information about the study purpose, risks and benefits of the study. For those who could not read or write and did not understand English language, the questions were read and explained to them using the local language they understood. Once the person agreed to participate after the purpose of the study and issues of confidentiality and right to withdrawal was made known to him or her, he or she was made to sign a consent form and therefore considered eligible for the study. A total of 380 respondents were then recruited for this study and questionnaires (Appendix D) were administered to these respondents when they have been discharged to go home either by reading and explaining to them or giving it out for them to read and answer it. 40 3.7 Data Analysis Data was entered into a coded book using the Statistical Package for Social sciences Software (SPSS) version 18.0. Frequencies of the data were run to assess for omissions or wrong entries wherever necessary. The entered data was also read over several times to ensure its accuracy and appropriateness. Analysis was conducted based on the research objectives. Transformation of some of the information gathered was made to make analysis at some instances easier. In analysing the data, descriptive frequencies such as percentages and means were calculated on the demographic features of the respondents and presented same. Determination of participation and level of participation was also done using descriptive frequencies and results present in a pie chart. Assessment of the influence of Attitude and Subjective Norms were measured both directly and indirectly using descriptive analysis. Perceived behavioural control was measured only indirectly while behavioural Intention was measured directly. A total maximum score of the variables were calculated and divided by two to get a median value where scores above the median value was considered positive and scores below considered negative. The relationship between the variables was done using Pearson and Spearman rank correlations analysis. Binary logistic regression analysis was done to ascertain the predictors of patient participation in their nursing care. Statistical power and significance was maintained by setting significance level at 0.05. 3.8 Validity and Reliability of Study According to Roberts et al, (2006), validity is a way of demonstrating and communicating the rightfulness of a research processes and the trustworthiness of research findings. It refers to how well a test measures what it is purported to measure. Reliability on the other hand refers to the degree to which an assessment tool produces stable and consistent results. To ensure validity and reliability of the data that was collected, pretesting of the 41 questionnaire was done using a small sample size of fifty (50) patients from a neighbouring hospital (New-life Hospital). Same inclusion and exclusion criteria were used for recruiting participants for the pretesting and Pretested data was analysed with focus on the internal consistency, Cronbach‘s alpha (between 0.72-0.76), inter-item correlation and item to total correlation. Results of reliability and validity were compared to the original questionnaire and modifications made in certain instances to improve on the validity and reliability. The researcher together with his research assistants also discussed and adopted the best words in the local Twi language for translation and interpretation of questions for respondents in situations where respondents could not read or write. Respondents were asked at the end of the questions of their challenges in answering the questionnaire. This was made to ensure that the right answers were given for the right questions To further ensure validity and reliability of the data collected and its accuracy, a thorough reassessment of the data was done by the researcher. A second party was also employed independently to re-examine the data collected and corrections made accordingly. The researchers‘ supervisors also went through the data to ensure its correctness and validity. Double checking of responses during data entry was also made to allow for the right information to be entered. 3.9 Ethical Consideration The study got scientific approval from the Noguchi Memorial Institute for Medical Research Ethics Review Committee of the University of Ghana, in line with the institutional scientific and ethical standards. Approval was also obtained from the Nsawam government hospital before participants were recruited for this study. Patients taking part in this study were made to sign a written consent form after explanation of the contents of the consent form and information sheet was made to them. 42 Details of the consent form and information sheet were read and explained to respondents who could not read by themselves in the presence of a witness, who was either a relative of the patient or the ward nurse. The right to withdrawal at any stage in the research process without incurring any penalty or wrath was also explained to each respondent. The purpose of the study and assurance of confidentiality was additionally explained to all respondents. Names and other identifying data of respondents were not collected so as to ensure anonymity. Interactions with individual respondents were done in a private place on the request of the respondents after they were discharged from the. Respondents were also assured that information gotten from them was only used for the research purpose and not for any other use. Each participant was also made to understand that they will not enjoy any direct benefit for their participation; however, indirect benefits were limited to the findings of factors influencing their participation in their nursing care. 3.10 Summary This chapter discussed the research methods used in conducting this research. These include the research design, the setting for the research, target population, inclusion and exclusion criteria, the sampling technique and size and data collection instrument. Other areas discussed in this chapter include, the data collection procedure, data analysis, validity and reliability of the study and the ethical consideration observed in conducting this research. 43 CHAPTER 4: FINDINGS OF THE STUDY The aim of this study was to identify factors influencing patients‘ willingness to participate in their nursing care. The study examined the attitudes of the respondents, their subjective norms, perceived behavioural control and the intentions of the respondents to participate in their nursing care. This chapter contains the findings of the study and describes the various characteristics of the participants. 4.1 Descriptive Characteristics of Respondents Table 4.1 shows the demographic features of the respondents. Out of the 380 respondents, majority (n = 203, 53.4%) were males. The respondents aged between 18-35 years were137 (36.1%) while those above 66 years had the least representation (n = 18, 4.7%). Half of the respondents (n = 192, 50.5%) were married while the others (n = 188, 49.5%) were single, widowed or divorced. Some respondents (n = 186, 49%) worked in the private sector while 120(31.6%) were unemployed. There were more Christian respondents (n = 263, 69.2%) compared with other religions. Majority of the respondents also had at least some basic level of education (n = 253, 66.6%). 