SCHOOL OF NURSING COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON. UNDERSTANDING THE NURSE-PATIENT INTERACTION AT KOMFO ANOKYE TEACHING HOSPITAL: THE PATIENTS‟ PERSPECTIVES AND EXPERIENCES OLIVIA NYARKO MENSAH 10064268 THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL NURSING DEGREE. JULY, 2013 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction i DECLARATION I, Olivia Nyarko Mensah, hereby declare that the work presented in this thesis is the result of my own investigation, and that except for other people‘s work, which have duly been acknowledged at the reference section, this dissertation has never been presented to this university or elsewhere for any degree. OLIVIA NYARKO MENSAH …………………… ……..………….. (STUDENT) Signature Date DR. (MRS) PATIENCE ANITEYE …………….…… ……...………… (SUPERVISOR) Signature Date MR. KWADWO AMEYAW KORSAH ……………… ………………… (SUPERVISOR) Signature Date University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction ii DEDICATION This research is dedicated to my incredible family, without whom I could never have accomplished this monumental task. My husband, Mr. Egya Gyanzah Eshun has unfailingly stood by my side, providing continuous positive affirmation and infinite support for this project. My mother, sisters and brothers, who have always blessed me with their patience and faith in me, and also giving me the opportunity to experience all the stages of growth and development both physically, cognitively and emotionally in the first-hand. The study is also dedicated to the wonderful patients and nurses who were at KATH during this project and those found in other hospital settings in Ghana and the world at large. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction iii ACKNOWLEDGEMENTS In starting with my appreciation, I have grown to believe that no one reaches a goal without the help and support of God and others. I wish to acknowledge the help of my supervisor, Dr. Mrs. Patience Aniteye, who I had as a mentor, teacher and friend. She is a person of immense wisdom and patience, gentle but with unyielding fortitude. In my most challenging times, it was largely her encouragement and patience that sustained me. I did not give up because she would not let me give up. I look up to her with appreciation as a brilliant teacher, but with gratitude for touching my human feelings. A dream begins with a teacher who believes in you, who tugs and shoves and leads you to the next plateau. Thank you for believing in me and for constantly reminding me that I could do it. Her academic and personal support leaves me thankful and inspired. What a privilege to have been one of her students. The times under her guidance have been a privilege and her examples have left an indelible impression in me. Life blessed me with the opportunity to meet Dr. Mrs. Patience Aniteye, an exceptional woman, whom I am still anxious to learn from. Much gratitude also goes to Mr. Kwadwo Ameyaw Korsah, for his insights into the research topic which enriched this research immensely. The creativity, determination and sense of joy with which he responds to life's challenges have led me to seek this in myself. I am grateful to the Dean of the School of Nursing, Dr. Ernestina Donkor, Also, to Dr. Prudence Nyaledzigbor and the rest of the faculty members for granting me the opportunity to be in this renowned profession. Without you the writing of the thesis would not have been possible. Their continuous encouragement and support is highly appreciated. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction iv Thanks to my colleagues at the school of nursing (MPhil,Year group 2013) for their invaluable inputs with regard to the content and structuring of this thesis. Thank you for making the time for it. I am grateful to all patients who were on admission at KATH during the period of the research, to the nurses and other professionals at the maternity, medical, surgical and the quality assurance units, for their unstinting support and encouragement. I want to show much appreciation to all who in diverse ways have contributed to the success of this work. Please know that I appreciate your efforts, contributions, support and understanding in all my academic endeavours. Finally, to the authors and publishers whose journals, articles and books were used as references in this work, I will always cherish your ideas and wisdom. God bless you all. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction v LIST OF ABBREVIATIONS A & E Accident and emergencies CCTV Closed circuit television FOW Females Orthopedic ward JHS Junior High School KATH Komfo Anokye Teaching Hospital MMW Males‘ medical ward MOH Ministry of Health MPhil Master of Philosophy MSc Master of Science MSLC Middle School Leaving Certificate MSW Males‘ surgical ward MTHS Month/s MW Maternity ward NMC Nursing and Midwifery Council of Ghana PRIM Primary School SHS Senior High School UK United Kingdom UNEMP Unemployed USA United States of America WHO World Health Organization WKS Weeks YRS Years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction vi ABSTRACT The nurse–patient interaction, a core of professional nursing practice, shows the relationship that exists between nurses and their patients in the care encounter. This study set out to explore and understand the experiences patients go through during their interactions with nurses and to find ways of enhancing nurse-patient interactions. The study took place at the maternity, adult medical and surgical wards of the Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. The target population for this study was all patients who were admitted for a week or more and had come for review after discharge at the time of the study. A qualitative exploratory approach was adopted and purposive sampling technique was used to select the desired sample. A semi-structured interview guide was used to elicit information from 12 patients. The data was analyzed using content analysis. The key findings were: nurses were found to be poor communicators, nurses discriminated among patients based on patients‘ social status and ability to pay for services rendered which led to deliberate neglect of patients. Nurses‘ poor attitudes were found to have a negative influence on the nurse/patient interaction. Many nurses had little or no respect for the rights of patients. Supervision was found to be poor leading to patients‘ ill-treatment, especially on night shifts. A few nurses were however described as good, supportive and caring. The inclusion of interpersonal skills, especially communication skills in nursing curricula, in-service training and workshops was recommended to improve the quality nursing care delivery at KATH. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction vii TABLE OF CONTENTS Contents Page DECLARATION .................................................................................................................. i DEDICATION ..................................................................................................................... ii ACKNOWLEDGEMENTS ............................................................................................... iii LIST OF ABBREVIATIONS .............................................................................................. v ABSTRACT ........................................................................................................................ vi TABLE OF CONTENTS ................................................................................................... vii LIST OF TABLES ........................................................................................................... xiii LIST OF FIGURE............................................................................................................. xiv CHAPTER ONE .................................................................................................................. 1 INTRODUCTION ............................................................................................................... 1 1.1 Background of the Study ............................................................................................... 1 1.2 Problem Statement ......................................................................................................... 6 1.3 Objectives of the Study ................................................................................................ 10 1.4 Research Questions .................................................................................................... 10 1.5 Significance of the Study ........................................................................................... 11 1.6 Operational Definitions ................................................................................................ 12 1.7 Organization of Work ................................................................................................... 12 CHAPTER TWO ............................................................................................................... 13 LITERATURE REVIEW ................................................................................................... 13 2.1 Introduction .................................................................................................................. 13 2.2 Meaning of Interaction in Nursing ............................................................................... 13 2.3 Communication as an Interactive Role ........................................................................ 14 2.4 Patients‘ Perception of Nurse-Patient Interaction ........................................................ 15 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction viii 2.5 Nurses‘ Job Satisfaction and Nurse-Patient Interaction ............................................... 19 2.6 Stress and Nurse-Patient Interaction ............................................................................ 20 2.7 Power Struggle and Nurse-Patient Interaction ............................................................. 21 2.8 Sense of Dignity and Nurse-Patient Interaction........................................................... 22 2.9 Sense of humour and nurse-patient interaction ............................................................ 23 2.10 Empathy and nurse-patient interaction ...................................................................... 23 2.11 Nurses-Patient Interaction and the Environment ....................................................... 24 CHAPTER THREE ........................................................................................................... 26 METHODOLOGY ............................................................................................................ 26 3.1 Introduction .................................................................................................................. 26 3.2 Research Design........................................................................................................... 26 3.3 Research Setting........................................................................................................... 27 3.4 Study Population and Sample ...................................................................................... 28 3.5 Inclusion Criteria ......................................................................................................... 29 3.6 Exclusion Criteria ........................................................................................................ 29 3.7 Sampling Technique ..................................................................................................... 29 3.8 Data Collection ............................................................................................................ 30 3.9 Data Analysis ............................................................................................................... 32 3.10 Methodological Rigour .............................................................................................. 32 3.11 Ethical Considerations ............................................................................................... 34 3.12 Limitations of the Study............................................................................................. 35 CHAPTER FOUR .............................................................................................................. 36 FINDINGS ......................................................................................................................... 36 4.1 Introduction .................................................................................................................. 36 4.2 Demographic characteristics of respondents ............................................................... 36 4.3. Patients‘ expectations and actual observations ........................................................... 38 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction ix 4.3.1 Caring environment ............................................................................................... 38 4.3.2 Humane Treatment ................................................................................................ 41 4.3.3 Supportive Nurses ................................................................................................. 44 4.3.4 Effective Communication ..................................................................................... 45 4.3.5 Respect for patients‘ rights .................................................................................... 47 4.4 Patients‘ perception of nurses based on their experience ............................................ 49 4.4.1 ―Good‖ Nurses ...................................................................................................... 49 4.4.2 ―Bad‖ Nurses ......................................................................................................... 51 4.2.3 ―Lackadaisical‖ Nurses ......................................................................................... 52 4.5 Nurses‘ Attitudes ......................................................................................................... 53 4.5.1 Positive Attitudes .................................................................................................. 53 4.5.2 Negative Attitudes ................................................................................................. 54 4.5.3. Ambivalent Attitudes ........................................................................................... 55 4. 6 Nurses‘ stereotyping and discrimination of patients ................................................... 55 4.6.1 Favouritism............................................................................................................ 56 4.6.2 Poor patients .......................................................................................................... 57 4.6.3 Distant Nurses ....................................................................................................... 58 4.6.4 Deliberate neglect of patients ................................................................................ 59 4.7 Patients‘ feeling of powerlessness ............................................................................... 59 4.7.1 Authoritarian Nurses ............................................................................................. 60 4.7.2 Patients‘ feeling of inadequacy ............................................................................. 61 4.7.3 Patients‘ exclusion from decision making ............................................................ 62 4.8 Ways of improving the Nurse-Patient Relationship .................................................... 63 4.8.1 Training ................................................................................................................. 63 4.8.2 Supervision ............................................................................................................ 64 4.8.3 Motivation .......................................................................................................... 65 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction x 4.8.4 Nurses‘ Accountability .......................................................................................... 66 4.8.5 Resources ............................................................................................................ 67 CHAPTER FIVE ............................................................................................................... 69 DISCUSSION .................................................................................................................... 69 5.1 Introduction .................................................................................................................. 69 5.2 Patients‘ Expectations and Actual Observations ......................................................... 69 5.2.1 Caring Environment .............................................................................................. 70 5.2.2 Humane Treatment ................................................................................................ 72 5.2.3 Supportive Nurses ................................................................................................. 73 5.2.4 Effective Communication ..................................................................................... 75 5.2.5 Respect for Patients‘ Rights .................................................................................. 76 5.3 Patients‘ Perception of Nurses based on Experience ................................................... 77 5.3.1 ―Good‖ Nurses ...................................................................................................... 77 5.3.2 ―Bad‖ Nurses ......................................................................................................... 78 5.3.3 Lackadaisical Nurses ............................................................................................. 79 5.4 Nurses‘ Attitudes ......................................................................................................... 80 5.4.1 Positive Attitudes .................................................................................................. 80 5.4.2 Negative Attitude .................................................................................................. 80 5.4.3 Ambivalent Attitudes of Nurses ............................................................................ 81 5.5 Nurses‘ Stereotyping and Discrimination of Patients .................................................. 82 5.5.1 Favouritism............................................................................................................ 82 5.5.2 Poor Patients .......................................................................................................... 83 5.5.3 Distant Nurses ....................................................................................................... 84 5.5.4 Deliberate Neglect of Patients ............................................................................... 84 5.6 Patients‘ Feeling of Powerlessness .............................................................................. 85 5.6.1 Authoritarian Nurses ............................................................................................. 85 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction xi 5.6.2 Patients‘ Feeling of Inadequacy ............................................................................ 86 5.6.3 Patients‘ Exclusion from Decision Making .......................................................... 87 5.7 Ways to Improve the Nurse-Patient Interaction ........................................................... 88 5.7.1 Training ................................................................................................................. 88 5.7.2 Supervision ............................................................................................................ 88 5.7.3 Motivation ............................................................................................................. 89 5.7.4 Nurses‘ Accountability .......................................................................................... 89 5.7.5 Resources .............................................................................................................. 90 CHAPTER SIX .................................................................................................................. 91 IMPLICATIONS, SUMMARY, CONCLUSION AND RECOMMENDATIONS.......... 91 6.1 Introduction .................................................................................................................. 91 6.2 Implications for nursing education. ............................................................................. 91 6.3 Implication for Nursing Practice .................................................................................. 92 6.4 Implications for Research ............................................................................................ 93 6.5 Summary ...................................................................................................................... 93 6.5 Conclusion ................................................................................................................... 94 6.6 Recommendations ........................................................................................................ 95 REFERENCES .................................................................................................................. 97 APPENDICES ................................................................................................................. 113 APPENDIX A: SAMPLE OF THANK YOU CARDS ............................................... 113 APPENDIX B: DISTRIBUTION OF MEDICAL ERRORS ...................................... 124 APPENDIX C: INTRODUCTORY LETTER ............................................................. 125 APPENDIX D: ETHICAL CLEARANCE .................................................................. 126 APPENDIX E: CERTIFICATE OF REGISTRATION FROM KATH ...................... 127 APPENDIX F: LETTER OF APPROVAL .................................................................. 128 APPENDIX G: CONSENT FORM ............................................................................. 129 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction xii APPENDIX H: INTERVIEW GUIDE ........................................................................ 132 APPENDIX I: THEMATIC CODE FRAME .............................................................. 135 APPENDIX J: PARTICIPANTS INFORMATION LEAFLET ................................. 139 APPENDIX K: SUMMARY OF DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS .......................................................................................................... 