A description of health care professionals’ experiences of encounters with patients in clinical settings

A description of health care professionals'experiences of encounters with patientsin clinical settings

Christina A.S. Takman RNT

Stortorps Rehabilitation and Convalescent home, StortorpsvaÈgen 43,

S-142 29 TraÊ ngsund, Sweden

and Elisabeth I. Severinsson RNT MNSc DrPH

Hedmark College, Department of Nursing Education, Elverum and Associate

Professor at University of Oslo, Institute of Nursing Science, PO Box 1120,

Blindern, N-0317, Oslo, Norway

Accepted for publication 17 March 1999

TAKMANTAKMAN C.A.S. &C.A.S. & SEVERINSSONSEVERINSSON E.I. (1999)E.I. (1999) Journal of Advanced Nursing 30(6),

1368±1374

A description of health care professionals' experiences of encounters

with patients in clinical settings

The aim of this study was to describe health care professionals' way of

experiencing their encounters with in- or outpatients, while working in acute

medical care hospitals. One main question was addressed: What are the

experiences which health care professionals have of their encounters with in- or

outpatients in clinical settings? Eleven health care professionals (physicians,

registered nurses and enrolled nurses) were interviewed and a phenomeno-

graphic approach was used, where data were analysed qualitatively. The results

indicate that the health care professionals' way of experiencing their encounters

with patients in acute medical care hospitals could be separated into three

categories of description: a gain in personal knowledge and understanding of

the patients' different `ways' of communicating experienced suffering; making

the patient feel con®dent and; focusing on the medical problems, not

understanding the patient's different `ways' of communicating their

experienced suffering. The ®rst two categories of description showed

encounters where the health care professionals felt that they could understand

the patients' expressions of suffering. The third showed encounters where the

health care professionals experienced dif®culty in understanding the patients'

expressions of suffering. There is a need therefore to support health care

professionals in improving their understanding of patients' suffering.

Keywords: health care professional, encounter, communication, suffering,

qualitative methodology, patient, phenomenography

INTRODUCTION

Patients in clinical settings encounter different health care

professionals during their in- or outpatient stay. The

encounter can be seen as a part of a holistic view,

Correspondence: Lecturer Christina Takman,

TraÊ ngsundsvaÈgen 22 A, S-142 63 TraÊ ngsund, Sweden.

E-mail: [email protected]

Journal of Advanced Nursing, 1999, 30(6), 1368±1374 Issues and innovations in nursing practice

1368 Ó 1999 Blackwell Science Ltd

described as a relationship between two subjects; the

health care professional and the patient (Dahlberg 1992,

1996). According to the de®nition given by Allen (1991),

the transitive verb, to encounter, can be meeting by chance

or unexpectedly, or as adversaries. It can also be seen as

participation in an encounter group. The philosopher

Buber (1990) is of the opinion that the world of relation-

ship in the encounter is created by subjects who are

entering the encounter as a subject in relation to the other

subject (I and You), but when the other person in the

meeting is known as an experience by the experiencing

subject, he is considered as an object (I and It). Health care

professionals can in¯uence the interaction and the char-

acter of the relationship with patients through their

behaviour in the encounter, where the patient can feel

con®rmed or excluded, or be given a sense of being

empowered or discouraged (Drew 1986, HalldoÂrsdoÂttir

&KarlsdoÂttir 1996, KaseÂn 1996). According to Osterman

& Schwartz-Barcott (1996), health care professionals can,

in the encounter with their patients, be present in differ-

ent ways; from physically being present, but emotionally

nonpresent, to absolutely emotionally present, completely

concentrated on the patient. The interaction can be

understood as being both technocratic, and thereby

routinized and strictly controlled, and focused contextu-

ally on individual action, social and organizational ideas

(May 1990).

The literature review

A computer-based literature search for papers on the

phenomenon of encounters in clinical settings related to

health care professionals and patients, covering the period

1982±96, has been carried out using the international

databases CINHAL and MEDLINE and the Swedish

domestic database SPRI-line. The survey of previous

research shows that several phenomena have been inves-

tigated, which occur in the encounter between health care

professionals and patients. Anderson & Zimmerman's

(1993) research on relationships demonstrated that the

relationship could be seen, by both patients and physi-

cians, as a partnership between themselves or as being

controlled by the physician. In the ®rst encounter, the

physiotherapist experienced the relationship as based on a

dialogue with the patient, or as a relationship where the

physiotherapist perceived herself as authority (Westman-

Kumlin & Kroksmark 1992). Relationships of ethical

dif®culty have been experienced by enrolled and regis-

tered nurses (SoÈderberg & Norberg 1993). Previous

research has shown that patients who had no need for

physical nursing care had little chance of interactions

with nurses (Peterson 1988). The interactions with

patients have also been seen as being powered by nurses

when mediated through language (Hewison 1995). Nurses'

feelings and thoughts when having encounters with

people who had attempted suicide have been investigated

(Pallikkathayil & Morgan 1988), as well as nurses'

thoughts about their role in the support for cancer patients

at night (Hanson 1994). Radwin (1995, 1996) discussed the

concept of knowing the patient as essential to making

individual decisions according to nursing practice. The

nurses' understanding was categorized into knowledge of

the patients' experiences, behaviours, feelings and

perceptions (Radwin 1995). Ford (1990) investigated

nurses' experiences of caring encounters in the context

of cardiac patients, and Taylor (1992) observed how

nurses and patients related to each other through their

af®nity as humans. Clarke & Wheeler (1992) suggested that

the understanding of nursing itself would be enhanced by

gaining perspectives on the meaning of care, for example,

when nurses are being supportive in the encounter with

their patients. Finally, Lindholm & Eriksson (1993) inves-

tigated suffering as being composed of pain, fear, despair

and lack of strength. Patients' suffering could be alleviated

when met with compassion.