44 Table: 4.1 Socio-demographic characteristics of respondents VARIABLE FREQUENCY PERCENTAGE (%) Gender Male 203 53.4 Female 177 46.6 Total 380 100 Age (18-35) 137 36.1 (36-45) 103 27.1 (46-55) 81 21.3 (56-65) 41 10.8 (66 and 18 4.7 Above) Total 380 100 Marital Married/Cohabitation 188 49.5 status Single 117 30.8 Separated/Divorced 57 15 Others 18 4.7 Total 380 100 Public 74 19.5 Occupation Private 186 48.9 None 120 31.6 Total 380 100 Religion Christianity 263 69.2 Islam 85 22.4 Others 32 8.4 Total 380 100 Education Basic 253 66.6 Tertiary 102 26.8 None 25 6.6 Total 380 100 Source: field work (2017) 4.2 Patients’ Participation in Nursing Care The pie charts (Figure: 4-1 & 4- 2) represents an assessment of respondent‘s choice for participation and their level of participation in the nursing care respectively. Out of the 380 respondents, majority (n = 359, 94.5%) admitted participating in their nursing care, while 21(5.5%) did not participate in their nursing care. Findings further showed some respondents 45 (n = 147, 38.7%) participated moderately while others (n = 87, 22.9%) had low level of participation. High Moderate 87, 23% Low 146, 38% 147, 39% Figure: 4.1: Participation Figure 4.2: Level of Participation 4.3 Influence of Respondents’ Attitude in their willingness to participate in their nursing care Table 4.2 is a descriptive table assessing the influence of respondent‘s attitude on their willingness to participate in their nursing care. The assessment was done using both a direct and indirect measurement of attitude and employing the use of a bipolar scale with ranges of ―Strongly disagree (1) to strongly agree (7)‖ to represent the semantics of the negative/positive ends of the questionnaire. The scores for each question was captured and entered into the SPSS software as; strongly disagree (1), disagree (2), slightly disagree (3), neither agree nor disagree (4), slightly agree (5), agree (6) and strongly agree (7). Higher total scores reflected higher positive attitude and vice versa. Scores of 24.5 and above were considered positive attitude towards patient participation while scores below 24.5 were 46 considered negative attitude towards participation in the nursing care. For response to individual items on a seven point scale, mean scores of 3.5 and above indicated positive attitude and below which was considered negative attitude. The results of responses when a direct measure of Attitude (Table: 4-2) to determine if it influenced respondents willingness to participate in the nursing care showed that; participation was Good (M = 6.31, SD = .86), Pleasant (M = 5.27, SD = 1.49), Useful (M = 6.14, SD = .99), Wise (M = 6.14, SD = 1.15), Enjoyable (M = 5.27, SD = 1.1), Desirable (M = 4.67, SD = 1.56) and Important (M = 6.18, SD = .9). The overall Total Direct Attitude score was (M = 39.98, SD = 4.38). The findings reveal that all the respondents had positive attitude towards participating in their nursing care (M = 39.98, SD = 4.38) as none of the respondents scored below a mean value of (M = 24.5). Table: 4.2: Direct Attitude and Characteristics For me participating in the nursing care rendered to me by the nurses during my stay in the ward would be: Direct Attitude and Characteristics Mean Standard Deviation Bad Good 6.31 .85 Unpleasant Pleasant 5.27 1.48 Useless Useful 6.14 989 Foolish Wise 6.14 1.14 Unenjoyable Enjoyable 5.27 1.10 Undesirable Desirable 4.67 1.56 Unimportant Important 6.18 .89 Total Direct Attitude 39.98 4.38 Source: Field work (2017) 7point semantic differential scale 47 Indirect measurement of attitude of respondents was also done to confirm the results of the direct measure. In measuring the Indirect Attitude (Table: 4.3), the score of each Belief Strength on the ―Unlikely/Likely‖ scale of the questionnaire was multiplied by their corresponding Outcome Evaluation score on the ―Extremely bad/Extremely good‖ scale of the questionnaire. The sum of the resulting products formed the overall attitude score. Mean scores above the total median value indicated positive indirect attitudes of respondents while mean scores below the total median value indicated negative indirect attitude towards participation in the nursing care. The analysis showed that, respondents understanding of their disease condition as a reason for their participation had a score of (M = 30.73, SD = 11.92), Participation as the only choice for their recovery showed a score of (M = 28.95, SD = 12.48), while patients‘ reason for participation is to get satisfaction in the nursing care had a score of (M = 28.16, SD = 12.87). The overall Total Indirect Attitude score of respondents was (M = 87.83, SD = 29.93). Using higher to indicate positive attitude, majority of the respondents‘ (n = 286, 75.3%) had positive attitude towards participation in their care while minority (n = 94, 24.70%) of the respondents showed negative attitude towards participation in their care. This confirms the results of the direct attitude measure. 48 Table: 4.3: Indirect Attitude and its characteristics Items Standard Mean Deviation 1.Always participating in the nursing care rendered me is; X 30.7 11.9 My participation in the nursing care will enhance my understanding of my disease condition. Understanding the disease condition Pairing 2.To me, participating in the nursing care rendered me is; X 28.9 12.5 My participation in the nursing care rendered will be the only option for my recovery. Participation as only Choice for recovery Pairing 3.My participating in the nursing care make me feel satisfied with the care X 28.2 12.87 If I participate in the nursing care rendered me during my stay in the ward, I will recover quickly. Satisfaction in the nursing care pairing Total Indirect Attitude 87.8 29.9 Status of Attitude Frequency Percent Negativ e Attitude 94 24.7 Positive Attitude 286 75.3 Total 380 100 Source: Field work (2017) 4.4 Subjective Norms Influencing Patients’ Willingness to participate in their nursing care Respondents‘ were assessed on whether significant others had any influence on their decision or willingness to participate in the nursing care. A frequency distribution of analysis was done in both Direct and Indirect forms. The direct analysis (4.4) revealed that, “important People” who felt that the patient should participate in the nursing care had a mean score of (M = 5.68, SD = 1.21), those who felt they were “expectation from significant others” to participate in the nursing care had a score of (M = 5.9, SD = 1.13), approval for 49 participation from ―Opinions of Valuable people” had a mean score of (M = 5.62, SD = 1.2), while those who felt influenced by ―Colleagues patients” to participate had a score of (M = 5.43, SD = 1.34). The Total Direct Subjective Norm score recorded was (M = 22.62, SD = 3.28). Analysis using higher scores to indicate feelings of social pressure to participate and lower scores to indicate lack of social pressure or support to participate, majority of respondents (n = 369, 97.1%) had experienced social pressure or support to participate in the nursing care while the rest (n = 11, 2.9%) did not feel supported or pressured to participate in their nursing care. Table: 4.4 Direct Subjective norm and its Characteristics Direct Subjective norm and its Characteristics Standard Mean Deviation Most people who are important to me think that…………participate in the 5.68 1.21 nursing care rendered me during my stay in the ward It is expected of me to participate in the nursing care rendered me during 5.9 1.13 my stay in the ward The people in my life whose opinions I value would….of me participating 5.62 1.2 in the nursing care rendered me Most patients in my unit have participated or will participate in the nursing 5.43 1.34 care rendered them during their stay here Total Direct Subjective Norm 22.62 3.28 Subjective Norms Frequency Percent Negativ e Subjective Norms 7 1.8 Positive Subjective Norms 369 97.1 Total 376 98.9 Source: Field Work (2017) In measuring the indirect subjective norms, questions assessing normative beliefs were multiplied against its correspondent questions measuring motivation to comply. 