141 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction xiii LIST OF TABLES Table 1: Themes and Sub-Themes from Transcribed Data………………………..37 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction xiv LIST OF FIGURE Figure 1: Complaint Trends From 2006-2010……………………………………8 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 1 CHAPTER ONE INTRODUCTION 1.1 Background of the Study Hospitals are established to give comprehensive care to people who are suffering either physically, psychologically or emotionally (Walsh & Crumbie, 2007). A hospital is an organization that functions to give care, both curative and preventive to members of the public (Coughlin, 2012; Shattell, 2002). Since most patients enter the hospital environment with a lot of anxiety, it is expected that their interactions with the nurses and other health professionals will serve as one of the many ways of allaying anxieties, solving health problems and helping in achieving satisfaction (Radtrek,2013; Neville, Lake, Le Munyin, Paul & Whitmore 2012; Watson, 2005). This is the reason why in recent years, the nursing profession has derived its focus not from the medical model, with its emphasis on the treatment and cure of pathological problems, but from the relationships between people, the environment and health. Specifically, the focus of nursing is derived from the interrelationships of people seeking health within the hospital environment as they interact with nurses (Walsh & Crumbie, 2007). A therapeutic nurse-patient interaction does not happen in vacuum but happens mostly at the hospital environment where caring relationships develop in a manner that enables partnership between a patient and a nurse with the aim of achieving wellness (McCabe, 2004).The nurse-patient interaction is defined as a helping relationship that is based on mutual trust and respect, being sensitive to self and others, and assisting with the gratification of the patient‘s physical, emotional, and spiritual needs through the University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 2 utilization of the nurses‘ knowledge and skills (Watson, 2005; Idczak, 2003; Hall, 2004; McCabe, 2004; O‘Brien, 2003;O‘Brien, 2001;Watson, 2001).Nurses are therefore expected to provide the highest level of quality nursing care to their patients at the hospital. To provide the required care involves the collaboration between the person who is sick and the healthcare professionals providing the care (Westbrook, Duffield, Crewick, 2011).This collaboration necessitates various interactions such as doctor-doctor interaction, doctor-nurse interaction, doctor-patient interaction and nurse-patient interactions amongst others. These interactions are expected to help provide a fluid and a well-coordinated care at the hospital (Shattell, 2004). Among the various interactions at the hospital, the most important is the nurse-patient interaction since unlike other health professionals, the nurses‘ interaction with patients is considered therapeutic. Also, nurses spend most of their time with patients providing care by engaging in constant interaction throughout the period of care. These interactions provide the nurses with knowledge to create the needed environments that favour harmonious encounters, and alternative ways to proceed with care when challenges arise (Agyemang, 2013; Westbrook, Duffield, Li & Crewick, 2011; Macdonald, 2007, Smith, Arya- Guerra, Bubiltz, 2005). The interactions are also important because they serve several functions for the patients including helping pass time, finding out about their illnesses and the interpersonal activities which create an informal help system. The critical nature of the interaction should therefore make the nurse-patient interaction one of the main focuses of scientific inquiry since the quality of care given is dependent on effective nurse-patient interactions (Sofaer & Firminger, 2005). In practice, each nurse-patient encounter is based on some University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 3 perceived expectations which are critical to the well-being and satisfaction of the parties involved. The interaction between the nurse and her patient is therefore expected to be based on mutual trust and agreement with reciprocal and comprehensive orientation (Hanson, 2007). For the nurse-patient interaction to be effective, it takes more than the provision of quality nursing care to meet the physical, psychological emotional and social needs. The patients should also have unrestricted opportunity to communicate and negotiate their daily care needs and issues that affect their well-being. In addition, Boscart (2010) maintains that nurses‘ humanistic relationship skills and behaviours are essential in fostering close, affectionate, family-like, and warm relationships with patients who spend an extended time in the clinical setting. Though the nurse-patient interaction is no doubt important Jewkes, Naeemah and Zodumo (1998) posited that the nurse-patient relationship was one of the most neglected areas of focus in scientific research in low and middle income than the high-income countries. However, in recent years it has been observed that the nurse-patient interaction is emerging as an important element of nursing practice in some parts of the world (Bougault, King, Hart, Campbell, Swartz & Lou, 2008). Globally, it is accepted that the crucial role of health systems in producing and delivering health care services makes the healthcare workforce one of the most important assets of any health system (WHO, 2003). In the past in the United Kingdom, given the pivotal role that nurses played in determining the efficiency, effectiveness and sustainability of the health care system, numerous researchers articulated that nursing as a profession was tagged and characterized by dedicated staff that were readily available when patient calls, having listening ears, making time for patients by chatting with them and allowing patients to form part of decision making process in their care (Agyemang,2013;Cleary, University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 4 Hunt, Horsefall, Deacon, 2012; Tyrrell, Levack,, Ritchie, & Keeling, 2012; Korsah, 2011; Pillay, 2009;Wysong, 2009; Shattell, 2004; Desmond & Copeland, 2000).This attention included timely response to call bells, nurturing, comforting, showing concern and giving motivation. These characteristics led to nurses being branded favourably as of the time as ―ministering angels‖ of care by the public (Smith, 2013;Rhodes, Morris & Lazenby, 2011; Pillay, 2009; Detrick et al., 2006; Davis, 2005 & Sterman, Gauker & Krieser, 2003; Jewkes, Naeemah & Zodumo, 1998 & Muff, 1982 as cited in Shattell, 2004). Currently in the United Kingdom, United States, Australia and other parts of the world, research findings have confirmed contrary to the old perception, that there is boredom on the part of patients as a result of inadequate time during care counters, lack of patient informational needs and poor staff-patient engagement which limit patients‘ access to communicate their informational needs in the hospital (Agyemang, 2013; Lasiter, 2013; Radtrek,2013; Haugan,2013a; Bresnick, 2013; Janner & Delenay, 2012;Hamsley, Balaidin & Worral, 2012; Shattell, et al., 2008; Cleary & Edwards, 2004). The situation in some African countries such as South Africa, Zambia and Ghana is congruent to the current situation in the UK, since nurses are perceived unfavourably because of their attitudes towards their patients. A number of research findings have confirmed the apparent lack of cordiality in nurse-patient interactions. In these studies, nurses have confirmed that their clients insult them and they also retaliate. Nurses attributed this to lack of respect on the part of the patients to comply with simple instructions they give as authorities in their communications (Korsah, 2011). In Ghana, some recent published newspaper articles in ―GhanaWeb‖ on patients‘ views concerning nurses-patient interactions at the Komfo Anokye Teaching Hospital (KATH) proposed that there should be a review of the patients‘ rights‘ policy and these rights must be spelt out and made University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 5 available to the public at all times. This is because in most public hospitals especially in KATH, most nurses were perceived as being in the wrong profession; and that the nurses instead of being patients‘ advocates, are usually harsh to their patients and show them no empathy. Most often nurses reportedly intimidate patients (Anku, 2012;Wiredu–Mensah, 2008). These observations about nurses support those of Murira et al., (2003), who maintained that nurses are mostly authoritarian and are not discreet in their interactions with their patients. The researcher, who is a nursing tutor at the Nursing and Midwifery Training College sited in KATH has also observed that nurses sometimes discuss delicate matters in loud voices without compassion and they seem to be interested in controlling and exerting power over their patients. This is interpreted by the patients as a sign of disrespect and this affect their sense of dignity. Nurses seem to have lost the understanding and knowledge that every patient regardless of their age and background deserves their compassion and respect which is best achieved through effective communication (Peplau, 1960). According to Peplau (1952), ―interpersonal relationship is a vehicle for establishment of partnership between patients and their nurses‖. The situation in Ghana concerning mutual respect in the nurse-patient interaction seems to have deteriorated in most public hospitals. From observations by the researcher, (a nursing tutor and clinical instructor in some hospitals in Kumasi) some nurses and patients exchange derogatory remarks during interactions in public hospitals. Most studies on the nurse-patient relationships have concentrated on the nurses‘ side of the story with almost a total neglect of the views of patients (Korsah 2011; Dahlin, 2010; Dowling, 2009; Shattell, 2004). To study patients‘ views with respect to their encounter University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 6 with nurses is therefore paramount and there is a need to understand what the patients are also saying. 1.2 Problem Statement Effective nurse-patient interaction is at the heart of good health care and recovery. Communication is also considered as the ―bedrock‖ needed in any thriving interaction (Kim, 2010; Miner-Williams, 2007). In line with this view, Peplau (1960) considered the building of a good relationship during the nurse-patient interaction necessary for the provision of quality patient-centred care in all health settings. On the positive side, some nurses spend more time with their patients and also listen and address patients‘ health problems that may be identified during hospitalization patients‘ confirmation of positive attitude of nurses is found to be exhibited on walls of most hospitals wards in the form of ‗thank you‘ cards with written words of appreciation to the nursing administration and ward nurses who took care of them (see Appendices AI, AII, AIII, AIV, AV, AVI, AVII, AVIII, AIX, AX and AXI). Despite its usefulness in healthcare, there is ample evidence which shows lack of effective therapeutic nurse-patient interaction in hospitals globally especially in sub- Saharan region of Africa including Ghana (Korsah, 2011; Ojwang, Ogutu, & Matu, 2010; Smith & Pressman 2010; Dovlo, 2005). The current situation indicates that, the nurse- patient interaction in health settings in Ghana is not cordial similar to other African countries such as South Africa and Kenya where nurses tend to focus on physical care and interact only in routines such as admissions, discharges and during medications briefly in a superficial way, with limited social and emotional cues (Ojwang, Ogutu, Matu, 2010; Jewkes et al.,1998). The lack of effective interaction between patients and University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 7 nurses has created an environment at the hospitals where patients‘ dignity is undermined by nurses and other health professionals. This observation has been made in both the local and international media. In 2010, an article titled ―I am not a Knee cap‖ was published in a major Norwegian newspaper and cited by Finset (2010). In the article the author indicated that he was hospitalized for a knee injury but because of the unfriendly nature of the care given at the hospital, he was mostly referred to as the ―knee cap‖ patient by some health care providers especially doctors followed by nurses. The article also indicated that people are mostly treated as objects (as cited in Mok & Chui, 2004) instead of human beings who receive care at the hospitals. Ineffective communication was cited as the main cause of the problem. Similarly, Wiredu-Mensah (2008) cited in an article featured in ―GhanaWeb‖ where a Ghanaian patient in coma was openly referred to as a ―vegetable‖, forgetting that comatose patients can hear and identify voices even in a comatose state. This underscores the lack of respect in the nurse-patient encounter which undermines the quality of care given. The obvious lack of effective nurse–patient interaction might have been the reason behind the move by the Komfo Anokye Hospital to set up complaints point under the quality assurance unit. The ―complaint points‖ are set up at vantage points in the polyclinics, Accidents and Emergency unit (A & E), close to consulting rooms of the hospital to address the numerous patients‘ complaints about the health providers. Despite this effort, the trend is increasingly becoming a source of worry not only to patients but the general public at large including some health professionals. To confirm the extent of the prevailing challenge in nurse-patient interactions, Korsah (2011) also elaborated that, the crisis in nurse-patient interactions remains a serious problem in Ghana despite criticisms and concern expressed by the Ghanaian public, the media, stakeholders, Ministry of Health (MOH), Ghana Health Service (GHS), and the University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 8 Nursing and Midwifery Council of Ghana (NMC). A lot of concerns have been shown but not much improvement seems to have been made. Statistics from the Komfo Anokye Teaching Hospital (KATH) indicate a trend of continuous increase in patients‘ complaints. From 2006 to 2010, the following were the number of complaints received by the quality assurance unit of the hospital; 2006(125), 2007(1156), 2008-(623), 2009- (1409), 2010- (1875). Figure 1: Complaint Trends From 2006-2010 Source: Field Data, 2013 from Quality Assurance Unit KATH Figure 1 represents the trend in patients‘ complaints from 2006 to 2010. As indicated, the number of complaints in 2006 was relatively low (125) when the programme started but shot up in 2007 to a staggering 1156 complaints. This informed the decision of the hospital authorities to decentralize the complaint system by establishing ―complaint points‖ at various units of the hospital. This could have increased the number of complaints but as shown by the number for 2008, there was a drop in the number of University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 9 complaints. This was attributed to the lack of education on the decentralization effort since many patients continued to go to the quality assurance unit to lodge their complaints. After intensifying the education, there was a continuous rise in the number of complaints since patients now had more places to lodge the complaints for redress. Although the unit has not till date specified the exact complaints that are lodged about nurses, there are statistics to prove that the complaints are negative and the highest percentage are about nurses concerning serious medication errors (see Appendix B) because of lack of involvement of patients. The experiences at KATH confirm the findings of a study by Chapman and Kimberly (2009) that, as health care providers try to accomplish more in less time, the relationships between patients and providers of care suffer. Also, stress and pressure from time constraints often cause miscommunication, flawed assumptions, and patient dissatisfaction (Chapman & Kimberly, 2009). The current challenge in health care is to create an environment in which open and transparent interactions will be the norm rather than the exception. An observation by the researcher who is a nursing tutor revealed that, there are nurses who verbally abuse their patients and relatives and vice-versa in the hospital where the researcher practices and teaches. These reciprocal negative interactions between nurses and their patients do occur at various times and settings at the hospital. Ineffective and inadequate nurse-patient interaction is therefore a real problem confronting the provision of quality health care in KATH and also Ghana. As governmental priorities worldwide continue to emphasize the inclusion of patients in healthcare delivery, there is a pressing need for research that focuses on understanding the view of patients on the obvious lack of effective interaction at the hospitals. It is University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 10 important therefore to find answers to the question: what experiences do patients go through during their interactions with nurses at KATH? 1.3 Objectives of the Study The main objective of the study was to understand the experiences patients go through during their interactions with nurses and to find ways of enhancing nurse-patient interactions. The specific objectives of the study were to: 1. Describe patients‘ experiences in the nurse–patient interactions at Komfo Anokye Teaching Hospital (KATH). 2. Identify and explain the factors that contribute to positive and negative nurse- patient interactions at KATH. 3. Find ways of improving the nurse-patient interaction at KATH. 1.4 Research Questions The research intended to answer the following questions: 1. What are the experiences patients‘ go through during their interactions with nurses at KATH? 2. What are the factors that contribute to positive and negative nurse-patient at KATH? 3. How can the nurse-patient interaction be improved at KATH? University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 11 1.5 Significance of the Study The study is significant because of the number of benefits that would be derived from the findings. The benefits will help various stakeholders involved in the health delivery system. The study will help nurses and other healthcare workers to understand and appreciate both positive and negative narrations of patients‘ experiences. This understanding will help caregivers to position themselves to find solutions to the issues which create controversies and misunderstanding among patients. It is believed that nurses will positively learn from their identified mistakes during their interactions with their clients or clients‘ families to improve evidence based nursing practice. The study will also assist nurses to promote the well-being of those seeking health care in health facilities in Ghana. The increased insight about nurse-client experiences in this study should help nurses and other health care workers establish positive and appropriate therapeutic relationships with their clients. The findings of this study will also help inform Ghanaian policy and decision makers to formulate policies that will protect the nurses‘ and the patients‘ rights to prevent abuse. The Nursing and Midwifery Council of Ghana can also benefit from this study to improve their curriculum, by making communication skills as part of practical licensing examination so that student nurses will be taught how to behave professionally toward patients during their interaction. This study would also be of help to other educational institutions especially those involved in health education, health research and health training programmes. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 12 1.6 Operational Definitions Nurse-client relationship: It is a therapeutic relationship between a nurse and a client built on a series of interactions developed over time. A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a doctor. A nurse is a person who is educated and trained and has successfully completed and passed a four year degree or a three years diploma in nursing or midwifery in an accredited nursing school. He/ She must be registered and certified as a professional nurse with the Nursing and Midwifery Council of Ghana (NMC) to operate in the country. 1.7 Organization of Work This study is organized in six chapters. The first chapter provides a background of the study, highlighting the problem statement, objectives of the study, research questions, and significance of the study. Chapter two provides an appraisal of relevant literature on nurse- patient interaction while Chapter three focuses on research design. Chapter four presents the findings of this qualitative study. Chapters five and six cover the discussion of the findings, nursing implication, limitations, summary, conclusion and recommendations respectively. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 13 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter reviewed literature relevant to the study objectives. A wide range of books, journals, papers and the internet were consulted for the appropriate information. For the review, the following databases were used: CINAHL, HINARI PUBMED, Medline, Science Direct and JSTOR. Search terms used as key words were ―nurse–patient interaction‖, ―patients‘ communication‖, ―nurse–patient relationship‖ and ―nurse–patient communication‖. The literature review was organized under the following headings: Meaning of interaction in nursing Communication as an interactive role. Patients‘ perception of nurse-patient interaction. The effect of nurses‘ job satisfaction on the nurse-patient interaction. Stress and nurse patient interaction Power-struggle and nurse-patient interaction. Sense of dignity and nurse-patient interaction Sense of humour and nurse-patient interaction. Empathy and nurse-patient interaction. Nurse-patient interaction and the environment 2.2 Meaning of Interaction in Nursing Interaction, which forms the basis of communication in nursing practice, is not a simple naturally occurring process, but rather a complex endeavour which requires intense University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 14 education and practice (Haugan, 2013b;Dahlin, 2010; Smith & Pressman 2010;Burke, 2008; Buckman,2005). Although researchers have described nurses‘ attributes that patients consider when judging nursing quality and good nursing care in general, little is known of patients‘ perceptions specifically of the interpersonal skill of nurses. Interactive roles have been practiced in both medicine and nursing. However, in recent years, nurse- patient interactions have emerged as a valuable nursing practice with substantial research work to support its return to practice globally (Bourgault, King, Hart, Campbell, Swartz, Lou, 2008). There is comparatively little work investigating both patients‘ and nurses‘ perception on quality nurse-patient interaction and how to ensure quality care (Bell, 2004 & Jewkes et al., 1998).According to some research work done in that area, quality nursing care implies effective communication; kindness, being readily available to patient, making time for patients effective pain management, timely response to call bells and how well nurses are able to meet their needs (Detrick et al.,2006; Davis,2005;Meade, Bursell & Keteisen, 2006; Sterman, Gauker & Krieger 2003; Moyle, 2003). The current research will throw more light on the nurse-patient interaction currently. Effective Communication is very important in any interaction and will also be the focus of the present research. 2.3 Communication as an Interactive Role Chapman and Kimberly (2009) in their study on improving Communication among Nurses, Patients, and Physicians stressed that good communication is critical to ensuring safe and reliable care. They observed that the current challenge in health care is to create University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 15 an environment in which open and transparent communication can take place between patients and health professionals, especially nurses. One way to do this is by adopting strategies that have been successful in other industries. Within the relationship component of communication, the types of nonverbal activities most often identified as important in nursing are gazes, nods or shakes of the head, eyebrow movements, smiles, direct interpersonal orientation, interpersonal touches, and back-channels (Gilbert, 2004; Shattell, 2004; Shattell, 2002; Caris-Verhallen, de Gruijter, Kerkstra, & Bensing, 1999). On communication, Mast, Hall, Kockner and Choi (2008) examined nonverbal activities among 163 adult observers of 11 video-recorded patient-nurse encounters. They found that observers‘ satisfaction with female nurses was correlated highly with more nodding, brow lowering, gazing, and forward leaning. Other than satisfaction, however, little is known about nonverbal activities and outcomes. More recently, in a content analysis of audio-recorded visits between five adult patients and nurses, Berry (2006) found that 50% of the Nurses‘ communication was seeking information and 37% was giving information. Berry noted that less is known about the outcomes of older patient-Nurse verbal activities than about those of physicians. There is the need therefore to know more about these non-verbal aspects of the nurse-patient interaction. This is because these non-verbal activities affect the perception of both the nurses and the patients with respect to the quality of care given or received. 2.4 Patients‟ Perception of Nurse-Patient Interaction In a recent descriptive study on staff nurses‘ perception concerning the practice of patient rounding, Neville et al. (2012) asserted that effective communication and delegation is a University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 16 tool for good interaction and it is perceived to be the most important aspect of the registered nurse‘s role. They further affirmed that communication is formalized by the presence of the nurse with patient especially before, during and after ward rounds and this impact on how patient and their family perceive nursing care. From the researcher‘s perspective, Neville et al. (2012) used a non-probability sampling technique in selecting the sample hence generalization would not be possible. Paasche-Orlow and Roter (2003) examined the proximal outcome of patients‘ satisfaction with communication in audio-recorded primary care visits between 564 adult patients and 59 physicians using the Roter Interaction Analysis System (RIAS). They found that physicians‘ psychosocial communication (e.g., seeking psychosocial information) was related positively to satisfaction. In a survey of 1,588 older patients with diabetes, Heisler, Cole, Weir, Kerr, and Hayward (2007) found that physicians‘ giving information was related to longer-term outcomes of medication adherence and foot care. Overall, the studies indicated that a content component of seeking and giving information tends to represent effective patient- physician communication. Evidence reveals that patients‘ perception of excellence in care is based on the perceived availability and visibility of nurses‘ level of knowledge or competence (Gurney, 2010 & Woodard, 2009). Furthermore, patients‘ perception of effective nurse-patient interaction at hospitals is associated with the care that patients require from their nurses. This means patients are more likely to perceive their interaction with nurses as effective if they have received high quality of care from the nurses. Numerous researchers have also examined patients‘ satisfaction with nursing care in general terms, as well as patients‘ perceptions of the quality of nursing care (Wysong & Driver, 2009). In the qualitative study by Wysong and University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 17 Driver (2009), their findings focused heavily on interpersonal skills of nurses than technical skills. All 32 participants in their anguish centred their discussion on the nurses‘ skills as the measure of judgement on whether nurses are skillful or not. Similarly, a review of the literature by Scandinavian researchers Johansson, Oleni and Fridlund (2002) indicated that patients‘ satisfaction with nursing care is influenced by the nurses‘ technical competence, as well as by the interpersonal relations between the nurses and the patients. In another research testing interpersonal competence of emergency nurses, when 40 patients in a private teaching hospital in California were asked what happened when a nurse was taking care of them, they almost exclusively described the interpersonal skills of the nurse, rather than the task that was being done (Fosbinder, 1994). In that study, four (4) major subthemes of interpersonal skills were identified, including; translating, getting to know you, establishing trust, and going the extra mile. All the studies indicated the importance of interpersonal skills in the day to day work of nurses. For this reason interpersonal skills are as important as technical skills if the nurse can be effective in providing quality care. The nurse-patient interaction is the avenue through which nurses can demonstrate their interpersonal skills. For this reason a patient‘s perception of quality care is related to his/her perception of the quality of the nurse- patient interaction. In a study by Thorsteinsson (2002) in Iceland, nurses who were perceived as giving high- quality care were described by patients as kind, joyful, warm, polite, and understanding and as having clinical competence.Clinical competence, however, was considered the most important nurse caring behaviour in another study from Iceland, in which ―know how to give shots and IVs‖, know what they are doing‖, know when to call the doctor, University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 18 and know how to handle equipment‖ were items with the highest scores (Zamanzadeh et al., 2010).The study considered technical competence the most important, although interpersonal skills was also considered necessary if nurses can achieve stated objectives in their care giving. A nurse can be very competent but without the collaboration of the patient little can be achieved with the highest technical competence. Also, according to a study by Gallagher & Seedhouse (2000), attributes of high-quality nursing care which was described by oncology patients as professional knowledge, continuity, coordination, attentiveness, partnership, individualization, rapport and caring. In another research, Radwin et al., (2005) highlighted oncology patients‘ descriptions of nursing care as: ―laudable‖, ―caring‖ (showing compassion, concern, and kindness), ―professional‖ (holding the standards expected of a nurse in knowledge, skills, and demeanor), and ―outcomes‖ (the affective, cognitive, or physical effects credited to nursing care). Also in an investigation by Cescutti- Butler & Galvin (2003) of parents‘ perceptions of staff competency in a neonatal intensive care unit, parents of critically ill babies perceived competence as a range of caring behaviors rather than solely the performance of tasks or procedures. Being offered choices, style and quality of communication with staff, being made to feel they were not a burden, and being given a sense of being in control were caring behaviours that parents equated with staff competence. All these studies underscore the importance of interpersonal skills of nurses in providing quality nursing care.The importance of ensuring quality nurse-patient interaction therefore cannot be overemphasized. The most important aspects of nursing care identified by postoperative patients in an Australian study by Kralik,, Koch, & Wotton (1997) were nursing attributes categorized as leading to a sense of being engaged with the patient .They included an open dialogue; University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 19 recognition of the patient as a unique individual; availability of the nurse; a friendly, warm personality; and having a gentle touch. The defining characteristics of good nursing care in another investigation by Davis (2005) in a phenomenological study of patient expectation concerning nursing care, patients mostly cited the demeanor of the nurses: gentle, calm, courteous, kind, attentive, available, empathetic, and reassuring. The nurse–patient interaction then becomes a process of perception and communication between person and environment and between person and person represented by verbal and non-verbal behaviours that are goal oriented because caring which involves interaction is the central focus and has positive impact on nursing practice. 