Creating and establishing a positive care relationship between nurses, patients and relatives : An ethnographic study of encounters at a department of medicine for older people

Sammanfattning: Background and aim: Numerous encounters take place in the healthcare sector every day. Although the encounters should be conducted in a safe and respectful manner, an increased number of complaints about communication and interaction have been reported to the Health and Social Care Inspectorate. When a nurse, patient and relative meet in a so-called triad encounter, the focus is on creating and establishing a care relationship with the facilitated by communication and interaction. Thus, if communication and interaction fail in these encounters there is a risk that the care relationship will be bad and the patient's needs not fulfilled, which can lead to poorly prepared patients with difficulties participating in their own care. The overall aim of this thesis was to explore and describe the care relationship, communication, content and social interaction in the triad encounter between nurses, patients and relatives at a department of medicine for older people.Methods: The four studies were designed using a qualitative, ethnographic approach guided by Vygotsky’s sociocultural and Goffman’s interactional perspective. Participatory observations (n=40) and informal field conversations (n=120) with patients, relatives and nurses were carried out (October 2015-September 2016) at the same time as field notes were written. Studies I, II and III were underpinned by an ethnographic analysis, while in study in IV, a thematic analysis with an abductive approach was conducted.Results: The result of study I, identified a process where patients, relatives and nurses used different strategies for navigating before, during and after a triad encounter. The process was based on the following categories: orienting in time and space, contributing to a care relationship and forming a new point of view. Study II, showed how nurses communicated, using four different voices which reinforced by body language, which formed patterns that constituted approaches that changed depending on the situation and orientation: a medical voice, a nursing voice, a pedagogical voice and a power voice. Study III, emphasized three categories of content of the communication exchanges: medical content focusing on the patient’s medical condition; personal content focusing on the patient’s life story; and explanatory content characterized by nurses attempting to increase the patient’s and relative’s knowledge about the patient’s health and nursing needs. Study IV showed that, to create social interaction, the nurses employed greetings, small talk and bodily expressions. Patients accepted the invitation with body language, while relatives employed various strategies to receive an invitation. Nurses led the conversation, patients followed and described their health problem through gestures, while relatives captured the moment to receive and give information. Nurses summarized using ritual language, patients expressed gratitude’s through verbal and non-verbal expressions and relatives verbally clarified the agreements. The synthesis of the four results showed a model with the four activities as puzzle pieces: navigating through different perspectives, being involved in the communication, being attentive to social interaction and explaining the relevant content. When the institutional environment is such that the asymmetry between the nurse, patient and relative is limited, and the norms and routines promote communication between them, it is more likely that the puzzle pieces fit together and an opportunity arises to create and establish a positive care relationship in the triad encounters.Conclusion: The nurses' role as a professional is crucial, as they start, lead and end the encounter. If nurses minimize the asymmetry and combine the medical, personal and pedagogical questions, an opportunity arises for creating and establishing a positive care relationship that enables the patients to become more active and relatives more visible. This can contribute to strengthening the patient’s position in the healthcare system and increasing patient safety.