50 The results (Table: 4.5) indicates that, respondents who felt ―supported by ward Nurses‖ to participate had a mean score of (M = 33.58, SD = 11.17), those who had ―support from friends‖ to participate had a score of (M = 26.35, SD = 12.27), while those who felt ―supported from their family‖ to participate had a mean score of (M = 27.73, SD = 12.25). The total Indirect Subjective Norm score was (M = 87.67, SD = 28.71). Overall, majority (n = 267, 70.3%) experienced social support to participate in their nursing care while the rest (n = 113, 29.70%) did not experience any social support or pressure to participate in the nursing care. 51 Table: 4.5: Indirect Subjective Norm Indirect Subjective Norms and its Characteristics Standard Mean Deviation 1. The ward nurses think….participate in the nursing care rendered 33.58 11.17 me during my stay in the ward. X When it comes to participating in your care, how much do you want to do what the nurses think you should do? Nurses pressure pairing 2. My friends think….participate in the nursing care rendered me 26.35 12.27 during my stay in the ward. X When it comes to participation in your care how much do you want to do what your friends think you should do? Friends pressure pairing 3. My family relations think….participate in the nursing care rendered 27.73 12.25 me during my stay in the ward. X When it comes to participation in your care how much do you want to do what your relatives think you should do? Family pressure pairing Total Indirect Subjective Norm 87.67 28.71 Status of Indirect Subjective Norm Frequency P e r c e n t Negati ve Indirect Subjective Norm 113 29.7 Positive Indirect Subjective Norm 267 70.3 Total 380 100 Source: Field Work (2017) 4.5 Intentions Influencing Patients’ Participation in their Nursing Care Assessment of respondents‘ intentions to participate in their nursing care was explored by measuring their personal ―intentions‖ to participate in their nursing care, their ―decision‖ to do so, and their ―determination‖ to participate in their nursing care. Table (4.6) is a frequency distribution of results regarding patients‘ intentions to participate in their nursing care. The results showed that respondents‘, ―Personal intentions to participate” in their nursing care had a mean score of (M = 5.92, SD = 1.19), respondents whose ―personal decision” influenced their decision had a mean score of (M = 5.95, SD = 1.03), while those who were ―determined to participate” had a mean score of (M = 6.19, SD = 1.04). The Total 52 Behavioural Intention score was (M = 18.07, SD = 2.69). Using higher scores above the median to indicate higher behavioural intentions to participate and lower scores to indicate low intensions, majority (n = 370, 97.4%) had high behavioural intention to participate in their nursing care while a few (n = 10, 2.6%) had low or no intention to participate in their nursing care. Table: 4.6 Intention and its Characteristics Intention and its Characteristics Mean Standard Deviation Influence of personal Intention 5.92 1.19 Influence of personal Decisions 5.95 1.03 Influence of personal Determination 6.19 1.04 Total Behavioural Intention 18.07 2.69 Status of Behavioural Intention Frequency Percentage Negativ e Behavioural Intentions 10 2.6 Positive Behavioural Intentions 370 97.4 Total 380 100 Source: Field Work (2017) 4.6 Perceived Behavioural Control (PBC) in patient participation in their Nursing Care Perceived Behavioural Control was measured by examining the product of Control Beliefs of respondents against the Influence of their Control Beliefs. Respondents‘ were assessed by measuring the influence of an enabling environment for participation, availability of a good environment for participation, support from nurses for participation and availability of support for participation. Table 4.7 is a frequency distribution showing the scores of responses on the various questions representing the influence of Perceived Behavioural Control in their nursing care participation. The mean scores for the influence of ―Enabling environment” showed a score of (M = 34.62, SD=12.06), ―Availability of good environment” 53 for participation had a score of (M = 31.93, SD = 12.92), ―Support from nurses” had a score of (M = 32.4, SD = 12.2), while ―Availability of support” for participation made a score of (M = 33.48, SD = 12.46). The total PBC score recorded was (M = 132.43, SD = 38.11) which indicated a strong level of influence of PBC on respondents willingness to participate in their nursing care. In detail, majority of the respondents (n = 308, 81.1%) had perceived control of their nursing care while (n = 71, 18.7%) did not have control over their nursing care. Table: 4.7 Perceived Behavioural Control PBC and its Characteristics Mean Standard Deviation 1.For me to participate in the nursing care rendered me during my stay in the 3 ward would be. x 4.62 12.06 I expect my ward to provide enabling environment to enhance my participation. Enabling environment pairing 2.If I want to, I will participate in the nursing care rendered me during my 3 stay in the ward. x 1.93 12.92 Availability of an enabling environment will make it….for me to participate in the nursing care rendered. Availability of good environment pairing 3.How much control do you have in participating in the nursing care 3 rendered you during your stay in the ward? x 2.39 12.19 I expect the ward nurses to offer me the needed support to participate in the nursing care rendered me. Support from nurses pairing 4.It is mostly up to me whether I participate or not in the nursing care 3 rendered me during my stay in the ward. x 3.48 12.46 Availability of needed support would make it ….for me to participate in the nursing care rendered. Availability of support pairing Total Perceived Behavioural Control 32 38.11 Status of Perceived Control Frequency Percent Lack of Control of participation 71 18.70 Control of Participation 308 81.10 Total 379 99.70 Source: Field work (2017) 54 4.7 Relationship between Patients’ Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions? A Pearson product-moment correlation was used to determine the relationship between attitude, subjective norms, perceived behavioural control and behavioural intentions of respondents. The results as indicated in Table 4.8 showed a moderate significant positive correlation between direct attitude and behavioural intention (r = .38, n = 380, p < .001), between indirect attitudes of respondents and behavioural intention (r = .37, n = 380, p < .001), direct Subjective norms and behavioural intention (r = .35, n = 380, p < .001) and between perceived behavioural control and behavioural intentions (r = .41, n = 380, P < .001). The correlation between indirect subjective norms of respondents and their behavioural intentions was however weak but significant (r = .24, n = 380, p < .001). The positive significant correlation means that a unit increase in respondents‘ positive attitude level, subjective norms and perceived behavioural control resulted in a correspondent increase in respondents‘ intentions to participate in their nursing care. Table: 4.8 Pearson Moment Correlations Results Behavioural Intention Variables n p-value (2 tailed) r ** Direct Attitude 380 <.001 . 3 8 ** Indirect Attitude 380 <.001 . 37 ** Direct Subjective Norm 380 <. 001 .35 . ** Indirect Subjective Norms 380 < 001 .24 ** Perceived Behavioural Control 380 <. 001 .41 **. Correlation is significant at the 0.01 level (2-tailed). 55 4.8 Correlation Between Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intention and Patient Participation in their Nursing Care. A series of Spearman‘s ranked-order correlation was computed to determine if there were any relationships between respondent‘s Attitude, Subjective Norms, Perceived Behavioural Control, Behavioural Intention and actual Participation in the nursing care. This non parametric tool was used because the dependant variable (Participation) was measured on a dichotomous scale (Yes and No). Table (4.9) is the correlation results and significance of the variables used in the analysis. The results shows a significant weak positive relationship between patients‘ behavioural intention and their participation (rs (380) = .14, P < .05) indicating that any increase in patients‘ intentions to participate in their nursing care ultimately leads to an increase in their participation. It also revealed a significant weak positive relationship between indirect attitudes of respondents and their participation in the nursing care (rs (380) = .12, P < .05), means that any unit increase in a patient indirect positive attitude towards participation in their nursing care resulted in an increase in their participation. There was however weak non-significant positive correlation between direct attitude and patient participation (rs (380) = .09, P > .05), indirect subjective norms and participation (rs (380) = .07, P > .05) and between perceived behavioural control and patients‘ participation in their nursing care (rs (380) = .08, P > .05). Correlation between direct subjective norms and patients‘ participation was however non-significant and negatively correlated (rs (380) = -.05, P > .05). This shows that increase in positive direct attitude of patients towards participation, indirect social support or pressure to participate and a strong behavioural control of their participation results in an increase in their nursing care participation although not significant. Correlation between direct subjective norms or feelings of social pressure or support to participate was unrelated to their participation and would result in decrease participation. 