2.5 Nurses‟ Job Satisfaction and Nurse-Patient Interaction There is no doubt that the level of satisfaction of nurses at hospitals has some relationship with the quality of the nurse-patient interaction. A study by Baxter (2002) indicated that there is a strong influence of job satisfaction on the quality of care nurses provide as well as on the nurse-patient relationship. This is so because nurses who are satisfied tend to deliver quality care. According to Thorsteinsson (2002) satisfied nurses tend to portray some traits that are necessary for effective nurse-patient interactions .In that study it was indicated that nurses who were perceived as giving quality care were described as kind, joyful, warm, polite and understanding and as having clinical competence. Job satisfaction is very important to effective nurse-patient interaction because as indicated by Newman, Maylor & Chansarken (2002), nurses who are not satisfied and feel undermined and undervalued are more likely to neglect their duties towards the patients. This means nurses who are dissatisfied with work will be more likely to be rude and impolite towards the patients they are supposed to care for with respect and patience. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 20 Again the importance of ensuring that the nurse is satisfied with his/her job was reinforced by the study by Johansson et al.,(2002), which found that patients‘ satisfaction with nursing care is influence by the nurses technical competence as well as by the interpersonal relations between the nurses and the patients. This indicates that nurses will be more likely to engage in interpersonal relations and effective interaction with their patients if they are satisfied in their job. 2.6 Stress and Nurse-Patient Interaction As found out by Menzies-Lyth (1988), nurses have to contend with personal, emotional and professional demands on them every day and these have effects on the quality of care given. The shortage of nurses coupled with the teeming number of patients at the hospitals tends to impact negatively on the nurses and create stress in their work. The stress in the nursing profession therefore originates from the inability of nurses to deal with the demands imposed on them by their day to day work. The connection between quality of care and stress level of nurses was shown in a study by O‘Donoghue et al. (2004).In the study it was found out that, long hours, lack of role clarity and high patient ratio have some correlation with unethical behaviours demonstrated by nurses towards their patients. This means that factors that increase the stress levels of nurses in their work also have relationship with the quality of the nurse-patient interaction and the quality of nursing care that will ultimately be provided. The work environment related stress can therefore induce some unethical work behaviours from the nurses. This was supported by Gibson (2004) who found out that the nurse-patient relationship and interaction may suffer because of the social environment within which care is given. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 21 Another source of stress in the nursing profession nurses has to do with the emotionality involved in the nursing work. As indicated by Roos (2005), that is the inability of nurses to deal with the emotions inherent in the nursing work can have serious and devastating consequences for the nurse-patient interaction. It can also affect the quality of care that is provided. To solve the problem and also improve the nurse-patient interaction, Laschinger et al. (2001) highlighted the need to ensure a supportive working environment in hospital. As the study found out, a supportive working environments is positively correlated with the quality of patient care. Nurses working in supportive environment will help them deal with the emotions and stresses they encounter in their work. Working in less stressful environment is more likely to bring about improvement in the nurse-patient interaction. The need to ensure a supporting working environment was also reinforced by AbuAlRub (2004), who was of the view that nurses who feel supported in their working environment and are at peace with their co-workers are more likely to perform excellently in the work and also are able to maintain higher levels of patient care. Nurses are confronted with numerous problems which affect their interaction with patients. To bring about improvement in the nurse-patient interaction these problems should be identified and dealt with. According to Gibson et al. (2003), if nothing is done about the inherent problems in the nursing profession, nurses are more likely to adopt an approach of silence but the real consequence will be shown in the unpleasant nurse- patient interaction. 2.7 Power Struggle and Nurse-Patient Interaction Few studies have indicated that the nurse-patient relationship involves power struggle based on the perceived powers the parties consider having. According to Kettunen, Poskiparta and Gerlander (2002) the nurse-patient relationship is founded on power University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 22 relations. Nurses perceive their power in their professional knowledge and show their power through controlling information, questioning and rewarding. The patients also perceive that their power is in their demand for the services of nurses and that set the stage for the power struggle which ultimately affect the nurse-patient relationship or interaction. Since nurses perceive themselves to be powerful in the relationship they in some cases expect some behaviour from the patients which if not demonstrated disturbs the bases of the relationship. The result of the power struggle was reported by Roos (2005) where nurses reported that they do not want to be questioned by their patients. The questioning by the patients was possibly perceived by the nurses as a challenge on their competence. For the nurse-patient interaction to be effective and productive the parties should be encouraged to tolerate and cooperate with each other. 2.8 Sense of Dignity and Nurse-Patient Interaction One factor that may affect the nurse-patient interaction is how well the patient perceives to have been treated by the nurse. According to Baillie (2007), patient dignity is enhanced when nurses ensure privacy and engage the patients in the way that makes them feel comfortable, valued and in control. When this is the case patients will be more likely to interact in a positive manner and also appreciate the work of the nurse. As shown by Jacelon (2002), the dignity of a patient may be threatened if the nurse shows by his/her action that getting the job done is more important than focusing on the patient as an individual or the nurse behaving in an authoritarian manner towards the patient. The importance of ensuring the dignity of patients has necessitated the campaign for the need to institute patients‘ rights. For instance in the United kingdom, there is increasing emphasis on patients‘ right to be treated with dignity (Department of Health, 2006). University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 23 That was in response to some studies which indicated that nurses were relating poorly to patients in ways that affected their dignity, such as ignoring patients and talking to patients in a harsh manner (Calnan et al., 2005). Other studies also supported the need to protect patients‘ dignity, based on findings that patients are mostly vulnerable to loss of dignity in hospital (Jacelon, 2003; Seedhouse & Gallagher, 2002). 2.9 Sense of humour and nurse-patient interaction For the nurse-patient interaction to be effective there is the need for the nurse to have a good sense of humour. This was supported by McClement et al. (2004) and Dean & Schmitzm (2003) who opined that patients feel relaxed and comfortable when nurses used humour. This will definitely make the patient interact freely with the nurse without fear. Though nurses having sense of humour is important to ensure effective nurse-patient interaction, other studies have also indicated the need for sensitivity when using humour (Olsson et al., 2002).The need for sensitivity with the use of humour is premised on individual differences. This is because what is intended for a joke might be interpreted differently. 2.10 Empathy and nurse-patient interaction Absence of empathy will make it very difficult for nurses to understand fully the needs and wants of patients and that will prevent the nurses from treating the patients kindly and generously, or to practice any worthwhile virtue in their day-to-day relations with the patients. Some studies have discussed the need for empathy in the nursing literature. For example Morse et al. (1992) have argued whether empathy should be the best mode for the nurse-patient interaction. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 24 According to Rowe and Sherlock (2005) the emotional relationship that exists between the nurse and the patient is based on the feeling of empathy for the patient‘s survival. Another study by Michie (2002) opined that the work of nurses would be made manageable and less stressful if they become more empathetic towards their patients in their day to day interactions. 2.11 Nurses-Patient Interaction and the Environment The nurse-patient interaction does not take place in a vacuum but in an environment. The environment impacts on the nurse-patient interaction and vice versa. In the study by Shattell (2002) the hospital environment was found to be very important in the nurses- patient interaction and that the nurse was found to be very prominent in the environment. This means the nurse contributes a lot to the nature of the hospital environment hence the quality of the nurse patient interaction. Also in a study by Cleary, Edwards and Meehan (2004),the environment emerged as one of the major themes on the study of the nurse- patient interaction. In the study nurses expected conducive environment to care for the patients effectively and the environment should be a safe one. A number of studies have tried to research into factors that influence the hospital environment. The findings of these studies have identified the culture at the hospital as one of the important factor that influences the hospital environment. For that matter to influence the hospital environment requires working on the prevailing cult ure at the hospital (Kirwan, Mathews & Scott, 2013; Larsen Larsen & Birkelund, 2013; Siddiqui, 2013; Korsah, 2011). The importance of the environment to recovery and also the nurses-patient environment was also emphasized by Florence Nightingale. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 25 The literature review has considered various variables that are critical to the nurse-patient interaction. Some of the variables include, stress level of nurses, empathy, sense of dignity, sense of humour, power struggle and nurse-patient interaction and the environment. The variables contribute towards the quality of the nurse-patient interaction. Summary of the Review Most of the research works on nurse-patient interaction have focused on nurses‘ communication in the interaction even when the unit of study was the patient. Patients‘ communication has received much less attention, reinforcing the idea that nurses have more power in the nurse-patient interaction. The nurse-patient interaction has not been researched into much in Ghana and other low and middle income countries. Other studies in the area have concentrated mostly on the nurses‘ perspectives on the subject of nurse- patient interaction. The focus of this research therefore will be on the perspectives of the patients who are mostly neglected. This is intended to bring some balance in the inquiry into the subject of nurse-patient interaction. This study also sought to contribute to filling this knowledge gap and to inform policy. In the next chapter, the research methodology is discussed. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 26 CHAPTER THREE METHODOLOGY 3.1 Introduction This section of the thesis deals with how the study was conducted. The aim of this chapter was to explain the research design and methods that were used in the conduct of this study. Since the guiding question for the study was aimed at understanding the nurse- patient interaction with the patients‘ perspective and experiences, this chapter begins by explaining the qualitative research design, method chosen, why the setting was chosen and procedures followed to achieve the study objectives. Also, the sampling techniques used to select the sample and the methods of data collection are present. An explanation of the philosophical inquiry, concepts and analysis on data collected and analysis are given. The chapter concludes with a presentation on methodological rigour and ethical considerations. 3.2 Research Design The study used the qualitative approach. This approach allows for flexibility in the collection of an array of perspectives from a number of participants in a study. In the qualitative method, there are prompting questions to explore subjective data. Examining life experiences (as is the case of this study) requires using the qualitative approach (Creswell, 2005). According to Macleod (2002) qualitative knowledge concerns subjective human experience and researchers who use this design normally follow the constructivist tradition, which emphasizes reality as a construction and the studied phenomenon as dependent on the participants‘ perceptions and experiences of it. Qualitative research University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 27 therefore is concerned with the description and interpretation of a phenomenon in the context in which it is experienced and understood from the participants‘ point of view (Mash & Woolfe, 2002). With the aim of understanding the participants‘ perspectives and experiences, it was therefore necessary to use the qualitative design for this study because it tends to capture the lived experiences of participants. 3.3 Research Setting The study took place at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. It is the second largest hospital in the country and the only tertiary health institution in the Ashanti Region. KATH (Gee) as known by the public is one of the autonomous and self- funded referral centre within the northern sector of Ghana consisting of the Ashanti, Brong Ahafo, Northern, Upper East and Upper West Regions. The hospital was built in 1954 as the Kumasi Central Hospital. It was later named Komfo Anokye Hospital after Okomfo Anokye, a legendary fetish priest of the Ashantis. It was converted into a teaching hospital in 1975 and was affiliated to the medical school of the Kwame Nkrumah University of Science and Technology. The hospital is also accredited for postgraduate training by the West African College of Surgeons in surgery, obstetrics and gynaecology, ophthalmology and radiology. The hospital currently has about 1000 beds, up from the initial 500 when it was first built. It caters for public cases only for people in the confines of Kumasi and also from other hospital in the confines of the northern sector in Ghana for further management. The hospital has clinical and non-clinical directorates which includes : Anaesthesia and Intensive Care Unit (ICU),Child Health, Dental, Eye, Ear, Nose and Throat (DEENT),Diagnostics, Medical-Surgical blocks, Obstetrics & University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 28 Gynaecology, Oncology, Polyclinic, Surgery, Accident and Emergency and Pharmacy Departments. The non-clinical directorates include the following: Domestic Services, Security, Supply Chain Management and Technical Services. The setting was used because the hospital has a staff strength of 3,412 with the staff cadre of doctors, nurses, pharmacist, administrators, quality assurance unit, cleaners, physiotherapists and security personnel with the nursing staff forming the majority of the workers. Most individuals that report to the hospital come in as referrals from some of the hospitals in the middle and northern sectors of Ghana. Also, the major constraints and challenges identified by the hospital management is that the hospital is struggling with how to effectively improve interactions, service delivery, and to reduce health workers exodus as well as how to maximize health system performance at any given level of resources. To do this, it is important to explore potential interventions like improving interactions to the recipient of health care which could move the health system performance curve upwards. 3.4 Study Population and Sample Creswell (2005) explains population as a group of people who are the focus of a research study and to which the results would apply. This is also the group on which the researcher would like to make inferences. For this study, the target population consisted of all patients who reported for care at KATH and spent a week or more on the ward. The sample for the study consisted of twelve (12) patients (see Appendix K) who were selected from the target population at the maternity, medical and surgical adult wards before their discharge from the hospital and during a follow-up (review) visit. These patients constituting the sample were told about the aims of the study and then taken through an in-depth interview on and after their first review date to collect the required University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 29 information in order to find answers to research questions. This was done at times and places convenient to the participants. 3.5 Inclusion Criteria Patients who were eligible for the study were those whose length of stay at the hospital was at least a week or more. The eligible patients were selected based on the criteria that they could speak and comprehend any of the ―Akan‖ languages (native languages) or English language because the researcher is fluent in communicating with the selected languages. Also, most inhabitants of Kumasi and nearby towns understand and communicated well in the ‗Akan‘ languages predominately ‗Asanti- Twi‘ and ‗Akuapim- Twi‘ (local Ghanaian dialects) and some used English language. All the participants used for the study were 18 years and above. 3.6 Exclusion Criteria Patients who were not used because they did not qualify for the study were those whose health status were unstable or were in the state of confusion or disoriented. All patients who could not communicate in any of the languages stated in the inclusive criteria were eliminated from the study. 3.7 Sampling Technique The purposive sampling technique was used in selecting the sample for the study. Since qualitative research does not aim for a statistically representative sample, the selected technique was deemed appropriate for the study. The purposive sampling technique was used because the participants selected were deemed to have the characteristics considered University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 30 appropriate for the study and from whom the needed data could be obtained. For example, all the participants were admitted to the hospital for at least a week and also had the opportunity to experience the nurse-patient interaction. This made it possible for them to report their experiences either positive or negative. To select the sample for the study, permission was obtained from the hospital authorities to conduct the study. The researcher then entered the wards to create rapport with the patients and gained their confidence and trust. Through this process, the researcher selected the participants that met the inclusion criteria. Four (4) participants each were selected from the maternity, medical and surgical wards. The patients had different health conditions and have all had contacts with the nurses at different levels. This initial contact with the patients gave the researcher the opportunity to gain the consent of the patients to take part in the research. After the consent of the selected patients had been gained, the sample selection was over. 3.8 Data Collection Data for the study was collected through interviewing the research participants. A pilot study was conducted at Suntreso Government Hospital to understand the natural settings similar to be used for the study. Also, the semi- structured interview guide was slightly adjusted after pretesting the tool at the Suntreso government Hospital. Before the interviews were undertaken, patients‘ information leaflet sheets and consent forms (see Appendix J and G) were explained to them and participants who were willing and interested in the study signed to indicate their agreement. The participants also agreed on pseudonyms they were to be called throughout the study. All the pseudonyms started with University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 31 letter ―C‖, for example ―Clara‖ (see Appendix K).This exercise happened in both the pilot setting and at KATH, the research setting. The in-depth interviews of the research participants took place on or after their first review dates. This arrangement was to provide for the convenience of the participants and also ensure confidentiality. The participants were made aware of the aims of the study for their consent before they were interviewed. All the interviews took place within the period from February 4th to March 5th 2013. The participants were interviewed face-to-face by the researcher lasting between 45-50 minutes in a comfortable environment selected by the patients. The interviews were in the English language or any of the local ‗Akan‘ languages (local Ghanaian dialect) using a semi-structured interview guide (see appendix H). The interviews were recorded on an audio-tape. Since the interviews were semi-structured and the questions were open ended, the researcher was able to ask specific questions from the interview guide (see appendix H) and at the same time allowed the participants to talk freely as they answered the questions in a narrative fashion (Polit & Beck, 2008). The interview schedule allowed flexibility in the ordering or rephrasing of questions (Bryman, 2001). The in-depth interviews enabled the researcher to do more detailed exploration of the phenomenon of interest. The ability to probe particular answers, clarify meanings and rephrase questions was considered important and were used during the interview session. Another key advantage of interviews is that they allow for in-depth experiences to be explored and can enable participants to talk freely and emotionally, with candour, richness, authenticity and honesty (Morrison, 2000). University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 32 3.9 Data Analysis The data collection and analysis were conducted simultaneously. At the end of each day of interview all the recorded interviews on tape were transcribed verbatim manually by the researcher. The accuracy of the manual transcripts was checked by reading over and at the same time listening to the audio-tape recordings. After all audio-recordings had been transcribed manually; the data was typed and then analyzed using thematic content analysis (Flick, 2006). Thematic analysis is a process of labeling qualitative information to identify and interpret patterns in ‗raw‘ text. The researcher carefully read and re-read the transcripts to identify recurring themes. The themes were given codes differentiating them. The researcher then grouped codes into a hierarchy with larger themes and their corresponding subthemes. Using a carefully developed thematic code frame (see Appendix I), the entire data set was coded. All phrases or sentences that fit a particular code were labeled as such. Following the coding, all information belonging to a code were copied and placed in separately labeled files in a computer. Along with appropriate quotes, these pieces of analysed data were read several times to unpack or tease out what the participants were saying about the phenomenon being studied. 