56 Table: 4.9 Spearman’s Ranked-Order Correlations Results Participation Variables n p- value (2-tailed) r2 ** Behavio ural Intention 380 < .05 .14 Direct Attitude 380 >. 05 .09 * Indirect Attitude 380 <. 05 .12 Direct Subjective Norm 380 >. 05 -.05 Indirect Subjective Norms 380 > .05 .07 Perceived Behavioural Control 380 > .05 .08 **. Correlation is significant at the 0.01 level (2-tailed). ) *. Correlation is significant at the 0.05 level (2-tailed). 4.9 Predictors of Patients’ Participation in Their Nursing Care A direct binary logistic regression analysis was conducted to determine predictors of patient participation in their nursing care. The model contained five (5) independent variables (Religion, Sex, Direct and Indirect Attitude and Direct Subjective Norms). A test of the full 2 model containing all predictors were statistically significant X ((6, N = 380) = 26.24, P<.005) indicating that the model was able to distinguish between respondents who participated and those who did not participate in their nursing care. 2 Over all, the final model as a whole explained between 8% (Cox and Snell R ) and 2 19% (Nagelkerke R ) of the variance in patient participation. As shown in Table 4.10, the Wald criterion demonstrated that all five variables made unique statistically significant contribution to the model (indirect attitude, religion, sex, direct subjective norm and direct attitude).The stronger prediction of participation were Muslims, recording an odds ratio of 6.74. This indicates that respondents who were Muslims were six times more likely to 57 participate in their nursing care than those who did not belief in Islam or Christianity. Indirect Attitude recorded an odd ratio of 1.02 indicating that respondents who had positive indirect attitude towards participation were one times more likely to participate than those who had negative attitude towards participation. 58 Table: 4.10Predictors of Patient participation in their nursing care 95% C.I Variables B S.E. Wald Sig. Exp(B) .for EXP(B) Lower Upper Model 1 Indirect Attitude .02 .01 8.22 .00 1.02 1.01 1.03 2 2 Model 1 Summary: R = .06, X (1) = 8.07, P < .005 Model 2 Religion 5.24 .07 Christians 1.18 .63 3.57 .06 3.26 .96 11.11 Muslims 1.91 .91 4.44 .04 6.74 1.14 39.75 Indirect Attitude .02 .01 8.52 .00 1.02 1.01 1.04 2 2 Model 2 Summary: R = .10, X (2) = 4.82, P < .005 Model 3 Sex -1.05 .52 4.07 .04 .35 .13 .97 Religion 6.20 .05 Christians 1.42 .65 4.82 .03 4.14 1.18 14.73 Muslims 1.99 .91 4.74 .03 7.28 1.22 43.45 Indirect Attitude .02 .01 6.92 .01 1.02 1.01 1.04 2 2 Model 3 Summary: R = .13, X (1) = 4.47, P < .005 Model 4 Sex 1.14 .52 4.82 .03 .32 .12 .89 Religion 5.66 .06 Christians 1.36 .65 4.38 .04 3.89 1.09 13.83 Muslims 1.94 .93 4.39 .04 6.95 1.13 42.54 Indirect Attitude .02 .01 9.84 .00 1.02 1.01 1.04 Direct Subjective Norm -.16 .08 4.00 .05 .86 .73 1.00 2 2 Model 4 Summary: R = .16, X (1) = 4.72, P < .005 Model 5 Sex -1.11 .52 4.56 .03 .33 .12 .913 Religion 5.2 .07 Christianity 1.34 .66 4.16 .04 3.81 1.05 13.79 Muslim 1.82 .93 3.85 .05 6.18 1. 38.16 Direct Attitude .12 .06 3.94 .05 1.12 1.00 1.26 Indirect Attitude .02 .01 3.85 .05 1.02 1.00 1.03 Direct Subjective Norm -.20 .09 5.14 .02 .82 .69 .97 2 2 Model 5 Summary: R = .19, X (1) = 4.17, P < .005 Source: Field work (2017) 59 4.10 SUMMARY OF THE FINDINGS The findings revealed that majority of the respondents (53.4%) were males. it also showed that majority worked in the private sector (31.6%) and 66.6% of respondents having at least basic level education. on participation in their nursing care, 94.5% of respondents participated with 38.7% participating moderately. Results Of The Objectives Set For This Study Revealed That, Respondents Had Positive Attitude Towards Participation (M=39.8, SD =4.38). 97.1% Of The Respondents Also Felt Social Pressure To Participate In The Nursing Care, 97.4% Of Respondents Felt Personal Intentions Influenced Their Decisions To Participate In The Nursing Care While 81.1% Of Respondents Indicated Perceived Behavioural Control Influenced Their Participation In The Nursing Care. The Results Also Revealed A Significant Positive Correlation Between Attitudes, Subjective Norms, Perceived Behavioural Control And Behavioural Intention Of Respondents. It Further Revealed A Significant Positive Correlation Between Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intention And Actual Patient Participation. The Correlation Was However Negative and Non-Significant Between Direct Subjective Norms and Actual Patient Participation. 60 CHAPTER 5: DISCUSSION OF FINDINGS This chapter contains discussions on findings from the information gathered from respondents in relation to reviewed literature pertaining to patient participation in their nursing care. The aim of this study was to explore factors influencing the willingness of patients to participate in their nursing care. Specific objectives this study sought to answer included the following; 1. To assess Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions influencing the willingness of the patient to participate in their nursing care? 2. To determine the relationship between patients‘ Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of patients to participate in their nursing care? 3. To examine the relationship between patients‘ Attitude, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Patients‘ Participation in their nursing care? 4. To determine the predictors of patients‘ willingness to participate in their nursing care? The discussions in this chapter are focused on the findings based on the objectives of the study stated above. 5.1 Role of Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions in Patients’ Willingness to Participate in their Nursing Care. Assessment of attitude, subjective norms, perceived behavioural control and behavioural intention in this current study was done taking into consideration the median value of the total response score, where higher scores or scores above the median value was 61 considered positive toward participating in the nursing care, while scores below the total median score was considered negative as recommended by Ajzen (2002). The results of this current study revealed that all the respondents showed positive attitude towards participating in their nursing care when a direct measure of their attitude was assessed. It further revealed that 94.50% of these respondents had actually participated in their nursing care, with most (38.70%) participating moderately and a sizeable percentage (32.90%) participating fully. These findings are consistent with some studies that have explored the role or influence of attitude in an individual engagement in a particular behaviour. For instance, a quantitative study conducted among Australian students with the aim of identifying the predictors of their intention to donate their body for medical science and research showed that attitude was a significant predictor of their intentions to donate their body for medical science and research (Delaney & White, 2015). A related cross-sectional study among enrolled nursing students aimed at exploring their intention to care for patients with alcohol dependence and its antecedents also confirmed the significant role of positive attitude in the students‘ intention or decision to care for persons with alcohol dependence (Talbot et al., 2015). The findings of this current study however contradicts a descriptive cross-sectional study (Fang et al., 2017) where Chinese undergraduate nursing students had negative attitude and intention towards pain management in a study to assess attitude and intentions regarding pain management among Chinese nursing students. These disparities in the findings could be due to sociocultural or geographical difference of respondents in both studies The positive attitude exhibited by respondents towards their participation in the nursing care in this study could be attributed to the fact that most of those who participated in this study were educated and therefore appreciated the importance of their participation in the nursing care. It could also be attributable to the dominance role of men in decision making in 62 most societies and cultures (Colfer et al., 2015) as majority of respondents in this study were men. The study further revealed that majority (97.10%) of the respondents‘ experienced social pressure to participate in the nursing care rendered. These social pressures emanated from respondents normative beliefs related to the ward nurses, friends, family relations and religious pressures. These findings confirms, York, (2017) study that assessed the perceived barriers to quitting tobacco smoking and taking part in a free cessation programme post- discharge among hospitalized smokers, where the role of subjective norms or encouragement from family and significant others were important in efforts to getting the patient cease smoking. It also confirms an experimental study where, subjective norms or pressures from family relations, positive attitude towards participation and good behavioural intention of respondents played a significant role in the participation of non-insulin dependent diabetics in the experimental study (Hazavehei et al., 2010). The findings further gives credence to Shams-Ghahfarokhi and Khalajabadi-Farahani, (2016) where subjective norms or push factors from family members and significant others for respondents to participate were contributory factors why pregnant women opted for Caesarean section instead of spontaneous vaginal delivery. The findings of this study on the other hand is inconsistent with Wang et al., (2017) where subjective norms in the form of lack of social support from parents and peers influenced Chinese adolescents‘ choice between playing online games and learning. The discrepancy emanates from the fact that respondents from the current study were matured and could make independent decisions. Most respondents in the current study were also married hence, had social support from spouses. The feelings or experience of social pressure to participate in the nursing care in this current study could most be attributed to spousal pressures or influences as most of the respondents who participated in this current study were married. 63 The current study also revealed that despite the influence of significant others in the respondents‘ decision to participate in the nursing care, majority of the respondents 81.10% indicated they had control over their decision to participate in the nursing care. This findings corroborates with that of a study conducted to assess the role of Attitude, Subjective Norms and Perceived Behavioural Control in the disclosure of extra-dyadic involvement, where it was found that individual‘s Perceived behavioural control of the extra-dyadic act was a significant contributor to his or her decision to disclose information regarding involvement in the extra-dyadic act (Seedall et al., 2013). Leske et al., (2017) however did not find perceived control to influence or predict dieting and non-dieting approaches among adults in Australia. The possible age nature of respondents coupled with the fact that the later study was conducted in a city where cost of living is always high could explain the reason most respondents had no control over their dieting and non-dieting approaches as poorer people might eat only what is available. The high perceived control exhibited by respondents in this current study although, initial feelings of social pressure to participate could be due to the fact that most of the respondents were educated and therefore could have a better grasp of the nursing care process hence, participating. It could also be due to support individuals or couples get during admission, as most of the respondents were found to have either married or cohabitating. It is important to note that despite the quest to get patients to participate in the nursing care been rendered, several factors including patients‘ state of condition, nurses attitude, hospital environment and demographic characteristics of patients could serve as barriers to participation therefore, nurses should be proactive in identifying these challenges so as to enhance a better patient participatory care (Johanne, Michelle, Marina & Maranne, 2015, Sainio et al., 2001). 64 Findings relating to respondents‘ intentions to participate in their nursing care showed that overwhelming majority (97.4%), had good intentions to participate in their nursing care and were determined to do so. Only 2.60% of the respondents had negative intention regarding participating in their nursing care. The findings confirms an observatory qualitative study conducted in a home care setting that examined the factors influencing patient participation in their care, where the level of desire of the patient coupled with competency level in the proposed act was a motivating factor which influenced their decisions to participate in their nursing care (Schoot et al., 2005). It further corroborates a quantitative study conducted in a recycling program to provide better understanding of norms in the theory of planned behaviour, where intentions were found to significantly predict behaviour (Nigbur, Lyons, & Uzzell, 2010). The findings also gives credence to a quantitative study that examined the clinical experiences of nursing students in relations to their compliance with standard precautionary measures, where it was found that students‘ behavioural intentions to comply with precautionary measures were significant in their experiences towards complying with standard precautionary measures (Kim & Oh, 2015). The significant levels of respondents‘ intentions to participate in their nursing care as revealed in this current study could largely be attributable to the respondents‘ positive attitude towards participation, positive subjective norms and respondents‘ control of the nursing care activity (Ajzen, 2006) 5.2 Relationship between Patients’ Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions. The study revealed a positive significant relationship between Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of respondents to participate in their nursing care. Specifically, the correlation between Behavioural intentions and Attitudes (Direct and indirect) of respondents was moderately significant (r = .38, .37, P 65 < .001). This means that when patients judge a particular nursing activity either directly or indirectly to be good or have a positive attitude toward a particular nursing activity, the intention of that patient to participate in such activity is increased by either .38 or .37). This findings corroborates with Brosseau and Li, (2005), where positive attitude toward safety, subjective norms and perceived behavioural control of respondents were found to be significantly and positively correlated with the intentions of respondents towards ensuring work place safety. The study further showed a moderate correlation (r = .35, .24, P < .001) respectively between respondents‘ feelings of social pressure (both direct and indirect) to participate in their nursing care and their behavioural intentions to do so. It explains that whenever respondents felt social pressure to participate in their nursing care, their intentions to do so increased by .35 or .24 times. This means that, the more an individual felt social pressure either from the family, friends, and religious association or from nurses to participate in their nursing care, their intentions to participate in the nursing care increased moderately. This confirms a cross-sectional study (Jonas et al., 2016), where a moderate positive correlation was found between family planning norms of nurses and midwives and their intention to provide maternal and child health care services to adolescents. The findings of this study further confirm Hasbullah et al, (2016), where subjective