3.10 Methodological Rigour The scientific community regards qualitative research as unscientific because of the inability to generalize the results. Roberts, Priest and Traynor (2006) articulate that to ensure rigour and trustworthiness of a study, the results of qualitative studies may not be adaptable universally, but the results may be comparable to settings similar to the study. In order to ensure that any research contributes effectively to the existing knowledge there is the need to ensure high levels of rigour in the procedures of data collection and analysis University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 33 (Morse & Field 2002). In this study, during data collection and analysis rigour was ensured through the following means. Firstly, to improve the credibility of research findings, Jackson and Stevenson (2000), recommend taking research findings back to the participants and giving them the chance to agree or disagree with the researcher‘s interpretations. To comply with this prescription, the verbatim transcribed interview data written and the research findings were taken back to the participants and explained in the local dialect for their comments. None of the participants in this research made changes in their narrations. Adequacy of data is important in qualitative research and this is achieved when sufficient data is collected. In this study, data adequacy was achieved by giving the participants the opportunity to talk about their experiences until they had no more to say. Also, the interviews continued until the point of saturation when no further new information was being provided. Transferability in a qualitative study is when the results may also apply to another similar setting, group, or context (Plummer-D'Amato, 2008). To achieve transferability, the study sample must be adequate in size and sufficiently varied (Plummer-D'Amato, 2008). To ensure adequacy of sample size for the research study, the sample taken was 12 patients from different wards. After interviewing this number of patients no new information was emerging so the researcher stopped the interview. Internal validity, most often used in quantitative studies, is the believability of the study results. The degree of truth obtained during data collection and analysis is the extent to which the research has credibility. The degree to which the study accurately represents the participants‘ ideas and perceptions determines the credibility of the study (Koch, 2006). University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 34 Internal validity was ensured as participants were assured of the confidentiality and anonymity of information provided therefore each participant was given a pseudonym which began with the letter ‗C‘ (see Appendix K). This made participants to talk freely without fear because they believed their real names were not used for nurses to label them in their next visit at the hospital (KATH). When this assurance was given participants showed keen interest in responding more freely on issues worrying them. Confidentiality and anonymity not only ensure that participants‘ identities are protected, but also ensure that results are not connected to an individual (Hallberg, 2007). Another way validity was enhanced in the study was through the categorization of responses. Categorization of responses increased the validity and reliability of the research study. 3.11 Ethical Considerations Ethical clearance was sought from the Institutional Review Board of the Noguchi Memorial Institute for Medical Research (see Appendix D) and the Committee on Human Researches, Publication and Ethics (CHRPE) at the Medical School, KATH, KNUST (see Appendices D and F) with an introductory letter from the School of Nursing, University of Ghana, Legon (see Appendix C). The information obtained from the participants have been kept by the researcher in confidence under key and lock for at least five (5) years and only the researcher and her supervisor will have access to the transcribed responses. Also, the consent of the participants were sought before they were engaged in the study. The authorities at KATH approved use of the study setting by giving a certificate (see Appendix E) before data collection begun. The consent of the participants was sought through the signing of the participants‘ consent form. The confidentiality of the data collected was assured. The participants were educated on the purpose of the study and no University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 35 compulsion was placed on a patient to take part in the study. During the course of the study, none of the participants recruited complained of any feeling of discomfort in responding to any of the questions. However a few participants cried when expressing their lived experience. The interview stopped, the researcher counseled them and only continued when the participant prompted that they should continue. 3.12 Limitations of the Study One limitation of the study was that the sample size was small and consisted of patients from only some departments of the public hospital and therefore was not representative of the population that visits the hospital. Also, to better understand the nurse-patient interaction, this study should have used both nurses and patients as samples. Patients formed only part of the parties involved in the interaction. Future studies should have in the sample both nurses and patients. In this chapter, the methodology of the study was described. The process of selecting samples, data collection and data analysis has been explained in detail and ethical consideration elaborated on. The following chapter discusses the findings from the data collected and outcome of analysis and is in accordance with identified themes. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 36 CHAPTER FOUR FINDINGS 4.1 Introduction This chapter presents the major findings of the study obtained from the data gathered using semi- structured interviews. The findings are presented under the objectives of the study and are grouped under six (6) main themes with their corresponding sub-themes generated from the data collected. The chapter will first highlight the demographic characteristics of participants in the study. This will be followed by a presentation of the themes identified. 4.2 Demographic characteristics of respondents The age ranges of participants were from twenty (20) to forty-five (45) years. Out of the twelve (n=12) participants, the majority, seven (7) were females and the minority of five (5) being males. With educational level, almost all the respondents with the exception of one have been to school at least to the basic level. Four (4) out of the 12 participants were JHS leavers, three (3) dropped out from school at the primary level and two (2) were SHS leavers and one (1) person was a middle school leaving certificate holder. There was also one degree holder and one had never had any formal education. With their occupation, nine participants were self- employed and the remaining three (3) were unemployed. Most of the participants belonged to the Akan ethnic group specifically the Asante, Akwapim, Denkyira and Fanti. Only two were from different tribes; Gonja and Hausa. In relation to religious background, ten (10) out of the twelve (12) participants were Christians and two (2) were Moslems. Eight (8) out of 12 were married, two (2) were single, one (1) was cohabiting and one (1) was widowed. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 37 All the participants were admitted to the adult wards; four each in medical, surgical and maternity wards. Each patient spent at least a week on the ward before going on discharge (see Appendix K for the demographic characteristics of participants). In the ensuing sections, the identified themes and their corresponding sub-themes are discussed. The presentation of findings via the main themes and subthemes are supported by verbatim quotations from the interview transcripts. Data from the interviews generated six (6) major themes and twenty –three (23) sub-themes. The identified themes and subthemes are presented in Table 1. Table 1: Themes and Sub-Themes from Transcribed Data MAIN THEME SUBTHEMES 1. Patients‘ expectations and actual observations. Caring environment Humane treatment Supportive nurses Effective communication Respect for patients‘ rights 2. Patients‘ perception of nurses based on their experiences ―Good‖ nurses ―Bad‖ nurses ―Lackadaisical‖ nurses 3. Nurses‘ attitudes Positive attitudes Negative attitudes Ambivalent attitudes 4. Nurses‘ stereotyping and discrimination of patients. Favouritism ―Distant‖ nurses Deliberate neglect of patients Poor patients 5. Patients‘ feeling of powerlessness. Authoritarian nurses Patients‘ feeling of inadequacy Patients‘ exclusion from decision making 6. Improving the nurse-patient interaction. Training Supervision Motivation Nurses‘ accountability Resources University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 38 4.3. Patients‟ expectations and actual observations One of the major themes identified was patients‘ expectations and actual observations. As many as five (5) sub-themes emerged from this theme. These were; caring environment, humane treatment, supportive nurses, effective communication and respect for patients‘ rights. Patients who come to the hospital for care have expectations. In their minds, they have a range of expectations from the health facility as well as the health workers which in their views should work together to help alleviate the health problem for which care is being sought. Based on these, they critically observe all that go into their care to evaluate whether what they expect is what is being done in relation to their care. In this section, the participants outlined what they expected during their admission to the hospital and what they observed on the ground. 4.3.1 Caring environment The experiences of patients at the hospital were found to be influenced by the nature of the setting within which the needed care was provided. Participants in this study expected the care environment to be conducive to alleviation of patients‘ sufferings and lead to recovery. It was found that the expectations patients had were contrary to the observations made. This had an effect on their interactions with the nurses who took care of them. The participants in this study were of the view that for the hospital environment to be a caring place nurses should have a sense of responsibility for their work, show concern for patients‘ wellbeing, show love and be receptive to patients concerning their health issues. The patients also expected nurses to be serviceable to patients and their relatives. The findings of this study indicated that some of the patients‘ expectations were met as participants commended the nurses about their readiness to receive sick people to the University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 39 hospital environment. Other expectations however were not met. Whether participants‘ expectations were met or not affected the nurse-patient interaction in one way or the other. With respect to the expectations patients have about the hospital as a caring environment, a participant of the study observed: “….. But the nurses are supposed to receive me nicely, smile to me, calm me down because, they should know that by all means I will have some fear in me… in fact, they made me feel secured and welcomed. For a minute, I felt at home”. Cynthia, age 25 years The participant indicated that the hospital environment should be welcoming since how a patient is treated the first time in the hospital setting and on admission will affect all the other interactions that will take place at the hospital setting, especially at the ward. In response to the question on how they expected nurses to behave at the hospital to improve the nurse-patient interaction, one participant stated: “What I will say is that the nurses should greet patients when they get to the ward, pray with them, ask of their health and find out if they have any complaints. They should make sure their medications have been served and also find out if the night nurses have been taking good care of them and not to yell, shout and fight with patients… Also, for me, I think every patient expects that nurses should have patience even at the period of exchanging greetings, so that patients can pour their hearts out to them because that will aid in their recovery as patients. What I mean is that nurses are supposed to show love, care for our needs, chats with us nicely and even encourage us” Carmey, age 20 years According to the patients, ―greeting‖ represents a sign of cordiality and nurses greeting them often created the right atmosphere for effective interactions to take place. This expectation is also in line with the culture of the patients and is a way of showing concern for the patients: “… So as nurses see a patient lying on a bed, they have to know that the person will definitely need their help, nurses should chat with their University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 40 patients so that even if the person is quiet, you will use the opportunity and time to know what is wrong with the person and ask about why the patient is quiet so that you console or comfort her. This is because nobody will be quiet without any reason but that behaviour is not seen with the nurses I met. If they greet us we will know that they care about us and we will also respond” Charllotte, age 34 years The participants of the study also expected the hospital environment to be a caring one and a place of refuge where there is peace; a non-suppressive home-like environment where one feels safe: “…The person will know that the hospital is the same as one‟s home so that alone will make the person calm down. If you are like me with nobody to visit you, you will always be thinking and you and I know it is not good for a sick person to do that because If you don‟t take care, you will recover and another sickness will resurface because of the excessive worrying” Charllotte, age 34 years In relation to the expectations of participants in this study, their observations made them having mixed feelings. These affected their interactions with the nurses. Some of the participants indicated that the environment within which care was provided was not conducive or caring enough and that had an impact on the nature of interactions that took place between them and the nurses. For example, one participant described the hospital as an uncaring environment: “At least I was expecting that when we finish using the bedpan the nurses would come for it and dispose the content. But they were not doing that and the ward mostly smelled. It was very embarrassing. That could have caused other diseases. Because of that, I started using the crutches by force to the toilet and anytime I tried my wound bled. … Sometimes the toilet (faeces) can be there for close to 3 hours. At times when you defecate around 6:00 pm it can be there till the night nurses come in at 8:00pm. As for them they normally come round and serve us with bed pans and take them as soon as we are done… As for me, I believe that they should carry certain activities for us, such as helping us to bath, discarding our waste for us”. Constance, age 25 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 41 The above statement was in response to a question on personal experiences the participant had gone through at the hospital ward during admission. The hospital environment (ward) in her view was not conducive and this affected the quality of the interactions with the nurses who provided care. Experiences by other participants indicated that the hospital could also be a caring environment: “The nurses always came and asked me, can we feed you. They gave me the opportunity to decide whether they should give me the food my wife brought or what the hospital gave me. They never did something without asking for my opinion”. Cudjoe, age 45 years This reportedly facilitated the exchange of information between the nurse and the patient thereby enhancing their interaction. 4.3.2 Humane Treatment Humane treatment emerged as one of the important subthemes under the theme ―patient expectations and actual observations. Participants in the study considered humane treatment to be the type of care given by nurses who demonstrate kindness, compassion, honesty, patience, giving encouraging words and making patients feel at ease and comfortable during treatment. The participants of the study believed that humane treatment would be achieved if nurses showed sympathy and empathy, exchanged greetings with patients and created rapport, continuously reassured patients and treated them as human beings in need. Participants believed that if patients are treated humanely, it has an effect their interaction with the nurses and it also lead to their fast recovery. The participants therefore expected to get humane treatment from their nurses in who were on duty during their stay at the hospital ward. This was identified in a statement by a participant that: University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 42 “It is expected that when a sick person is brought to the hospital, nurses have to be patient in all their dealing with the sick person. I mean the nurses are supposed to treat patients well so that the sickness they came to the hospital with, will be cured through drugs, doctors‟ advice and a good relationship that exist between the health workers and the patients. This will also aid patients to recover fast and go home before the expected time”. Collins, age 38 years The need to be given humane treatment was also emphasized by some of the participants who affirmed that: “I wish that the nurses will have sympathy and also try to understand us so that the care they render to us will be better and of good quality” Christa, age 38 years ―Ok when we say some one loves somebody, is like the person feels for the brother or sister. She puts herself in the person‟s shoes and thus has feeling for that person, but if you don‟t have love you don‟t mind what happens to your brother or sister. But the one with love will show concern and say sorry if you are hurting. This was what I was looking forward to from the nurses right from the day of admission” Carmel, age 34 years It was believed that if nurses had sympathy and understood the conditions patients found themselves in, they would understand the patients better and that would lead to improved nurse–patient interaction. In response to a question on their experiences with the nurses at the ward, some participants expressed: “…They even feel the pain you are going through and most of the times console us. Sometimes when you are crying, they tend to have their gesture changed to show signs of pain and sorrow…” Constance, age 25 years “Some of the nurses too both young and old assured us that things will be well in no time and show sympathy with regard to the state of my ill- health, helped me when I wanted to respond to natures call, find out my feelings in dealing with people in the ward and encouraged me” Christa, age 38 years. „They advised me well else I wouldn‟t have had my baby. They also helped in taking in my medications as it was even difficult taking them at home. Also, they always told me that it will be well whenever I was bleeding. The University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 43 way they cleaned me when I was bleeding hmmm, eh! In fact, they really helped me a lot” Cynthia, age 25 years It was found that nurses who showed sympathy and empathy tended to treat patients nicely and engaged in positive interactions with them. This is because patients developed trust in them and they became their confidants. In contrast to having humane treatment, it was found that other participants also received treatments that were inhumane and this influenced their interaction with the nurses negatively. A participant recounting her experiences expressed that: “The nurses‟ interactions with patient I saw were similar to their own behaviour and cultures because during my admission period, I saw that they do not have sympathy. They did all kinds of things to me as a patient forgetting that I, the patient, is also a human being. It was accident that brought me to the hospital and as I speak now, my husband died through that accident. Sometimes, I had to cry my head out that, I have 6 young children in the house waiting for me to show them my motherly love and be concerned with their welfare, why would I love to stay at the hospital ward? And for what purpose! I don‟t have a husband, my mother too is deceased, I don‟t have a father that is why I could not get the 300 Ghana cedis for the operation yet, they just don‟t want to understand me especially the matrons” Christa, age 38 years The remark was from a patient who could not pay her hospital bill because of her peculiar circumstances. Patients reportedly want nurses to show that they understand them and are concerned even if they could do nothing to help them. The need to show concern on the part of nurses in their interactions with patients was also reiterated by another participant: “She said I should get down from the bed and lie on the floor because I hadn‟t settled my debt. And she said it in a harsh manner because someone was going to lie on the bed. She brought me a mattress to lie on the floor but I didn‟t want to. I went to sit on a bench and she asked me to get up and if I refuse she will make the police arrest me. God is our healer but the words of encouragement of the nurses ….especially words like “God will help you”, really helped me”. Carmey, age 20 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 44 Providing humane treatment at the hospital is essential to maintaining positive nurse-patient interactions. 4.3.3 Supportive Nurses Nurses who are supportive are essential for the nurse–patient interaction. Supportive nurses were considered to be nurses who demonstrate readiness to provide the services required of them and also do everything possible to ensure that patients are comfortable and ultimately achieve the required recovery. Supportive nurses are those who are also ready to hold and hug the patient in times of distress, pain and discouragement: “Some of the nurses too hold and touch you gently as if you were their sister.” Cynthia, age 25 years “Eh! Some show love. Some people know that this was not how you were and then you are so as a result of an accident”. Constance, age 25 years Participants emphasized their expectation of always having the supportive touch of their nurses and also having nurses that are empathetic, non-judgmental and always ready to assist with all the activities involved in their care as exemplified: “For someone who is sick, sometimes you are happy and other times too you will feel pain. So it is therefore the duty of the one who is caring for you to find out why you are quiet and find ways to make you comfortable. Sick people should be happy always”. Charllotte, age 34 years Another participant noted: “When patients are admitted to the ward, nurses are expected to help them change their sanitary pads because of the soiling from their bleeding. Some of the nurses will have to get closer to patients so that there will be some form of cordiality and familiarities to allow them change the soiled cloth for them.” Cynthia, age 25 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 45 The above remark was made by a participant who was admitted at the labour ward. Despite the expectations of the participants, their actual experiences at the hospital made it possible to determine whether there were supportive nurses at KATH and how their behaviour influenced the nurse-patient interaction. The supportive nature of nurses at KATH was described by some participants: “… Also, when I first came on admission, I couldn‟t move from my bed to the wash room. Some nurses were readily available whenever I called them to help me especially to the toilet. They were always around to help. Such nurses are really working to help the citizens of the country and the government. When you want anything, they are there to help” Collins, age 38 years “Others turned and looked at the calling patients, asked them what their needs were and helped them in their situation. When a patient tells them she has toilet in her refined chamber pot (bedpan), they were always quick to pick it up and dispose off in the toilet for her. I think with such nurses, it is their inborn traits” Christa, age 38 years The participants observed that if nurses were supportive, patients developed confidence in them and this brought improvement in their interactions. Patients could easily tell nurses their concern without feeling intimidated. 4.3.4 Effective Communication Effective communication was found to be fundamental to quality patient care. Communication is not only simply sharing of information but requires overt demonstration of nurses‘ knowledge, skills and empathy. Participants in the study expected that nurses would focus on talking to them properly as humans and that communication should focus more on issues such as the daily progress of their health, explaining procedures to them, asking them about their feelings and University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 46 reassuring them. Comments by participants indicate how effective communication is essential in the nurse-patient interaction: “Some nurses discuss the patient‟s sickness, its progress and sometimes explain what should be done as well as what not to be done to help improve the condition.” Collins, age 38 years “They‟ll come and interact well with you, find out what is wrong with you and give you drug.” Cynthia, age 25 years “With regards to communication engagements, when a staff passes by they sometimes ask how I was doing when I was at the critical state, I responded by nodding my head other times too, when I need something and they are passing I signaled them with my hands or sometimes try to shout, by saying either nurse! Or boss! And the person will come. I used the opportunity to tell the person what I needed and the person will carry out what I asked for. So with my communication with them, sometimes they initiate and other times I initiate it.” Cudjoe, age 45 years “They really talked to us well and even when we don‟t understand anything when we ask them they take their time to explain it to us. I don‟t have any problem with how they talked to us.” Clere age, 32 years The findings showed that some nurses were poor communicators and thus negatively influenced the nurse-patient interaction. It was found that nurses sometimes used wrong timing and tone of voice that tended to misconstrue the message they wished to pass on to the patients. This often generated negative emotions in the patients: “What I saw was that they shout at patients, so it made it very difficult for me to talk to them or ask them for anything because when you just open your mouth they say eii! Why? What is it? It then keeps you mute and you can‟t even continue with what you were saying”. Cynthia, age 25 years Effective communication was found to be necessary in the nurse-patient interaction. This is because effective communication is not only essential for accuracy of diagnosis but has University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 47 been elaborated by the participants as a significant factor contributing to patients‘ satisfaction. 4.3.5 Respect for patients‟ rights The participants considered respect for their rights as crucial for the maintenance of good nurse-patient relationship. Patients tended to reciprocate respect for their rights by respecting the nurses in return and opening themselves up for deeper nurse-patient interactions. Patients expected that beyond the routine duties of the nurses, their rights should be respected. “In fact we the patients expect more from the nurses than what they can give. There is the need for them to show some kind of respect in their dealings with us. … Hmm what I mean here is that besides everything they do for us, they should at least accord us the respect we deserve as human beings”. Collins, age 38 years Patients expected nurses to keep the information about their condition and other personal information confidential. Patients developed more trust in nurses who kept their personal information in confidence. This created the situation where they could open up to them as their care givers. “One thing they did that made me happy was that, they kept secrets of patients”. Cynthia, age 25 years Even though some patients reported that their rights as patients were respected, most of the participants mentioned that their rights as patients were violated. This prevented them from relating well with the nurses who took care of them. A participant considered that their rights were violated by remarking that: University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 48 ”On another routine admission, when I went back to the hospital, because of what happened in my previous admission, I was isolated with patients who were coughing. So I told them that I didn‟t like the place because I wasn‟t coughing. I told them over and over and sometimes even shouted at the nurses that “do you want me to cough or what”? Just to let the senior nurses know my plight. I did everything I could that day but they didn‟t understand so they took me there and after staying there for a while, I started coughing just like the other patients. I became very angry with what they did to me” “…Nurses at KATH wouldn‟t tell you whether you are progressing or deteriorating. Sometimes when you ask a nurse about the progress of your condition, she will tell you to wait for your doctor to come and tell you what the progress is but I think every patient has the right to know about his/ her health progress. Collins, age 38 years One of the participant‘s reports about nurses showed how disgruntled some patients are: “Some of the nurses too think they live in houses that are so special that they don‟t have to respect others. But the fact is that; you don‟t know where other people are coming from and therefore cannot presume to be better than others at least the patients also expect to be treated as humans. … No, if they will do something for you, they will just come and start doing it without telling you anything oh … So at times I wonder why some of them are nurses. Is it because of the uniform that‟s why they are doing it or what, because some are not working. For the nurses, they don‟t want to hear about patients‟ problems at all. They only come and administer the drugs and go their way. They just put them in your hands and tell you to swallow it”. Carmel, age 34 years The participants thought that nurses should treat them with their due respect and explain procedures to them. They did not want to be treated as if they were insignificant: “At least they should show some respect and explain every activity they want to perform on a patient. For instance they could have said; please I have brought your drugs but not just put the drugs in my palm. Yeah, as a normal routine they should create an environment for patient to at least smile, ask how we the patient are fairing. Wait for us to respond and encourage us with your support as nurses” Clement, age 31 years. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 49 Lack of respect for patients was found to be a major problem at KATH. It was said to be the underlying cause of some of the friction between patients and nurses. 4.4 Patients‟ perception of nurses based on their experience Patients‘ perception of nurses was identified as one of the main themes of the study. Under this main theme, three sub-themes were obtained namely: good nurses, bad nurses and lackadaisical nurses. Patients who report at the hospital develop their own perception about their caregivers. These perceptions of the patients about nurses are mostly based on their experiences or interactions with them. The patients‘ interactions with their nurses are affected by their perceptions of them. This means the quality of nurse-patient interaction is dependent on the type and nature of perceptions patients have of their nurses. For patients to perceive their nurses positively, there is the need to ensure the patients have good experiences at the hospital. 4.4.1 “Good” Nurses The perception of nurses as good by the participants was found to have influence on how they subsequently related to the nurses. According to the participants, good nurses tend to exhibit characteristics such as good communicators, encourage patients, show concern for patients, and ensure privacy when dealing patients. Also, such nurses have good sense of humour, are serviceable, friendly, passionate and hardworking. The other characteristics described by patients were the nurses‘ politeness, their keenness as good listeners, helpers, approachable, their readiness to teach patients and how empathetic they are; they helped patients to meet their spiritual needs: “…Ok as I was saying; one of the nurses, I remember was good. I was once asked to go for a scan and because of the leg pain I couldn‟t walk and how University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 50 this nurse carried me into a wheel chair and took me for the scan, .... When we came back to the ward, it was time for her to go home so I gave her GH5 for her to use as transportation but she did not collect the money. She just said it was her duty to assist me” Charllotte, age 34 years “Some of the nurses came to us to find out how we were doing, what brought about the accident and a whole lot. Some asked about how we were able to survive at the hospital and encouraged us with Gods words and even cited example of incidents that God has intervened in the Bible.” Christa, age 38 years In this research, it was also found that some patients consider nursing as a calling and that nurses that are called exhibit unique characteristics that make them good nurses. Some of the characteristics identified included being empathetic, kind and passionate about their job. The following were remarks made by some participants. “There are some nurses who are called by God to serve and therefore they are not only good but are also kind, but others are extremely bad. My reason for saying this is that, they come closer to patients to listen to their calls, talk to patients, motivate and encourage patients. The way and manner some nurses will talk to you is very pleasing to the ear and eye, it really motivates you. Some nurses as I said also come teaching you what to eat and not to eat so that you become happy even as you stay at the ward” Collins, age 38 years Another participant observed and said that: “… During my admission at KATH I identified a nurse whom I saw to be “a called nurse” I am saying this because she has a heart for the work she was doing. Nothing annoys her. She did not look at the uniform or what she will get from the work but saw the work as just a calling into a ministry to save lives. … Ok, a nurse who has been called has patience; she explains everything to you and consoles you during every procedure. So you won‟t feel the effect more. When she is giving you drug, she makes sure that she watches you swallow the drugs before she goes. She just doesn‟t give the drugs to you and instruct you to swallow them after she has left. For instance, I received 10 pints of blood during my stay at the hospital. Sometimes because of fear, I became worried. But this called nurse stayed with me and monitored the flow till everything got finished on daily basis. In fact I saw a difference in her because other nurses will not do what she did for me. Carmel, age 34 years In contrast some nurses do not exhibit characteristics that portray them as good nurses. They are ―bad‖ and do not treat patients well as one of the participants noted below: University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 51 “Ok, those who are not called by God do not have mercy and they don‟t show love. I don‟t even know what to say… but in fact, they don‟t show love at all. For some of the nurses, what they will do will make you feel sorry and bad and even worsen your sickness”. Carmel, age 34 years Generally it was found that patients related cordially with their nurses if they perceived them as good. Participants considered good nurses as trustworthy and because of that were opened to them in terms of the amount and nature of communication that they engaged in with them. Patient‘s perception of nurses as good therefore impacts positively on the nurse-patient interaction. 4.4.2 “Bad” Nurses It was found that some patients considered and branded some nurses as bad depending on characteristics they portrayed. They were described as arrogant, verbal abusers, rude, give no explanation for procedures they performed on patients, use of provocative language and gestures on patients. It was also found that patients reacted to the bad nurses differently. While some did nothing because of their perceived lack of power, other patients also retaliated after being exposed to bad experiences. Below are statements by some participants indicating their experiences with ‗bad‖ nurses: “…Some others too, when you call them, they won‟t mind you, and they won‟t even look at your face and some will even tell you that you are troublesome…. And as patients‟ on the ward, you will sometimes see that your colleague is in pain and is not able to shout but the suffering person can tell you to call the nurse for her. But when you go to call, she tells you ah, you are disturbing me!” Cynthia, age 25 years “The ward matron came to the ward one day; saw a pure water rubber tied in rubber bag under a bed closer to where I was lying. She picked the polythene bag and threw it at me. I explained to her I didn‟t create the mess she then went to dispose if off without even saying sorry or to say it wasn‟t intentional.” Carmey, age 20 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 52 “Ei!!! Some nurses, the way and manner in which they presented themselves to us was bad. In fact you will be even afraid to call them. I see such people with such gestures as extremely dangerous and bad who can kill. That was the lifestyle of some of the nurses at KATH”. Constance, age 25 years All the above remarks indicate that, how patients perceive nurses is critical to the way they relate to them. The nurse- patient interaction cannot be effective if the parties perceive each other negatively. 4.2.3 “Lackadaisical” Nurses The participants indicated that some nurses exhibit care free behaviour that influenced their relationship with their patients. The behaviour of those nurses tends to cast doubt on their willingness to assist their patients and therefore such behaviours do not help develop confidence in the patients about nurses. “This is because when we go to the hospital, we don‟t have anybody to help us financially, and during my stay at KATH, some of the nurses were equally not ready to give in their best to help me.” Christa, age 38 years ―For some, when they come to serve you in bed, their kind of services turns to worsen your disease condition. You will not even know whether he/she is rendering a service to help improve the image of the country he/ she is dwelling. When it happens like that, most patients don‟t get any happiness in whatever they do. The nurses always have the perception that they are in government work and in whatever situation they will be paid but they don‟t put in their best to work well and I can now understand the reason why the public doesn‟t respect nurses of late.” Collins, age 38 years “Sometimes, when they come they do their own things. When it comes to the time for our medications, they serve it and then return to whatever they were doing”. Constance, age 25 years Patients want to feel that their nurses care about them. If patients do not perceive this from the actions of the nurses, they find it difficult to relate with them in a trustworthy University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 53 manner. This means that nurses do not only have to be caring but they must be perceived to be caring. 4.5 Nurses‟ Attitudes Nurses‘ attitudes was identified as one of the major themes of this study and out of it emerged three (3) sub-themes, namely, positive attitudes, negative attitudes and ambivalent attitudes. Nurses‘ attitudes in this study refer to the opinions and actions patients perceive nurses to demonstrate in the nurses-patient interaction which may be productive or counterproductive. Nurses with positive attitudes were found to be more appealing and contributed positively to the nurse-patient interaction.. 4.5.1 Positive Attitudes Positive attitudes of nurses were found to be one important sub-theme that emerged from the study. Nurses‘ attitudes influence the quality of the nurse-patient interaction since the attitudes of the nurse determined how he/she does the nursing job and relates with the patients they are caring for. According to the participants, positive attitudes of the nurses that improve the nurse-patient interaction include willingness to help, show of concern, having a good sense of humour, being non-confrontational and being responsive to patients‘ needs. It was found that if the nurse had a positive attitude it impacted the caring environment positively and affected the nature of interaction that took place between the nurses and the patients. The following are statements by the participants which indicate how positive attitudes of nurses influenced the nurse-patient interaction: ―They are good because in the morning they will come to me and ask me “how are you”? So for that one I can say they are good .I also didn‟t see them worrying anybody at the ward”. Charles, age 27 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 54 “For some, immediately when you call she will come because she knows that if you were not in need you wouldn‟t have been here. For the rest, if they like they will come and if they don‟t like they won‟t come.” Charllotte, age 34 years “The nurses crack jokes that make us laugh and even make those in labour laugh. That‟s all I can say.” Clere, age 32 years “Yes, those who come on night duty especially…. One nurse shared the word of God with us and also taught us on the operation that we have had such as not lifting items and also not doing hard work. They chat with us when they come on duty, about our condition and they also educate us.” Carmey, age 20 years 4.5.2 Negative Attitudes Some negative attitudes that were identified included: nurses being provocative with their language, confrontational in discussions, impatient, feeling of superiority, making derogatory remarks and delaying in care responsibilities, not ready to answer patients‘ questions and insulting patients‘ intelligence. The participants indicated that negative nurses‘ attitudes created uncaring and unfavourable environment at the wards which created tension between the nurses and the patients making it difficult for a favourable interaction to take place. Some experiences of patients that indicated negative nurses‘ attitude were: “When I first asked her for help, she gave me a “cheek” before she helped with my need but I didn‟t see it to be the best thing for her to do. I didn‟t like that situation and her behaviour at all. For some, the way they will walk towards you when they are called is very provoking, you wouldn‟t have any joy in you talking to them and this even increase the extent of a patient‟s sickness” Collins, age 38 years “The nurses who came for that shift remarked mostly that “look at the way he is lying there!” they insulted me in that manner because that time I looked very ugly because I had reduced in weight and have become very lean. Sometimes when they are serving drugs the way they will pour them in my University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 55 palms… anybody watching me could see that because of what I did they hated me because of what I said they did not take good care of me. They really hated me. ….They said because I have reported them, if they are sued, they will also teach me a lesson. Because the family agreed to sue them because they didn‟t take good care of their family member and made him fall and died, they will show me. They were saying that they will take me to “juju” (consult the fetish priest) and they will make sure I am troubled in life. They even shouted at me that “we will show you very well, anywhere that will help us we will go” Collins, age 38 years “Sometimes, she tells you, “I am asleep, don‟t disturb me.‟‟ Some of them, when they touched you, it was as if excuse me to say you are not a human being. It‟s like you were a filthy thing. The way she touches you, it‟s very sad”. Cynthia, age 25 years 4.5.3. Ambivalent Attitudes Patients expected their nurses to be decisive and always responsive to their needs. If patients perceived the nurses to be indecisive and unresponsive it affected their trust, confidence and relationship with them. Ambivalent attitudes of nurses created suspicion in patients: The following remark by a participant indicates an ambivalent attitude of a nurse: “Some of the nurses too, when you ask them anything about your condition, they tell you in return that “why don‟t you ask your doctor”. One of them kept on asking me “why are you asking me instead?” Anytime I asked questions about the progress of my disease condition.” Collins, age 38 years 4. 6 Nurses‟ stereotyping and discrimination of patients Participants in the study indicated severally that nurses discriminated among them during their provision of nursing care. For that reason ―Nurses‘ stereotyping and discrimination of patients‖ emerged as one of the main themes of this study. The following sub-themes also emerged from the identified main theme; favouritism, poor patients, distant nurses and deliberate neglect of patients. It was found that some nurses deliberately neglected, favoured or treated badly some patients because they were labeled as members of a University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 56 particular group or because of their socio-economic status in society. This theme emerged prominently because it was considered one of serious challenges facing the nurse-patient interaction at KATH. 4.6.1 Favouritism It was found that some of the nurses showed favouritism during care of the patients at the ward. The show of favouritism was seen to create a sense of inequality in the care environment which violates the need for justice. The participants indicated that factors that formed the basis of the show of favouritism included: patients‘ social status, patients‘ inability to pay for services rendered. The participants maintained they were emotionally affected by the acts of favouritism on the part of the nurses and this influenced how they interacted with the nurses. The participants who were discriminated against reported that they reacted to the discrimination they experienced by making sure that they did not go closer to the nurses: “… hmmm, the nurses only see to the care of other people on the ward who had the required money and were able to afford to go through the operation but not to waste their time on the others like me who didn‟t have the financial means. But at least the nurses should have considered that the fact that I did not have money to go through the operation prescribed to solve my health problems does not give them the chance to treat me different from the rest of the patients. Ei!!! (…crying) I wish that throughout my life I will never be admitted to KATH again because when I came for the admission to KATH, I did not get better because of these identified stresses”. “… Sometimes the mere fact of seeing a nurse makes me afraid and fearful. the situation was very serious because sometimes, it was painful to see that, when they even come to write drugs for other patients when we have all complained about pain they didn‟t even include us because the nurses will tell the doctors that we do not have money”. Christa, age 38 years. “Respectfully, I started talking to the nurse by first addressing her as „Madam‟ and even begged her by first saying “please my pail is full with urine, can you help me empty it”? She gave me a strange look and told me on University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 57 the face that “emptying of urine containers is not my job. Meanwhile as of the time, she had just finished emptying the urine bag of another patient. Collins, age 38 years The nurses at KATH reportedly were selective in the care of patients. They pick those they want to help and ignore others. Below is one of the statements made by a participant who was admitted at the maternity ward. She remarked that she was hurt by what a nurse said about her preference for delivering babies from well-to-do families. The participant remarked during the research interview: “Ei sister! let me tell you this before I forget, some of the nurses could open their mouth to say “Ah with the kind of things this person has brought; I just even feel like delivering her baby or even talking to her. And this world too, we can‟t all be the same. They give those from wealthy families‟ special treat. My reason for saying this is that, those women from well-to-do families, sometimes even leave the containers in which they spit into on the nurses books found on the nurses table. They keep mute without saying anything but let a poor person do the same. As I was saying if you are suspected of coming from a wealthy family you are treated different from those they consider to come from poor families. The rich people are treated and talked to with caution but the poor ones are treated and talked to anyhow. With my stay here that‟s what I have seen”. Cynthia, age 25 years 4.6.2 Poor patients Most of the participants lamented on the kind of treatment which people who were considered poor received at the ward. It was noted that poor patients were identified by their inability to pay for the services at the hospital and the withdrawn disposition they exhibit on the wards. It was further found that poor patients who were discriminated against tended to withdraw from the nurses and that affected their interaction with them. The participants reported that the perceived poor patients are usually denied care they are entitled to and are sometimes humiliated in the presence of other patients and staff: University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 58 “Sometimes, when someone comes to the hospital and he/she does not have anyone to help with his/ her financial needs, nurses will never mind whatever that person does” Christa, age 38 years. “…because When I was admitted at KATH, I did not undergo any operation just because, I was asked to pay an amount of GH 300 cedis but when I looked at my family I did not have anyone to help and support me financially therefore they did all kinds of things to me because I couldn‟t settle my hospital bills” Christa, age 38 years “When I was on admission at KATH too when one is rich, the attention given you is different from someone who does not have money. In fact I have suffered extremely with bad words and have also been humiliated which I will never forget about.” Christa, age 38 years “Some of the actions of the nurses especially the matrons made me feel like I wasn‟t a human being. “Today you will sleep on the floor!” “We would not serve you any meals here!” are some the harsh comments they gave to me. They made me know and felt that the poor patient does not even belong to the human race”. Christa, 38 years 4.6.3 Distant Nurses Distant nurses refer to nurses who were mostly physically present on the wards but psychologically absent. It was found that those nurses were disinterested in engaging in meaningful interactions with their patients and were also not concerned about the needs of their patients. Other characteristics of distant nurses that were identified included; lack of respect for patients, talking rudely to patients and lack of physical contact with patients. It was found that distant nurses do not make any positive contribution to the nurses-patient interaction. A remark made by a participant about the behaviour of a distant nurse was: “Sometimes, they stand afar to talk to you. Other times they just look on not ready to come close to where you are lying. Things that are rather discussed in secrete exploded for other patients to hear.” Charllotte, age 34 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 59 4.6.4 Deliberate neglect of patients Nurses in some cases consciously neglected their patients, leaving them to suffer. Almost all the participants complained that they were neglected at one time or the other. Patients who considered themselves neglected by the nurses in some instances reacted negatively which in turn impacted negatively on the nurse-patient relationship at the hospital. It was also reported that in some instances the deliberate neglect by the nurses even led to the death of some patients. The participants also indicated that when patients were neglected, they found it difficult to communicate with the nurses: “… So on that faithful night I watched the young boy (patient) as he went to urinate but later on, when he got back to his bed to sleep, he couldn‟t sleep on his bed well because he was weak after walking. So in trying to sleep on his bed, I saw him fall from the edge of the bed to the floo...During that time, I was weak and couldn‟t help him so I shouted “he has fallen oooooooooo!” to alert the nurses and I slept. It was later around 3:30 am that I saw the nurses come to the ward. It was realized that the young man was dead under my bed. They picked him and placed him on his bed.” Collins, age 38 years Other participants noted: “… She shouted “Eei sister! Be patient why? Have I told you that I am not coming or what?” This shows that the person has heard you but as the Akan proverb says “wate, nnanso w‟abubu nnua egu n‟asu mu” literally mean that the nurses heard but blocked their ears with sticks with the intention of not minding the patient when she called. Christa, age 38 years Sometimes the toilet (faeces) can be there for close to 3 hours. At times when you defecate around 6:00pm it can be there till the night nurses come in at 8:00pm. As for them they normally come on rounds and serve us with bed pans and take them as soon as we are done.” Constance, age 25 years 4.7 Patients‟ feeling of powerlessness This theme refers to lack of control or involvement of patients in their care due to their perceived lack of power in the nurse-patient interaction. Three (3) sub-themes emerged University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 60 out of this main these. The sub-themes were the following; authoritarian nurses, patients‘ feeling of inadequacy and patients‘ exclusion from decision making. Nurses perceived themselves as more powerful in the nurse-patient relationship, because of the privileged position they occupy and also their access to specialized skill. Patients on the other hand perceived themselves as powerless because they considered themselves to be on the receiving side of the relationship. This sets the stage for a situation where nurses see themselves as more powerful and deny patients free expression and participation in decisions concerning how they are cared for at the hospital. 