norms were found to be significantly correlated with the intentions of students to buy online shopping. On the relationship between Perceived Behavioural Control and Behavioural Intentions, the study revealed a significant positive correlation (r = .45, P < .001), which explains that any increase in the patients‘ perceived control of participation, resulted in an increase by .45 times of their intention to participate in their nursing care. This finding is in line with a cross-sectional quantitative study that assessed factors influencing investment decision making among 104 business students of the Cave Hill campus of the University of 66 West Indies, where correlational analysis revealed that, the students perceived control of their investment decisions were positively and significantly related to their intentions to invest by applying for shares from established companies (Alleyne & Broome, 2011). To increase patients‘ intentions to participate in their nursing care in this regard, therefore, would require beside other things the involvement or improvement on all activities or measures that allows patients to assume absolute control of the decision making process of their care. This will involve creating a cordial nurse-patient relationship, empowering of the patient to take charge of their care and ensuring a participatory environment for care (Sahlsten et al., 2009). The positive correlation between the variables found in the study and discussed above means that any positive increase in the Attitude of respondents towards participation, Subjective Norms (social pressure) to participate and the individual‘s perceived control of the behaviour would result in a correspondent increase in respondent‘s Intention to participate in their nursing care. 5.3 Relationship between Patients’ Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Actual Participation in Their Nursing Care. An analysis to determine the relationship or correlation between patients‘ attitude, their subjective norms, their perceived control of the nursing activity, their behavioural intentions and their actual participation revealed that; correlation between patients‘ behavioural intentions and their actual participation was positive and significant although weak (r = .14, P < .05). This means that whenever respondents had any positive increase in their intentions to participate in their nursing care, their actual level of participation increased by 0.14 times. This current findings confirm Lehmann, Ruiter, van Dam, Wicker, & Kok, (2015), where an assessment of healthcare workers to determine if their intentions were related or correlated with them receiving an Influenza vaccine from Belgian Hospital revealed a significant positively correlation between their intentions and for them receiving 67 influenza vaccines from Belgian hospital settings. The findings of this study also confirm a quantitative studies (Bert Voerman, 2007; Debra A. Dunstana, 2012), that explored the relationship between behavioural intentions of respondents and their expectations to return to work, where behavioural intentions were found to be positively correlated with respondents‘ expectations to return to work. The findings of this current study however, was contrary to a quantitative study (Bert Voerman, 2007), that examined the determinants of participation in social support group for prostate cancer patients where behavioural intentions of prostate cancer patients were not related to their participation in social support groups. In the later, perceived control was rather related to cancer patients participating in social support groups. The disparities in the findings could be due to the fact that, the later study was conducted in the Netherlands which is an advanced country, and so prostate cancer patients are most likely to be exposed to different forms of available care and support, hence may not literally be so much determined to participate in support group programmes. The study also revealed a similarly significant positive correlation (r = .12, P < .05) although, weak between patients‘ attitudes (Indirect) and their actual participation in the nursing care activities. This explains that whenever respondents had positive attitude regarding a nursing activity or judges that activity to be good, there is an increase in their level of participation in that nursing care activity by 0.12 times. The finding of this current study is contrary to other findings (Werner & Grayzman, 2011). In this study, patients‘ attitudes was found to be positively and significantly correlated with their behavioural intentions to participate in a given behaviour but not the actual behaviour. The findings do not agree also with the model (Theory of Planned Behaviour) used in the study which established a relationship between Attitude and Behavioural intentions but not between Attitude and actual behaviour (Fishbein. et, al, 2011). 68 Enhancing patient participation in their nursing care requires creating a nursing care environment conducive to influence patient positive judgement of the nursing care for participatory activities. These will include creating a cordial nurse-patient relationship, avoidance of dominant roles by nurses, and making patients to assume central role in their care (Kolovos, Kaitelidou, Lemonidou, Sachlas, & Sourtzi, 2016; Sahlsten, Larsson, Lindencrona, & Plos, 2005). 5.4 What are the Predictors of Patients’ Willingness to participate in their Nursing Care The findings from the analysis show, Attitude (both direct and indirect), Sex, Subjective Norms and religion all predicted patients‘ willingness to participate in their nursing care. This therefore means that when patients have high positive attitude towards participating or sees participation to be good in their nursing care, would actually participate in the nursing care. Men according to the findings were also more likely to participate in their nursing care than females while patients who experienced pressure from significant others to participate in the nursing care were more likely to participate than those who did not experience social pressure to participate in the care. The finding further indicates that patients who are either Christians or Muslims are more likely to participate in the nursing care than those who believed in the African traditional religion or other religions. The findings from the current study further confirms a quantitative cross- sectional study conducted to determine the predictors of patients undergoing chemotherapy intention to engage in medical errors prevention, where Attitude of patients and their subjective norms or feelings of social pressure were found to be significant predictors of their intentions to engage in medical errors prevention and monitoring (Schwappach & Wernli, 2010). The finding also confirms a quantitative design study on patient participation conducted in Netherland, that assessed factors related to patients‘ intention to participate 69 in social support groups for prostate cancer patients; where it was found that demographic factors such as age, lack of social support, positive attitude and a high perceived control predicted one‘s intention to participate in a social support group (Bert Voerman, 2007). This findings further gives credence to the study conducted by Lapkin et al., (2015) on the role of Attitude, Subjective norms and Perceived behavioural control in one‘s intention to perform a behaviour where it emerged that Attitude of respondents, Subjective norms or societal pressure and perceived behavioural control of the act significantly influenced the willingness to engage in such behaviour. Again, in their study to identify the predictors of medical professionals intention to allow family presence during resuscitation, Lai et al., (2017) identified the role of Attitude and Subjective norms as significant predictors of medical staff intention to allow family presence during resuscitation. Attitude and Subjective norms also predicted students‘ willingness to work with people with intellectual disability in a study that assessed the predictors of nursing students‘ intention to care for patients with disability. Subjective norms according to that study was the strongest predictor of students‘ intention to care for people with intellectual disability followed by the attitude of students toward working with individuals with intellectual disability (Werner & Grayzman, 2011) The findings of this study on religion also confirm the significance of religion as asserted by Ghazzawi, (2016) in a quantitative study that assessed the influence of religion on job satisfaction, where it was found that religion had a significant influence on job satisfaction. The role of religion in decision making was also found to be significant in a quantitative study that explored the correlation between religious beliefs and behaviours and one‘s intention to abstain from premarital sex (Mohtasham Ghaffari1, 2015). 