4.7.1 Authoritarian Nurses In the care environment, the nurses due to the privileged position they occupy tend to exercise some control and power over the patients they care for. The participants opined that the nurses used their power to dictate to them disregarding the right of the patients to be involved in issues concerning their care. It was found that the nurses interpreted the patients‘ attempt to voice out their opinions as an attack on their authority which led to acrimony on the part of both parties. The participants insisted that they should be consulted on issues that affected them since that can deepen their relationship with the nurses. With regard to increased participation of patients in their own care, it was found that it will improve when there is a better understanding between nurses and patients: “…the angry nurses also brought their anger on me. Some even ask me that “what right do I have to tell patient‟s relatives that, the patient died because he fell from his bed”? They became very wild on me.” Collins, age 38 years “There are some places too we were restricted to go but when you go there, they shout ‟hey!‟ we don‟t pass here‟. Meanwhile they could have said University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 61 „woman, please we don‟t pass here‟. So it becomes very difficult for me to ask such a person for help when something bothers me”. Cynthia, age 25 years “Always they expect you to do what they want and things they impose on you. It was difficult, hmm, if you are conversing with your friends and you see them, you can‟t even continue. Food that they serve doesn‟t come early but if you go to buy food outside also they will be saying hey! So you want to tell us that you are rich. Without even asking for the reason why you have taken that decision to buy food.” Charllotte, age 34 years The nurses were reportedly in complete control over patients and hardly gave them any chance to be involved in their own care. The patients considered themselves as passive recipients of care. They felt intimidated and powerless since they had no say in what happens to them in the hospital. The care was perceived as ―top down‖, being imposed on them instead of there being mutual agreement on what was to be done. 4.7.2 Patients‟ feeling of inadequacy With the idea of patients being in a weak bargaining position, patients mostly considered themselves as incapable of doing anything to influence the nature of care rendered to them by their nurses. This idea was found to originate from the patients‘ perception of nurses as having power over them concerning activities at the hospital. The participants also considered the nurses as having more knowledge about their conditions. They perceived themselves as being at the mercy of the nurses. Some participants made the following comments indicating their feeling of inadequacy in the care environment: “When she said that, I just kept quiet since I was the sick person, I didn‟t have the power and the “mouth” to say anything so as to allow them to cater for me well to aid in my fast recovery from the sickness I reported. Besides that, I brought my own self to the hospital to be cared for because if it hadn‟t been the sickness I wouldn‟t have been at the hospital. I just watch them to do whatever they like”. Collins, age 38 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 62 “I cry, because I don‟t have money to settle my debt even though I have been discharged and she keeps yelling at me. I was in a state that I could do nothing so I just had to bear all the insults”. Christa, age 38 years 4.7.3 Patients‟ exclusion from decision making According to the participants they were mostly excluded from decisions that concerned their care. Most of the participants considered their opinions as not very important since the nurses had all it took to take care of them. It was found that the exclusion of patients from decision making was also partly due to the undue concentration of nurses on technical jargons. Thirdly, patients did not challenge their exclusion from decision making because they lacked the understanding that it was their right to be involved in decision making. Below are some of the remarks by participants showing instances of their exclusion from decision making concerning their care: “What can you say; they know what they have been taught in the course of their training and therefore decide for the patient because the patients didn‟t know anything about their professional language. They seem not to be ready to discuss it so I am not worried and enthused to know either”. Cosmos, age 43 years ―For that I can say when I was lying there they were not discussing my condition with me and I don‟t understand why? Oh for that no, if those in afternoon shift close and the evening people come they go on ward rounds and they say this person is with this problem. They tell themselves and they go back. They don‟t say anything like that to the patients.” Charles, age 27 years “They don‟t involve me in decisions concerning my condition but I comply with anything am told”. Clere, age 32 years. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 63 4.8 Ways of improving the Nurse-Patient Relationship This is the last main theme identified and from it five (5) sub-themes emerged. The following were the sub-themes; training, supervision, motivation, nurses‘ accountability and resources The main theme refers to activities and measures that bring about improvement in the nurse-patient interaction. It should be noted that it takes effort to bring about improvement in the nurse-patient interaction. 4.8.1 Training Almost all the participants cited training as an important measure for improving the nurse-patient interaction. Lack of interpersonal skills was identified as the main area where training was needed. Most of the participants had little or no problem with the technical skills of the nurses but complained mainly about how they related to them as human beings. The participants in the study also believed that in-service training could help improve the knowledge and skills of the nurses. It was also indicated by the participants that nurses seemed to lack the foresight of the challenges they were to face when they entered the profession. Suggestions were therefore made that they should be well trained in order to reduce the reality shock they seemed to experience. Some of the statements by participants on the need for training to improve the nurse- patient interaction were: “Things that will make them (nurses) stop their bad behaviour like teaching them how to interact and deal with human being when they are sick”. Collins, age 38 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 64 “I think the authorities should let them undergo training on how to properly talk and care for patients they come across with so that we can have our peace of mind during our stay at the hospital”. Christa, age 38 years “This is why when they are going for their training they should be taught how to care for people and through this it will help us a lot”. Constance, age 25 years “Training that can help in the improvement of the work depend on the way they talk, how they can stay with the patients”. Charles, age 27 years “There is this thing I know, that nursing is all about dealing with people. So I think before you become a nurse there is a need to teach them sincerely of all the nasty things and the risk they will be seeing in the work profession so that when they come to the field and see them, they you will not be shocked. Carmel, age 34 years “The hospital authorities should establish laid down and structured training on interpersonal relationship especially through nursing workshops”. Clement, age 31 years 4.8.2 Supervision Supervision was identified as one of the means by which the nurse-patient interaction could be improved. Participants indicated that nurses behaved the way they do because of poor supervision. In participants‘ view nurses think that they can do what they like without being sanctioned. The night shift was cited as the least supervised working period of the day. Serious violations were said to take place during those times. Participants also indicated that they found it difficult to get superior nurses to complain to and that if periodically supervisors were visiting the wards they would have complained to them. The participants believed that if supervision were improved it will help improve the nurse-patient interaction. Some observations by participants showing their experiences about the nature of supervision at KATH were: University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 65 “For me I have problems with the nurses who come on the night shifts because during the day the workers are many in the work so they are much conscious and then also during the day the in-charges are also around. When you call a nurse and he / she doesn‟t mind you some in-charges will even call them for you. It is the nurses mostly at nights that I have problems with because during that time, there is no supervision so the nurses do whatever they want”. Collins, age 38 years “I think the nurses have to be checked well when they come to work. Yes! Very well. Tell them to take the work as their own. So they should work hard to also help the sick people under their care so that the sick people will be happy and talk positively about them. I would like nursing leadership and the hospital authorities to also advise them that the sick person need them so they should not be hostile to them”. Collins, age 38 years “Besides that management should also take it upon themselves to supervise the activities of staff. I know that a few of them pass by and say hi to us, they should not relax, they should continue” Cudjoe, age 45 years Lack of supervision was cited as a major flaw that caused nurses to show negative attitudes towards patients. The vast majority of participants highlighted the urgent need for supervision of nurses by their superiors to check their bad behaviour especially during night shifts. 4.8.3 Motivation Motivation was seen as the driving factor that energizes behaviour guiding it towards the required direction. To get the required behaviour from the nurses it was found that they ought to be motivated. Various ways of motivating the nurses were identified. It was found that if the needs of the nurses were not met, it would be difficult for them to work towards achieving the needs of patients. Sometimes nurses‘ bad attitudes were based on their own sense of insecurity. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 66 Below are opinions of the participants on how nurses could be motivated in their work to help bring about improved nurse-patient interaction: “As I was saying, the government should help them because there are some who are about to go for pension but have no money. If this happens they don‟t even have the love to care for us because their needs are not met”. Christa, age 38 years. “Hmm, As for the nurses, I beg of the authorities of the hospital and the government to motivate them with breakfasts lunch and increase their salaries because I see them working far more than the doctors and I need to commend them. … Sometime common water to work with is a problem. Leaders are to help and encourage them because they are suffering!” “Well, as the adage goes “a bird in hand is worth two in the bush” though the nurses depend on what they are given as salaries, I think when they are paid well for a work done; it will motivates them to do their work well. Do you get it? Because there are nurses who go home from work and cannot even eat at all because of what they see at the work place”. “Won‟t you motivate and appreciate her? For me, nurses must be treated fairly and better with other health professionals because it took the care and the effort of the nurses at ward “B1” as well as that of the doctors to get me this far. So why won‟t you let her feel appreciated”. Cosmos, age 43 years 4.8.4 Nurses‟ Accountability It was observed that some nurses were not accountable for the work they were doing. They were held accountable only when serious incidents occurred which had legal dimensions. To improve the nurse patient interaction, participants suggested that nurses should be continuously checked and made accountable for all the care they provide to the patients. It was noted that without any form of accountability, nurses could assume a sense of invincibility which will not be favourable for the maintenance of cordial nurse- patient relationships. This means that nurses should note and be aware that there is a limit to the behaviour they can demonstrate. Some of the statements participants made with regard to nurses‘ accountability were: University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 67 “In fact, the nurses should be checked and made answerable to the hospital authority for their action”. Collins, age 38 years “If it is possible, those who are bad nurses must be called to books. I mean they must be made to answer for their actions they put up”. Christa, age 38 years. 4.8.5 Resources For the nurses to work effectively there is the need for them to have the resources they need to work with. It was found out that if nurses lack the resources they need to work with it creates stress in them and that is mostly transferred in diverse ways to the patient. Participants indicated that in some situations nurses were angry with them not because they had done anything wrong but there was shortage of hospital materials they needed to work with. Lack of resources was therefore found to contribute to the deteriorating nurse- patient interaction. To bring about improvement almost all the participants indicated the need to provide the nurses with all that they need to work with; “I knew about this because the man was close me and the only two partitions (screen) were used by other nurses who were also dressing similar wounds, therefore the nurse was forced to dress the wound without their curtains (screen)”. Cosmos, age 43years “I plead that all the needed things that nurses need to work with should be given to make them work better. The things they used to cover patients‟ wounds when dressing should always be there for them. The hospital authorities should help and encourage nurses because they are suffering!” Cosmos, age 43years “There are others things government can do; provision of vehicles, provision of drugs and provision of other things that the hospital need. As I said that teachers say there is always room for improvement. Management should continue to support the staff with logistics”. Cudjoe, age 45 years University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 68 In summary, this chapter described the findings from the data collected. The participants‘ experiences generated six (6) main themes and twenty three (23) subthemes. These findings are discussed in the next chapter along with comparisons with existing literature. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 69 CHAPTER FIVE DISCUSSION 5.1 Introduction This chapter discusses the findings generated from the data collected from participants in relation to the literature reviewed in the area of this research. The study was designed to understand patients‘ perspectives and experiences of the nurse-patient interaction. The study specifically sought to: Describe the patients‘ experiences in nurse–patient interactions at Komfo Anokye Teaching Hospital (KATH). Identify the factors that contribute to positive and negative nurse-patient interactions at KATH. Find ways of improving the nurse-patient interaction at KATH. The chapter initially provides an overview of the key findings and their significance in the light of the literature reviewed. The main themes and their corresponding sub-themes which emerged from the study are presented, discussed and integrated with literature. References to existing literature were made throughout the discussion in order to situate the research findings within the context of the body of nursing knowledge. These findings are expected to help improve the nurse-patient interaction and ultimately lead to the achievement of patient care goals. 5.2 Patients‟ Expectations and Actual Observations In analyzing the data about the experiences of patients, some factors were identified that influenced the nurse-patient interaction. These factors consisted of the caring University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 70 environment, humane treatment, supportive nurses, effective communication and respect for patients‘ rights. These expectations of patients about the care that should be provided at the hospital and what they actually received was highlighted by Shanner (2006), who expanded Nightingale‘s primary concept about the care setting to include concern for the social, psychological and emotional aspect of interaction. In the ensuing sections, the major findings are discussed in the light of the reviewed literature. 5.2.1 Caring Environment In this study, the participants identified that the quality of the care setting has a great influence on the quality of care given. Scotto (2003) concurred that the caring environment should be an offering of intellectual, psychological, spiritual and physical help that human beings need in order to achieve the goals of care. Participants therefore expected the care setting to be one that brought about alleviation of suffering and that which lead to recovery. This expectation of the participants was in line with the findings of Tejero (2011), that nursing is actualized in every encounter with a patient but the goal of the nurse is focused on patients‘ well-being which is realized through the interactions between them in the care setting, irrespective of the cultural context. In the views of the participants, caring environments would be created when nurses show a sense of responsibility for their work, show concern for patients‘ well-being, show love and when nurses are serviceable to patients and their relatives. The need for a caring environment was also reiterated by Glasberg (2007) who compared the individual person to a plant that may thrive or die depending on the kind of environment in which it grows. This means that the individual patient at the hospital would need a conducive environment to promote his/her well-being University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 71 and recovery; otherwise it would be difficult to achieve the intended care goals of the nurse. Also, it was found that for the patient to receive the required care for optimum recovery, the care environment should be welcoming. This means the hospital environment should not be hostile to the patients since the first encounter at the hospital can influence all the subsequent experiences of the patient. A number of study findings have indicated that caring is undeniably fundamental to the nurse-patient interaction (Finfgeld-Connett,2007; Cossett, Cote, Peprny & D‘Aoust-x , 2006; Lindstrom, Lindholm & Zetttelund, 2006; Watson, 2003 ; Blaauw et al.,2003; Edlund, 2002; Erickson & Ritter , 2001; Campbell & Gordon, 2000) . In line with this it is expected that the emergency units and the nurses who receive patients at the OPDs should be well trained to give good first impressions to patients. The hospital environment in participants‘ view should be a place of refuge where patients should receive all the care and support needed for recovery. For this to be achieved, the environment should be such that patients can easily communicate with their care givers and also feel at home. This expectation or view of the participants was in line with the findings of Ndubisi (2007) and Morse (1991). According to Morse (1991), for a caring environment to be maintained at the hospital, both nurses and patients must communicate openingly with trust and respect for each other. Furthermore, Ndubisi (2007) stated that nurses should provide the patients with timely and trustworthy information to enable them feel at home and accepted. Contrary to those expectations of participants, this study found out that the environment at KATH was largely uncaring. A number of instances were cited where some patients lost their lives because of the nature of care given at the hospital. Some participants considered the hospital in question as a place where one could easily lose one‘s life as a patient. These views of the care University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 72 environment (the hospital) were shared by Shattell (2002). In his study findings the hospital environment was described by patients as dangerous, disconnecting and identity disaffirming. This negative view of the hospital should be corrected if patients are expected to have confidence in the health facility and interact positively with health care providers, especially nurses. Despite the negative experiences by some of the participants, others experienced a favourable and caring environment which impacted positively on their interactions with the nurses. According to them, they received the required information from the nurses who also provided them with the needed support. Groogan (1999) also considered provision of accurate information and encouragement to patients as necessary for the creation of a therapeutic environment. The provision of a caring environment is therefore vital for optimum nurse-patient interaction. A serene, calm setting with no turbulence is the most preferred by patients and seemingly therapeutic. 5.2.2 Humane Treatment The findings of this study indicated that participants believed that humane treatment of patients by the nurses would be achieved if nurses in their daily duties showed sympathy and empathy, exchanged greetings with patients, created rapport, continuously reassured patients and treated patients as human beings in need .Sivonen and Delmar (2011) posited that the ultimate aim of caring should be to preserve a person‘s dignity ,his /her absolute value as a human being with rights of self-determination. In a study by Shattell (2004), Berg and Danielson (2007), it was found that patients felt they were treated as human beings when caregivers demonstrated qualities such as humility, kindness, patience and efficiency. Brady (2009) also highlighted that patients need to be treated as persons or human beings. It was also found that patients expect to be treated humanely at the University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 73 hospital and that contributes immensely to positive nurse-patient relationship. The participants indicated that patients sometimes retaliated against inhumane treatment by the nurses. Ojwang, Ogutu and Matu (2010) posited that patients mostly retaliated when they perceived callous treatment from their nurses. The current study also found that humane treatment leads to faster recovery. This may happen because provision of humane treatment creates the required environment for healing to take place. The enhanced environment seemingly impacts positively on the nurse-patient interaction which leads to cooperation between the nurses and the patients. According to the participants of the study nurses who showed sympathy and empathy tended to treat patients well and engaged in positive interactions with them. Nurses who were empathetic could identify with the patients and their situation, hence their ability to treat their patients humanely. To make the patients willing to interact with the nurses, participants indicated that they mostly wanted to feel that their nurses understood and were concerned about them even if they were not able to help them in particular situations. This means nurses should be caring and also be perceived as caring by the patients. 