70 5.5. Summary This chapter contain discussions of findings of this study and its relation with other findings that already exist in patient centered care nursing practice. Findings from this study which were similar to other findings which have already been done were recognized, while findings which were contradictory to other study findings were discussed accordingly. In summary, this study revealed that, patients aged between 18-45 years are willing to participate more in their nursing care than those above that age group and that most of those who participated did so moderately and not fully. The study further revealed that patients who participate in their nursing are influenced by their judgement of whether the nursing care is good or bad, the feelings of pressure from significant others to participate, their perceived control of the nursing care activity, and their behavioural intentions to do so. The study also showed that patients‘ judgement of whether a particular nursing care activity is good or bad, their feelings of social pressure from significant others to participate and their perceived control of nursing care activity is significantly and positively related or correlated with their intentions to participate in their nursing care. The study further revealed that patients‘ behavioural intentions and their judgement of good or bad of a nursing care activity are significantly and positively related to their actual participation in their nursing care. Findings from this current study also showed that, attitudes of patients towards participating in their nursing care, influence of their significant others such as parents or spouses, being male, and being a Christian or Muslim significantly predicts patients‘ willingness to participate in their nursing care. With regards to the Theory of Planned Behaviour, this study demonstrated the significance of the model in identifying the factors influencing patients‘ willingness to participate in their nursing care. In the first place with reference to the model, positive 71 attitude towards a nursing care activity was found to influence patients‘ willingness to participate in that nursing care. Also, positive pressures from close relatives and significant others were found to influence the willingness of patients to participate in their nursing care. In reference to the model as well, patients‘ perceived control of the nursing care activity and their positive behavioural intentions significantly influenced their willingness to participate in their nursing care. The findings of the present study also supported the correlation between attitude, subjective norms, perceived behavioural control and behavioural intentions. This is because the findings revealed that positive attitude of patients toward participating in their nursing care, pressures from relatives and significant others to participate in the nursing care and patients‘ perceived control of the nursing care activity were correlated with their behavioural intentions to participate in their nursing care. It also supported the correlation between behavioural intentions of respondents and actual behaviour as patients strong intentions to participate in the nursing care were correlated with their participation in their nursing care. In the chapter that follows, the implications of this study‘s findings for nursing practice, nursing education, nursing research and for policy makers are presented. Summary, conclusions and recommendations are also presented in the ensuing chapter. 72 CHAPTER 6: SUMMARY, IMPLICATIONS FOR NURSING, CONCLUSION AND RECOMMENDATIONS This chapter contains the implication of the findings in this study to nursing practice, education and nursing research. It also presents summary of the findings, conclusions made from the study and recommendations geared at promoting patient participation and nursing practice in Ghana. 6.1 Summary of the study This study was conducted to identify the factors influencing patient participation in their nursing care using a cross – sectional methodological design where structured questionnaires were administered to respondents The study revealed that most of the respondents were aged between 18-45 years of age. Majority of the respondents admitted participating in their nursing care. On what influenced their decision to participate in their nursing care, respondents identified their feelings or judgement of whether the supposed nursing care would be beneficial to them, they also indicated the influence of their significant others or subjective norms, their perceived control of the nursing care and their personal determination or behavioural intentions to participate in their nursing care as the factors that influenced their decisions. The study also found a significant positive correlation between attitudes of patients, their subjective norms, perceived behavioural control and their behavioural intentions to participate in the nursing care. It further revealed a significant positive correlation between attitudes of patients, their behavioural intentions and their actual participation in the nursing care. 73 The study further revealed that, attitude of respondents, their religious affiliation, their sex and the influence of their significant others or subjective norms predicted their participation in their nursing care. 6.2 Limitations of the study The study to identify the factors influencing patients‘ participation was a difficult task and so had limitations regarding findings. Firstly, the study design was a quantitative approach and therefore, did not delve into the lived experiences of the respondents as in the case of qualitative designs. Besides, most of the responses were obtained by self – report which could result in respondents either under or over – estimating their participation levels. Secondly, the recruitment of respondents for participation was done using a judgemental means which is liable to researcher biases, hence a limitation of this study. Respondents were selected using researcher discretion, though taking into consideration the inclusion and exclusion criteria. Also, the sample used for this study, though, quite sizeable, it was not large enough to make generalization of the entire Ghanaian populates Thirdly, most of the questionnaires were administered using the local language for those who could not read or understand them. This could affect the reliability of those questionnaires, and as well could lead to socially desired responses, hence, thorough reviewing and adopting the best local words for interpretation was done among the researcher, his supervisor and the research assistance. The findings were also limited to the research setting and therefore, could not be said to be true in other hospital settings Fourthly, the study was limited to only the patient‘s perspective or understanding of the phenomenon being studied; hence, the nurses‘ perspective were not taken into consideration. It was also limited to only inpatients that had stayed in the ward for more than 24 hours and therefore patients who had stayed less than 24 hours and those from the 74 outpatient departments who would have provided additional information to the phenomenon were excluded per the inclusion criterion. Finally, The data analysis used in this study was descriptive, correlation and regression analysis which looked at relationships and other critical constructs influencing patients‘ willingness to participate in their nursing care; hence, other forms of data analysis that would have provided further insight into the phenomenon was not used. 6.3 Implications for Nurses and Nursing Practice In recent times, health care services and nursing practice requires that nurses should at all-time take cognizance of the views and inputs of the patient under their care. This will require creating an enabling environment that allows or empowers the patient with the confidence and free will to make inputs into their care. This study explored the factors influencing the willingness of patients to participate in their nursing care. The findings which showed that patients positive judgement of the nursing rendered, the positive influence of their relatives including the ward nurses, their perceived control of the nursing care activity and their behavioural intentions which is mostly borne out of their attitude, subjective norms and their control of the perceived nursing act can help nurse managers and clinical nurses to design evidenced – based protocols that take into consideration these findings so as to improve on patient participatory nursing care. It will also help nurse managers, individual nurses and hospital authorities to organize in-service training sessions for nurse assistants and other Para-medical staffs where the concept of patient participation and patient centered care will be explained to them. This will help to improve upon the nurse – patient relationship in the care setting and will go a long way to enhance participatory care services in the hospital setting. 75 6.4 Implication for Nursing Education The increasing literacy rates across the world coupled with patients understanding of their health rights and the need for them to be involved in decision regarding their care has called for pragmatic measures to address or successfully involve patients in their care. The findings of this study will offer nurse educationist the opportunity to design curricula that recognizes the need to involve patients and their relatives in the nursing care. It will also offer nurse educationist opportunity to review their curricula to involve activities that improves on patient‘s attitude towards nursing care or their judgement of how beneficial the nursing care would be to them. This will go a long way to improve upon the Nurse-patient relationship as well as creating a participatory environment that allows patients to make decisions regarding their care. Allowing patients the opportunity to be fully involved in their nursing care will also help to improve on their satisfactory level of the care rendered and their judgement of the entire nursing care. 6.5 Implication for Future Research Patient participation in their care, despite its usefulness in patient care has seen a dearth of research information especially in Ghana and Sub-Saharan Africa. This study attempted to fill some of these gaps or lapses concerning patient participation in their care in Ghana. The study revealed several important components needed to enhance patient participation in their nursing care; however, more research is needed to address several areas that are important for patient participation in their nursing care. The current study examined patients‘ perspective of the factors influencing their willingness to participate in their nursing care. There is the need to also explore nurses‘ perspective of the factors influencing patients‘ willingness to participate in their nursing care. 76 Moreover, measurement of patients‘ attitude, subjective norms, perceived control and behavioural intentions were done using a self-administered questionnaire modified from the Theory of Planned Behaviour. It is important to note that though this instrument has been used widely to measure decision among respondents, its measures are subjective which could result in participants either under-reporting the phenomenon or over-reporting the situation. It is important that feature researches should focus on measuring the objective views of the respondents as well. Besides the above, a cross-sectional design was used, which means that data gathered from respondents to assess the various variables were all analysed at a particular point in time. It is therefore, important that future researches in the area of patient participation assess these variables for over a period of time to determine if there will be variations in the patients‘ responses to the different variables over a period of time. 6.6 Implications for Nursing Administration/ Facilities/ Units/Policy Makers Governmental and Non- governmental agencies such as the World Health Organization, Ministry of Health , Ghana health Service, health facilities and nursing departments whose sole purpose is to formulate laws and policies to guide health care practice, should adopt these findings and formulate them into laws or protocols to in their various units to enhance and promote patient-centred care practice. These findings will also offer policy makers and unit‘s heads including nurse managers a frame work upon which to design policies that will re-orient already practising nurses on the need and ways to engage patients during nursing practice. Educative programmes aimed at enhancing nurses and patients understanding of their rights and responsibilities regarding health care, could also be rolled out by policy makers. Policies should also be drawn that requires health care managers in health care settings to as a matter 77 of law periodically assess patients to identify their level of participation and the challenges they encounter trying to participate in their nursing care 6.7 Conclusions of the Study Patient participation in their nursing care is an important component of patient centred care which plays a greater role in patient satisfaction with the care rendered and to some extent determines the outcomes of patient admission. it is important therefore, to assign greater importance to the needs, challenges and activities that influences or are hindrances to the participation of patients in the nursing care been rendered. This will help to create a patient centered care environment where the rights and responsibilities of patients and their relatives are respected. It is the researcher believe that, if health care organizations, hospitals, governmental and non-governmental organizations adopt the findings of this research which includes; the need to give care in an environment that makes patients develop positive attitude towards the care, allowing inputs from patients and relatives into the care, allowing patients chance to practically participate in the nursing activities if they can and giving patients the chance to actualize their intentions to participate in the nursing care, the clarion call internationally for patient centered care would be achieved and health care would be a better one than it is currently. 6.8 Recommendation Based on the findings of the study, the following recommendations have been made to improve on health care practices and delivery.  The Ministry of Health and the Ghana Health Service should develop a guideline on how to effectively involve patients in their nursing care. 78  Regular in-service training of nurses on the concept of patient participation and good nurse-patient relationship should also be organized.  Health care professionals should be encouraged to do in-depth assessment of patients to ascertain their capability of engaging in any nursing care activity before engaging them.  Educating nurses on the rights and responsibilities of patients and the need to respect these rights of patients should be done periodically.  Nurses should be encouraged at all times to educate patients on the rights and responsibilities during care  Measureable level of involvement of patients‘ relatives or significant others should be done as they are significant in the decision making of the patient.  Central government through the Ministry of Health should establish a patient- centered care centre which mandate is to foresee that patients are well catered for during admissions. 79 REFERENCES Ajzen, I. 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