5.2.3 Supportive Nurses According to the participants interviewed supportive nurses demonstrated characteristics such as readiness to provide the services required of them and also do everything to ensure that patients were comfortable. Supportive nurses were concerned with doing what was right and patients found it very easy to interact with them thus reportedly bringing about improvement in the patients‘ condition and leading to recovery. The activities of supportive nurses which according to participants helped in the nurse-patient interaction and recovery was supported by the findings of Mok and Chiu (2004) who observed that nurses who developed trusting relationships with patients demonstrated a holistic University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 74 approach to caring, show their understanding to patient suffering, were aware of patients‘ unvoiced needs, provided comfort without actually being asked and were reliable and dedicated to patients‘ care. Without the appropriate support of the nurses in the care setting, little can be achieved in terms of free flow of information which is vital for the nurse-patient interaction. It was also found that supportive nurses were always ready to hold and hug patients in times of distress, pain and discouragement. This was congruent with the findings of some research studies which showed that supportive nurses tended to be assertive, spoke calmly and used tones of voice that said ―I care about you‖. They also made therapeutic touches such as holding and hugging patients, respecting the differences in culture .This was found to help achieve harmony in mind, body and spirit (Pullen & Mathias, 2010; Shattell et al., 2006,2007; Bergs & Hallbergs, 2007; Rydon, 2005).These findings were also consistent with those of Jackson and Stevenson (2000) who emphasized the need for nurses‘ support through ―mothering‖ vulnerable patients by playing a nurturing role and providing physical support. Furthermore the findings of the current study were consistent with those of Routasalo and Isola (1996) where some patients perceived touch as beneficial and important. However, a study by McAllister et al.(2004) and Cline (1989) showed that some patients perceived touch as invasive and uncomfortable and urged nurses to avoid touch since it is unacceptable in some cultures. Although touch from the nurse might be necessary, it should be done taking into consideration the prevailing cultures and the appropriateness of the touch. In this study, supportive nurses were found to be empathetic and non-judgmental. This corroborates the findings of some studies which affirmed the importance of the demonstration of empathy and friendliness in the nurse-patient interaction (Ommen et al, 2008). University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 75 Given these qualities that were found in supportive nurses, the participants of the study indicated that they had confidence in nurses who were supportive and that made it possible for them to open up to them .This influenced positively their interaction with the nurses who took care of them. For the nurse-patient interaction to be improved therefore nurses should be more supportive in their engagements with their patients. 5.2.4 Effective Communication Effective communication in the health care environment requires knowledge, skill and empathy. It encompasses knowing when to speak, what to say and how to say it (Clark et al., 2009). In the study, it was found that patients expected nurses to treat them as human beings and that their interaction with the nurses should focus more on issues concerned with their care such as daily progress of their condition, explaining procedures and asking about patients‘ feelings and reassuring them. This is considered to make the nurse-patient interaction more relevant and meaningful to the goals of health care delivery. Finset (2010) affirmed that patients were sometimes treated as objects at the hospital rather than as human beings. In his study ineffective communication was cited as the main problem behind treating humans as objects. Thus for effective communication to take place, there is the need to respect patients and that respect should be reciprocated by the patients, creating the conditions for positive nurse-patient interaction. The current study portrayed the importance of effective communication in the nurse-patient interaction. This means that if there is lack of effective communication little can be achieved between the nurses and the patients. However, this study at KATH found the nurses generally to be poor communicators in their interactions with patients. The lack of effective communication University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 76 among nurses was also confirmed by studies such as Korsah (2011),Smith & Pressman (2010); Dovlo (2005).The authors indicated that nurses lacked effective communication skills in their dealing with patients. Contrary to the literature on nurses as bad communicators, McCabe (2004) found in his study that nurses were good communicators when they used the patient-centred approach. Effective communication should therefore be improved at the hospital if the nurses and the patients are to cooperate effectively for better outcomes. 5.2.5 Respect for Patients‟ Rights One important finding of this study is that maintaining respect for the rights of the patient is crucial for the nurse-patient interaction. This is because if nurses respect the rights of their patients they earn that respect back and that creates an atmosphere of trust between the nurses and the patients. According to Groogan (1999), health providers need to protect patients‘ rights and make them feel confident to make their own decisions. This means that if patients‘ rights are respected patients become confident and empowered .This in a way helps to deal with the power imbalance in the nurse-patient relationship. Participants in the study indicated that personal information of patients should always be kept confidential. It was established that the rights of patients at KATH are violated. Violation of patients‘ rights was found to be one of the major problems at KATH. This finding corroborates other study findings from Kenya, which focused on indicators that violate or promote patients‘ rights in the health care context .The findings of the study by Ojwang, Ogutu and Matu (2010) showed that impoliteness of nurses did not only show disrespect, but meant violations of dignity which prevents the chance of free expression .Their findings further indicated that when patients‘ rights are denied, they resort to retaliation by violating the dignity of nurses who care for them. This endangers the University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 77 mutual support, collaboration and partnership required for effective nurse-patient interaction. Respect for the rights of patients is therefore very important for the nurse- patient interaction. 5.3 Patients‟ Perception of Nurses based on Experience Participants of the study recounting their experiences at the hospital indicated that their perception of their care givers influenced how they related to them. Under this main theme, the sub–themes identified were ; ―good‖ nurses, ―bad‖ nurses and ―lackadaisical‖ nurses. 5.3.1 “Good” Nurses In the study it was realized that nurses perceived as good by patients were those who related positively with their patients. It was found that good nurses were those who were good communicators, encouraged patients, showed concern for patients, ensured privacy, had a good sense of humour were approachable, empathetic and helped patients to meet their personal needs. These perceived characteristics of good nurses were consistent with the study findings of Thorsteinsson (2002), where high quality nurses were perceived as those who were kind, joyful, warm, polite and understanding. Also, Larrabee and Bolden (2001) after interviewing 199 soon to be discharged patients found that according to the patients, quality care involved ―providing for my needs‖, ―Treating me pleasantly‖, ―Caring about me‖ and ―Providing prompt care‖. It was noted in this current study that all the facets of quality could be provided by only ―good‖ nurses with characteristics already identified. Also in another study with paediatric patients, Brady (2009) revealed that a ―good nurse‖ is one who is available to listen and spend time with patients. Good nurses were said to exhibit characteristics such as obedience, sensitivity, solidarity, honesty and University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 78 transparency which are valued. When nurses are considered as good by patients a sense of trust is created between them which is important in the nurse-patient interaction (Bresnick, 2013; Smith, 2013; Anderson, 2013). As indicated by Mok and Chiu (2004), a relationship of trust is formed and such nurses are not only regarded as good caregivers but also regarded by patients to be part of their families or as ―good friends‖. This goes to indicate that the quality of the nurse-patient interaction is influenced by how patients perceive the nurses who care for them. This means it is necessary to try and influence the perception of patients about nurses if quality nurse-patient interaction is to be achieved. Another important finding of this study was the perception of nursing as a ―calling‖ by the participants. To them, nursing is a calling and those who are called normally exhibit characteristics such as, being empathetic, kind and compassionate towards their patients. Davis (2005) also affirmed the characteristics of ―good nurses‖ as kind, attentive, available, empathetic and reassuring. In all, it was generally noted in this study that when patients perceived nurses as ―good‖ they were influenced positively and this led to improved nurse-patient interactions. 5.3.2 “Bad” Nurses Bad nurses in this study were found to have characteristics such as , being arrogant, verbal abusers, rude, use of provocative language and gestures. It was also found that patients reacted to bad nurses differently. While some did nothing because of their perceived lack of power, others retaliated. This is where patients argue violently with nurses on the ward. The perception and effects of ―bad nurses‖ were highlighted in the findings of a study on ―rating of nursing‖ by Otani (2010). In that study, the findings showed that a bad nursing experience had an uneven negative result on the perception of patients in the nurse-patient interaction. This means that bad nurses do not promote University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 79 positive and effective interaction with patients. For the nurse-patient interaction to be effective there is therefore the need for nurse managers to make it a priority to discourage poor nursing practices. 5.3.3 Lackadaisical Nurses The study found that some nurses showed apathy in the way they performed their day to day care duties in the wards. The perception patients had of these nurses affected how they related to them. These types of nurses were found to create doubt in the mind of patients and that prevented development of trust in the nurses which was crucial in the nurse-patient interactions. It was also found that patients found it difficult to relate to nurses in a trustworthy manner if those nurses showed lack of concern for the well-being of the patients. These nurses‘ way of working tended to create the stereotypical perception among the public that nurses are just handmaids of doctors and always depend on doctors for direction (Gordon, 2005). When this happens patients will tend to show lack of confidence in the nurses. This will prevent free flow of information from them (patients) thus hampering effective nurse-patient interaction. The effect of lack of interest of nurses in their job which influenced negatively the nurse-patient interaction and the quality of care provided was corroborated by findings of Attree (1999). According to Attree (1999), patients considered the nature of care given and interpersonal aspects of care as key issues concerned with the quality of care delivered. When nurses show apathy in how they do their job, it affects how they relate with patients and also the quality of care they provide. This ultimately affects the nurse-patient interaction. For the nurse- patient interaction to be improved there is the need to work towards improvement in motivation of nurses which will affect how they relate to patients on a day to day basis. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 80 5.4 Nurses‟ Attitudes Nurses‘ attitude was found to be one of the main factors that influence the nurse-patient interaction. Under this main theme, three sub-themes were identified which are; positive attitudes, negative attitudes and ambivalent attitudes. 5.4.1 Positive Attitudes Under this sub-theme it was found that nurses who demonstrate positive attitudes towards their patients influence positively the nurses-patient interaction. This is because positive attitudes of nurses impact on the quality of care given. This study identified the following which constitute positive nursing attitudes; willingness to help, show of concern, having a sense of humour and being non-confrontational. Detrick et al., (2006) posited that quality nursing care implies effective communication, kindness, being readily available to patients and timely response to calls. This finding is significant since working on the attitudes of nurses can lead to improvement in the nurse-patient interaction. The characteristics identified as constituting positive attitudes is also significant since various hospitals can concentrate on those characteristics and bring about enhancement in the general attitudes of their nurses. 5.4.2 Negative Attitude Negative attitudes of nurses was found to include , nurses being provocative, feeling of superiority, making derogatory remarks about patients, delay in care responsibilities, not ready to answer patients‘ questions and insulting patients. These attitudes of nurses do not foster cordial relationships between nurses and patients and impact negatively on the nurse-patient interaction. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 81 It was also found that negative attitudes of nurses created uncaring and unfavourable environment at the ward which created tension between nurses and patients making effective nurse-patient interaction impossible. The issue of nurses demonstrating negative attitudes was emphasized by Can, O‘Connor, Dermott and Hood (2013). In their study it was identified that nurses had negative attitudes towards their patients. According to O‘Donoghue et al., (2004), negative and uncaring staff attitudes towards patients contribute greatly to poor care and results in the neglect in homes for elderly patients. This means that for patients to interact effectively with nurses, the issue of negative nurses‘ attitudes should be resolved. 5.4.3 Ambivalent Attitudes of Nurses It was found that patients expected their nurses to be decisive about and responsive to their needs. Ambivalent nurses were those that were found to be mostly hesitant and unsure about the various activities or procedures that constitute their daily routine at the hospital. Since the ―power‖ of the nurses is reportedly derived from their possession of care giving skills, they lose their power if they demonstrate indecisiveness in their behaviour. This can also create suspicion and doubt in the minds of the patients and can take away the confidence they already might have developed in the nurses. When patients do not have confidence in their nurses because of indecisiveness, they will limit the interactions with them. This indecisiveness was demonstrated when participants complained that their nurses always waited to consult the doctors on almost every issue about their (patients) care. This finding supports the stereotypical view of the public about nurses which was also emphasized in the study by Gordon (2005), that nurses are merely handmaid of doctors and that they are dependent on the doctors for directions. Nurses‘ University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 82 indecisiveness may be due to lack of skills to perform their duties. Nurses should therefore be provided with opportunities such as training to improve on their competencies. 5.5 Nurses‟ Stereotyping and Discrimination of Patients This theme captured the situation where a patient was or patient groups were labeled and treated in different ways from those in other groups because of their perceived superiority or inferiority, mostly connected to their social status, socio-economic status, gender and age. According to Ojwang, Ogutu and Matu (2010), the tendency to label and discriminate among patients causes degradation, the feeling of worthlessness and humiliation, shame and guilt, as well as anger associated with resentment and hostility. These altered the sense of belonging among patients, making them feel different. Under the above theme, sub-themes identified include, favouritism, poor patients, ―distant‖ nurses and deliberate neglect of patients. 5.5.1 Favouritism In the study, some patients were discriminated against at the hospital. One way in which this was done was that some patients were given preferential treatments. Regarding show of favouritism, it was found that the factors forming the bases of the show of favouritism included, social status of patients, and inability to pay for services rendered. This contravenes the patients‘ rights to be treated equally. The show of favouritism also violates the dictates of the nurses‘ pledge that ―I promise to care for the patients under my care irrespective of their gender, race, colour, creed or socio-economic status‖. Patients dealt with the issues of favouritism by isolating themselves from the nurses who showed favouritism. For the purposes of justice, all patients should be treated equally. This tenet University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 83 of care is vital in nursing as well as medicine. Justice is a core principle in the Hippocratic oath of doctors. 5.5.2 Poor Patients Participants of the study indicated that poor patients were tagged as poor based on their inability to pay for services. They added that perceived poor patients were normally withdrawn or laid back. Discriminating against poor patients fits the description by Jacobson (2007) that there is a tendency to treat a patient badly based on achieved or ascribed status or apparent membership in a lower-status group. Also, it was indicated that perceived poor patients reacted to instances of favouritism shown to well-endowed patients by isolating themselves from their care givers. This tended to affect the nurse- patient interaction. It makes communication between the nurses and the patients very difficult. Canales (1997) intimated the seriousness of labeling groups of people by indicating that labeling and stigmatization of patients act as a barrier to communication. This means that for the nurse-patient interaction to be effective, efforts should be made to avoid labeling people which can lead to discrimination. Another important finding of the study was denying patients the care they were entitled to because of their socio-economic status. Sometimes, the perceived poor people were denied service because they protested against the way the nurses were treating them. A study by Breeze & Repper (1998) found that nurses who labelled patients as ―difficult‖ often avoided or distanced themselves from those patients. This is not the best practice expected of nurses. It goes against the principle of nursing, infringes on the rights of patients and negatively affects the quality of care provided. Such practices of nurses should be discouraged if the image of the healthcare facility is to be preserved. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 84 5.5.3 Distant Nurses In this study distant nurses were found to have certain characteristics. These characteristics included disinterest in patients, lack of respect for patients, talking rudely to patients, lack of physical contact with patients. A study by Carvelli (1995) identified some characteristics of distant nurses. In distancing themselves from patients, nurses tended to be less supportive, they responded less promptly to patients‘ requests for assistance and provided little or no comfort measures. This means that when nurses distance themselves from their patients, this can have a serious effect on the nurse-patient interactions. The study also indicated that some of the nurses were physically present at the ward but were psychologically absent. This was why some nurses were found to be unresponsive to patient calls, an apparent lack of emotional attachment to their job and patients. According to Bassett (2002), intimate care requires that the nurse is physically and emotionally close to the patient. Distant nurses do not make any positive contribution to the nurse-patient interaction. 5.5.4 Deliberate Neglect of Patients Neglect was defined by Hodge (1988) as cited in Myburg (2007) as the failure to provide any treatment, care and good services necessary to improve a doctor‘s treatment plan. Myburg (2007) expanded the meaning of neglect to include failure to meet other physical needs such as toileting, bathing, feeding, safety needs, empathy and understanding. Where this failure is deliberate, with the intention to harm or ‗punish‘ patients, it is seen to be violent in nature. Describing the nature of the neglect in this study as deliberate connotes, conscious effort on the part of the nurses to neglect their patients. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 85 The study found that nurses in certain situations consciously neglected their patients. This impacted negatively on the quality of care provided. The neglect of patients by nurses was cited by other researchers who indicated that there were instances of total neglect of the views of patients at the hospital (Korsah, 2011; Dahlin, 2010; Dowling, 2009).When patients become neglected, they tend to develop a sense of isolation which might compel them to react in diverse ways. Some behaved angrily and others isolated themselves the more from the nurses who neglected them. It was also found that neglected patients found it difficult to communicate with their care givers, impacting negatively on the nurse- patient interaction. 5.6 Patients‟ Feeling of Powerlessness Feeling of helplessness refers to situations where patients considered themselves as powerless in the nurse–patient relationship. They considered themselves incapable of influencing issues concerning their care. Under this main theme, the sub-themes identified were, authoritarian nurses, patients‘ feeling of inadequacy and patients‘ exclusion from decision making, 5.6.1 Authoritarian Nurses It was realized from the study that nurses at the ward in certain situations behaved in an authoritarian manner towards their patients. The basis for the authoritarian behaviour was found to be the perceived power disparity between the nurses and the patients. Nurses always sought to control their patients. The current study‘s findings corroborated the findings of Murira et al.(2003) that, nurses are mostly authoritarian and not discrete in their interaction with patients. With regard to the power imbalance between the nurse and the patient, Campbell and Gordon (2003) indicated that the nurse-patient relationship is one of unequal power and that nurses derive their power from their specialized University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 86 knowledge and access to privileged information. Irvin (2008), considering the power situation at the ward argued that the mere placing of the term ― nurse‖ first and ―patient‖ second in literature on nurse-patient relationships indicate a perceived level of control or power over the patient . Nurses therefore tend to have authority and influence in the health care system and that is used to control the patients in the nurse-patient interaction. Another finding of the study was that nurses interpret patients‘ attempt to voice their opinions as a challenge to their authority. This finding is similar to findings of the study by Roos (2005),that indicated that nurses do not want to be questioned by their patients. In the current study, nurses tended to label such patients as difficult. Similarly, the findings of the study by Breeze and Repper (1998) showed that patients were labeled as ―difficult‖ when they challenged or threatened nurses‘ competence or control. When this happens it is the nurse-patient interaction that suffers because it impedes effective communication which is critical in the nurse-patient interaction. Possibly, this sense of authority on the part of nurses may be due to lack of understanding between the nurses and the patients. This study showed that increased participation of patients in the nurse- patient interaction will result in better reciprocal understanding between nurses and patients. Furthermore, Darmann (2000); Shattell (2004) showed that power imbalances in the nurse-patient interaction influence the quality of communication or interaction between nurses and patients. This is an issue that can be taken up in in-service training to sensitize nurses to work on their poor attitudes for better patient care. 5.6.2 Patients‟ Feeling of Inadequacy The findings obtained under this sub-theme seemed to be connected to the imbalanced power relations between nurses and patients. Patients in the study had a feeling of inadequacy believed to come from their perception of lack of power to influence their University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 87 care. The participants indicated that nurses were in positions of authority and power in the interactions and therefore they could control and punish undesirable behaviours causing patients to feel inferior and ignored as was also noted by Myburg (2007).This makes the patients feel inadequate to insist on contributing towards issues concerning their own care. Patients indicated that since nurses had the specialized knowledge and competencies they were placed in better positions to make decisions on their conditions and that they as patients seemingly had nothing to contribute. This erroneous view of patients should be challenged since they also have considerable power. They should be encouraged to insist on their rights to contribute to their own care. 5.6.3 Patients‟ Exclusion from Decision Making The participants of the study as patients were excluded from decisions concerning their care. Their exclusion from decision making was partly due to the undue concentration of nurses on technical and professional jargons in their communication with the patients. This finding is supported by the findings of Williams et al. (2005a) that the use of jargons affected patients‘ participation in the clinical setting. This may be due to the fact that when nurses used technical jargons, patients found it very difficult to understand and thus could not communicate effectively with their nurses. Also patients do not challenge their exclusion from decision making because they lacked the understanding that it was their right to be involved in decisions concerning their care. To correct this anomaly, there is the need for patients to be educated on their rights so that they would develop attitudes needed to insist on their right to be involved in decision making. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 88 5.7 Ways to Improve the Nurse-Patient Interaction The sub-themes that were identified under this main theme were training, supervision, motivation, nurses‘ accountability and resources. 5.7.1 Training Training is necessary for the acquisition of skills needed to perform a job satisfactorily. In this study, it was found that nurses lacked interpersonal skills and that was the area training was much needed. In the study by Naik, Gantasala and Prabhakar (2010) it was found that nurses needed training in etiquette to enable them serve patients better. In the current study also participants thought that nurses lacked the sense of appreciation of the challenges they would face in their profession. Hence they were ill prepared to withstand the challenges when they started their practice following completion of their course from the nursing training colleges. In-service training was suggested for improving the performance of nurses on the job. Avenues should be created for nurses to improve on their competences. Nurses should be made to undergo periodic training. This will help improve their interactions with patients. 5.7.2 Supervision Supervision is necessary to ensure that workers perform their duties as expected. In the current study, participants believed that lack of supervision accounted for the unprofessional behaviour of nurses since they knew their malpractices could go undetected and unpunished. It was also found that supervision during the night shifts was poor and that several of the nurses‘ violations took place at night. Improvement in supervision can bring about improvement in the nurse-patient interaction. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 89 5.7.3 Motivation This study‘s findings also showed that satisfying the needs of nurses was linked to the satisfaction of the needs of the patients. This is because nurses are supposed to meet the needs of patients so if the nurses have problems,that will negatively influence the efforts of nurses to meet the needs of patients. This finding corroborates findings of a study where nurses recognized a connection between their working conditions and the ability to care properly for their patients (Bridges, 2013; Ramanujam, Abrahamson & Anderson, 2008). In a study by Agyepong, Anarfi and Asiamah (2004), lack of motivation was found to be the main cause of dissatisfaction among health workers, including nurses. It is clear that if nurses are dissatisfied with their work, it will affect their interaction with their patients. Needed measures should be undertaken to ensure that nurses are motivated to give off their best at the work place. 5.7.4 Nurses‟ Accountability In this study it was found that nurses were most often not accountable for the services they provided. When nurses are not made accountable for their actions, their sense of responsibility is diminished and this makes them believe they can do acts as they choose. Participants of the study reported that, nurses often treated them badly because they knew nobody will ask them any question or they will not be accountable to anybody concerning how they performed their duties. It was also found that without the sense of accountability, nurses assumed the sense of invincibility which negatively affected the nurse-patient interaction. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 90 5.7.5 Resources Resources represent both the human and non-human assets that are used by the organization to achieve its goals. In this regard resources include all the materials, facilities and also adequate number of nurses needed to achieve the objective of providing for the needs of the patients. In the study it was found that if nurses lacked what they needed to work with it created stress in them and impacted negatively on their interactions with their patients. The need for nurses to have resources to work with was supported by the findings of Langley et al., (2009) who observed that for nurses to be able to do their work well they should be supplied with the resources needed .This will help to achieve the required outcomes. This chapter discussed the key findings of the current study in relation to relevant studies already existing in the body of nursing knowledge. The findings of research work similar to the current study‘s findings were highlighted. Similarly, findings that deviated from the present study‘s findings were noted and discussed. In the final chapter that follows, the implications of this study‘s findings for nursing practice and education as well as an overall summary, conclusion and recommendation are presented. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 91 CHAPTER SIX IMPLICATIONS, SUMMARY, CONCLUSION AND RECOMMENDATIONS 6.1 Introduction This chapter presents the implications of the study findings to nursing practice, nursing education and research. The chapter also presents a summary of the study findings, the conclusions and recommendations for improving the nurse–patient interactions and ultimately the quality of care at KATH. 6.2 Implications for nursing education. This study‘s findings have a number of implications for nursing education .In the first place, the study has shown the need to develop the competence of nurses at the hospital in order to make them more productive and effective in their interaction with patients. This effort should start from the time the nurses are in school or the pre-service period. In school, nursing students should be taught important skills such as interpersonal skills and general communication skills. These skills, if well-developed are expected to make them more effective nurses after school and also more competent in their interaction with their patients. Nurse educators need to closely examine the curriculum section on communication skills and incorporate interpersonal relationships with emphasis on nurses-patient interaction. The course content in the curriculum should have nursing care theories such as Watson‘s to provide the framework for a healing environment. The outcome of the study has noted the apparent lack of mentoring, preceptorship and clinical supervision of registered nurses and midwives (RN & RM) especially on University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 92 weekends and night duties which was identified as militating against improved nurse- patient interaction. The required mentoring and preceptorship for the student nurses can give them the right appreciation of the nursing profession while in school. This will help deal with the problem of reality shock which new nurses tend to face. Another aspect of the study findings that has implications for education concerns the report by the participants that the nurses seemed to lack appreciation of what actual nursing entailed. The nurses, especially the new ones were reportedly suffering from what the participants described as ―reality shock‖. They reportedly seemed overwhelmed by the nature and the volume of work that was expected of them. To deal with the problem of ―reality shock‖, nursing students should be exposed to and provided with information on the exact experiences they will be having after school. This will make them well prepared for the world of work after school. In the study, it was realized that some nurses denied patients their rights which impacted negatively on the nurse patient interaction. This has implications for nursing education; student nurses should be taught the rights of patients and be encouraged to respect them. 6.3 Implication for Nursing Practice The implications of the findings for clinical practice is that nurses should be more patient- focused than task-focused. For this to be possible, nurses should be well trained to acquire all the competencies needed to relate well with patients. Supervision was found to be poor so efforts should be made to improve on supervision so that nurses will perform as required. The use of Closed Circuit Television (CCTV) should also be considered since just the awareness of being watched can control the behaviour of the nurses. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 93 6.4 Implications for Research The study findings have shown the need for further research with a larger sample to understand the phenomenon of nurse-patient interaction better. To allow generalization of the findings there is the need to use a quantitative approach and also use patients from public and private hospitals. Using both nurses and patients in a single study will also ensure more understanding of the phenomenon than just concentrating on patients or nurses separately. This is because the phenomenon in question involves the nurse and patient their interaction and this involves the two parties. 6.5 Summary This study sought to understand the nurse-patient interaction specifically the patients‘ perspectives and experiences at the Komfo Anokye Teaching Hospital (KATH).The overall purpose was to unravel the positive and negative factors influencing the nurse- patient interaction to help understand the nurse-patient interaction at KATH and also to find ways of enhancing the interactions. Besides the main objective, the study also sought to meet the following specific objectives of the study. Describe the patients‘ experiences in nurse–patient interactions at Komfo Anokye Teaching Hospital (KATH). Identify the factors that contribute to positive and negative nurse-patient interactions at KATH. Find ways of improving the nurse-patient interaction at KATH. A qualitative approach was used and purposive sampling technique was used. Data was collected from twelve (12) participants using a semi- structured interview guide. The data University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 94 was analyzed using content analysis and it yielded six main themes and twenty three (23) sub-themes. The following are the key finding of this study. Nurses at KATH were found to be poor communicators which stems from their negative attitudes towards patients which influenced negatively the nurse-patient interaction. Effective communication was found to be important in the nurse-patient interaction. Respect for patients‘ rights and deliberate neglect of patients was found to be a major problem at KATH. Overall, the findings of the study have indicated that the nurse-patient interaction at KATH is important since it influences the health outcome of patients. Various factors were identified that influence the nature and quality of the nurse-patient interaction. It has been realized that the nurse-patient interaction is fundamental to the nursing care and activities. 6.5 Conclusion This study set out to understand the experience patients go through during their interactions with nurses at KATH and to find ways to enhance better interaction. The findings of this study have largely proven that nurses are not generally treating their patients well at KATH. The vast majority of nurses reportedly exhibit poor attitudes toward their clients and show them little or no respect. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 95 Nurses were also portrayed as showing favouritism amongst patients. However a few patients indicated that, a minority of nurses are good and treat them well. It is imperative that measures are taken to improve nurse-patient interaction at KATH. Since this study focused patients‘ perspective, future studies should focus on both nurses‘ and patients‘ perspectives. 6.6 Recommendations Based on the findings of the study, the following recommendations were made: Regular workshops and seminars should be held for nurses where communication with patients and patients‘ relatives should be discussed In-service education should include training in communication including interpersonal skills. Nurses should be motivated. This should be in terms of their remunerations and other conditions of service. The working environment should also be conducive for the nursing work. There should be sanction put in place to correct nurses who maltreat patients. Management should ensure that nurses are made accountable for what they do. Well behaved nurses should be motivated by giving them incentives to boost their morale. 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University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 113 APPENDICES APPENDIX A: SAMPLE OF THANK YOU CARDS University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 114 APPENDIX A II University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 115 APPENDIX A III University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 116 APPENDIX A IV University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 117 APPENDIX A V University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 118 APPENDIX A VI University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 119 APPENDIX A VII University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 120 APPENDIX A VIII University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 121 APPENDIX A IX V University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 122 APPENDIX AX University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 123 APPENDIX A XI University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 124 APPENDIX B: DISTRIBUTION OF MEDICAL ERRORS Source: Field Data, 2013 from Quality assurance unit, KATH University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 125 APPENDIX C: INTRODUCTORY LETTER University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 126 APPENDIX D: ETHICAL CLEARANCE University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 127 APPENDIX E: CERTIFICATE OF REGISTRATION FROM KATH University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 128 APPENDIX F: LETTER OF APPROVAL University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 129 APPENDIX G: CONSENT FORM University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 130 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 131 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 132 APPENDIX H: INTERVIEW GUIDE Research topic: Understanding the nurse-patient interaction at KATH: The patients‘ perspectives and experiences. Researcher: Olivia Nyarko Mensah (MPHIL Nursing Student) Address: School of Nursing, University of Ghana, Legon Telephone numbers: 0244773708 These lists of questions are developed according to the themes identified in the literatures review to guide the researcher. The participant‘s response will also guide the questions. The interview guide will contain a list of open-ended questions which have been derived from the objectives of the study. SECTION A: Demographic data Pseudonym: Age: Gender: Educational Level: Occupation: Marital status: Ethnicity/Tribe: Religion: Ward: Duration of care: University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 133 SECTION B: Communication as an interactive role 1. How would you describe the nurse-patient interaction at the Komfo Anokye Teaching Hospital (KATH)? Probes: i. Describe your own interactions with the nurses that took care of you during your admission in KATH. ii. How were the interactions of nurses and other patients at KATH? iii. How were you engaged in communication with the nurses who care for you whiles in bed? 2. Tell me about some of the experiences you have gone through during your interactions atKomfo Anokye Teaching Hospital (KATH)? Probes: i. How would you describe such experiences that you went through? ii. What are some of your experiences (both positive and negatives) and why do you think it is so? iii. What effect has the nurse-patient interaction at Suntreso caused in your recovery? 3. In your opinion, what are some of the contributory factors to a positive or negative nurse-patent interaction at the KATH hospital wards? 4. Tell me about an interactive encounter you remember at KATH? Probes: i. How did it start? ii. What brought about the interaction iii. Talk about any encounter with the nurse you can remember that was positive? iv. What precipitate the interaction? v. What appreciation did you show to the nurse to boost his/her moral vi. Which of the interactive encounter can you remember to be negative? vii. What were the positive or negative implications of such interactions ward your recovery? SECTION C: Patients‟ perception about nurses in the nurse-patient interaction 5. How did youperceive those who care for you at the hospital ward? i. Probe: What are some of the things they did which were important contributory factors to your recovery? University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 134 SECTION D: Power struggle and nurse-patient interaction 6. Explain how you were involved in the decisions of care during your stay. SECTION E: Stress and Nurse-Patient Interaction 8. How stressful do you become when your decisions are not taken with respect to the nurse-patient relationship? 9. What do you think are the experiences that bring about stress in the interactive encounter? i. Probes: How true are those opinions about nurses? ii. In what ways do you think those opinions about nurses affect their work? In what ways do you think nurses reinforce those opinions? 10. How do you think the nurse-patient relationship at the hospital can be improved? THANK YOU. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 135 APPENDIX I: THEMATIC CODE FRAME THEMES AND SUBTHEMES CODE DESCRIPTION 1. First main theme: Patients‟ expectations and actual observations PE Patient‘s requirements from their interactive engagements with nurses and how the requirements were met or unmet. i. ii. iii. iv. v. Subthemes : Caring environment cre It is the non-threatening, therapeutic and comfortable environment which gives sense of hope to the patients. Humane treatment hut Treating patients‘ in a kind manner Supportive nurses sun Nurses who give the required help to the patients and show kindness when assisting them. Thus, showing concern for the patients. Effective communication eco Meaningful and useful conversations with patients about their health. Respect for patients‘ right rep The rights of patients to be told about their care and outcome of their care. 2. Second main theme: Patients‟ perception of nurses. PPN These are the features of good and bad nurses in the view of the patients University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 136 i. a Subthemes : a. ―Good‖ nurses gon Competent nurses who do their work efficiently. b. Lackadaisical nurses lan Nurses who show apathetic and relaxed features in doing their work. c. ―Bad‖ nurses ban Nurses who show unkind behaviour to their patient. 3. Third main theme : Nurses‟ Attitude NUA These are the opinions and actions of nurses in relation to patient‘s care. i. ii. iv Subthemes : Positive attitudes pat Opinions and actions of nurses that patients like and are comfortable with care to patient. Negative attitudes nat Opinions and actions of nurse that patient dislikes are not comfortable with. Ambivalent attitudes ama Nurses who show indecisive attitude. 4. Fourth main theme : Nurses‟ stereotyping and discrimination of patients NUD Nurses labeling patients favourably or unfavourably and based on that treating patients differently. i. i i Favoritism fav Nurses placing some patients above others in terms of the quality of care provided. Poor patients pop Patient who are labeled poor and discriminated against by nurses.. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 137 ii. iii iv Distant nurses din Nurses who stay ―far away‖ from their patient. Deliberate neglect of patients den Nurses refusing consciously attend to patients in rendering care to patients. 5. Fifth main theme: Patients‟ feeling of Powerlessness FOP The perception of lack of control or involvement of patients in their care i. ii. i iii. Subthemes Authoritarian nurses aut Nurses using their privileged position as a source of power for dictating to patient. Patients‘ feeling of inadequacy pin Patients lack of knowledge about their condition and their care. There is a perceived inability to do anything about their situation. Patients‘ exclusion from decision making ped-m Patient‘s not involved in decisions concerning their health. 6. Sixth main theme: Improving nurse-patient relationship IMP These are activities and measures that bring about improvement in the nurse-patient interaction. i. i. Subthemes : Training trn Teaching and guidance nurses need to perform better. sup The need to have nurses work and University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 138 ii. Iii iv v Supervision activities regulated, controlled and evaluated with the aim of mentoring and reviewing nursing activities. Motivation mot The incentives and encouragements to boost nurses‘ morale and improve performance. Nurses‘ accountability nac Ensuring that nurses are answerable for their actions. Resources res Need for enough equipment, fund and logistics for nurses work. University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 139 APPENDIX J: PARTICIPANTS INFORMATION LEAFLET Title of Research: „UNDERSTANDING THE NURSE-PATIENT INTERACTION AT KATH: THE PATIENTS‟ PERSPECTIVES AND EXPERIENCES‟. Name(s) and affiliation(s) of researcher(s): Olivia Nyarko Mensah, School of Nursing, College of Health Sciences, University of Ghana, Legon Dr. Patience Aniteye, School of Nursing, College of Health Sciences, University of Ghana, Legon Mr. Kwadwo Ameyaw Korsah, School of Nursing, College of Health Sciences, University of Ghana, Legon Background: In recent two decades, there have been concerns and challenging issues about nurse- patient interaction. Most people have reported of the possible progressive decrease in the quality of care rendered to them because both nurses and patient cannot pin-point which roles they are to play in the interactive encounter and therefore the era of nurses have positive labels from the family is gradually fading way. There is a need to understand the existence of the nurse-patient interaction and the patients‘ perspectives and experiences in KATH and identify the contributing factors that are influencing both the positive and negative interaction and also know the thread- ways of maintaining the positive factor to improve care. Purpose of research: The Purpose of the study is to understand the nurse –patient interaction at KATH and to find ways of enhancing the interaction at KATH. Procedure: Eight (8) to Twelve (12) participants who will report KATH for admission and have spent a week or more will be used for the study. All participants must be patients or previous patients at the selected adult wards such as medical, surgical and maternity wards. Preferably the participant should be patient who are on or close to be discharge and will be reporting back for their first review. The participants shall be required to go through interview section lasting between 45minutes to 1 hour at your University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 140 place and time of convenience to unveil their experiences during admission with a semi- structured interview guide and the discussion will be audiotaped. Contacts: If you have any question concerning this study, please do not hesitate to contact Miss Olivia Nyarko Mensah (Name of Researcher) on 0244773708 Note: Further, if you have any concern about the conduct of this study, your welfare or your rights as a research participant, you may contact: The Chairman Nouguchi Memorial Institutional Research Committee, Legon Accra and The Chairman Committee on Human Research and Publication Ethics Kumasi Tel: 22301-4 ext 1098 or 020 5453785 University of Ghana http://ugspace.ug.edu.gh Understanding the Nurse-Patient Interaction 141 APPENDIX K: SUMMARY OF DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS PARTICIPANT S NO. 1 2 3 4 5 6 7 8 9 10 11 12 PSEUDONYMS Collin Christa Cosmos Cynthia Constanc e Cudjoe Charles Carmey Charllotte Carmel Clement Clere AGE(YRS) 38 38 43 25 25 45 27 20 34 34 31 32 GENDER Male Female Male Female Female Male Male Female Female Female Male Female EDUCATIONA L LEVEL JHS No Formal Edu. Md sch JHS SSS Degree SHS Prim JHS Prim SHS Prim OCCUPATION Painter Unemp. Weld Decor Unemp Ph consult. Unemp. Semstress Trader Food vender Shop attendants Clerk ETHNICITY/ TRIBE Akan/ Ashanti Akan/ Ashanti Akan/ Denkyira Akan/ Ashanti Akan/ Akwapim Akan/ Akwapim Akan/ Fanti Akan/ Ashanti Gonja/ Salaga Akan/ Ashanti Akan/ Ashanti Hausa RELIGION Chris Chris Chris Chris Chris Chris Chris Moslem Moslem Chris Chris Moslem MARITAL STATUS Married Widowed Married Married Single Married Single Cohabiting Married Married Married Married WARD MMW D4 FOW C1a MSW B1 MW A4 FOW C1a MMW d3 MSW B2 MW A3 FOW C1a MW A3 MMW D3 MW A4 DURATION OF CARE 1 WK, 3 DAYS 1 MTH 3WKS 3 MTHS 1 MTH , 2WKS 2 MTHS 1 WK 6DAYS 2 WKS, 2DAYS 1 WK 7 MTHS 1 MTH , 2WKS 3 WKS 1 MTH University of Ghana http://ugspace.ug.edu.gh