In summary, previous research shows examples of

interactions and relationships that have occurred in the

encounter between health care professionals and patients,

but it lacks descriptions of health care professionals' way

of experiencing their encounters with patients. There is a

need, therefore, for further research in relation to the

phenomenon described to increase the understanding of

how health care professionals experience their encounters

with in- or outpatients in clinical settings.

THE STUDY AIM

The speciality chosen in the present study is acute

medical settings, and the aim is to describe health care

professionals' way of experiencing their encounters with

in- or outpatients, while working in acute medical care

hospitals.

Method

Phenomenographic approachThe phenomenographic approach was chosen, as this

approach is not concerned with psychological processes

but with the internal relationship between the human

being as experiencer and the world around them as

experienced, that is, a second-order perspective (Marton

1978, 1988, Marton & Booth 1997). This implies that

human thinking is studied from a position where the

thinking and the world around are not isolated from each

other (SaÈljoÈ 1997). The experiencer is focally aware of the

object of experiencing, but not of `her way of experiencing

it' (Marton & Booth 1997 p. 118). The ®rst-order perspec-

tive, on the other hand, describes the world as it is

(Marton 1978). The idea of the phenomenographic

approach is to describe variations of qualitatively

Issues and innovations in nursing practice Health care professionals' encounters with patients

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(6), 1368±1374 1369

different understandings of the experienced world

(Marton 1978, 1988, Westman-Kumlin & Kroksmark

1992, Marton & Booth 1997). Phenomenography is not

as well known in nursing research as it is in educational

research (Marton 1978, 1981, 1988, Marton & Booth 1997).

The phenomenographic method began to be developed in

the late 1970s at the Department of Education and

Educational Research at Gothenburg University in Swe-

den, by Professor F. Marton and colleagues (Marton 1981).

In educational settings, the phenomenographic method

has been used to identify, formulate and tackle research

questions of relevance to learning and understanding

(Marton & Booth 1997). In nursing research Baker (1997)

proposed the phenomenographic approach to be appr-

opriate in research into the clinical decision-making of

nurses and, in the ®eld of physiotherapy, Westman-

Kumlin & Kroksmark (1992) described physiotherapists'

different ways of experiencing their establishing of ther-

apeutic relationships.

Collection of data

InformantsThree categories of health care professionals (enrolled

nurses, physicians and registered nurses), in total 11

informants, were selected to improve the possibility of

acquiring different perspectives on the area of study. This

choice was made in order to select those health care

professionals who regularly encountered patients in acute

medical settings (in nursing as well as in medical care).

The health care professionals' age was in the range

28±62 years; four were men and seven were women.

Three were physicians, ®ve registered nurses and three

enrolled nurses, and their experiences of health care

ranged from 5 to 45 years, mean years at work being

19 years. The context chosen was acute medical clinical

settings in three University Hospitals, where the health

care professionals had the ability to encounter in- and/or

outpatients.

ProcedureThe method of data collection chosen in this study was

individual interviews designed according to the pheno-

menographic approach. The interviews were conducted

in 1995 during a 4-month period, by the ®rst author (CT).

The health care professionals were asked to describe

encounters with in- or outpatients, which they remem-

bered clearly. The ®rst author drew lots for selecting

which of the three groups of health care professionals

(physicians, registered nurses or enrolled nurses) to

interview at each hospital. The medical head and the

director of nursing in each medical setting, at three

University Hospitals situated on the east coast of

Sweden, were contacted by the ®rst author. They were

asked to choose respondents in the selected group with a

`long experience' of medical hospital care and to give

those who were chosen a letter including information

about the study and the audio-taping. In order to obtain

informed consent the respondents were contacted by the

®rst author and asked if the information given by letter

was understood and whether they wanted to participate

in the study in the form of tape-recorded interviews. All

agreed to take part in the study. The interviews were

conducted in a quiet setting within the facility but as far

as possible from the health care professionals' actual

workplace. The interviews lasted between 30 and 90

minutes, and were transcribed verbatim. The interviews

were unstructured and began by asking the health care

professional to narrate an encounter with a patient in a

clinical setting which he/she remembered clearly

(Svensson 1984, Kvale 1996). This was followed by

follow-up questions in relation to the respondents'

answers in order to deepen the interview (Svensson

1984, Marton & Booth 1997).

Analysis of data

The analysis was carried out in accordance with the

phenomenographic approach, which involves repeated

readings of the transcribed interviews in order to gain a

thorough understanding of each interview. The analysis

was conducted by relating parts of each interview to the

whole interview and each interview to the others.

Similarities and dissimilarities of the components of

the interviews that emerged during the analysis were

placed in different categories of description (Westman-

Kumlin & Kroksmark 1992, Marton & Booth 1997).

Finally, the categories of description were checked by

the second author (ES) independently in order to reach

consensus. The health care professionals are referred to

as enrolled nurses (EN-), physicians (P-), registered

nurses (RN-), female (-F), or male (-M) and the patient

as male throughout the text below. The interviews are

numbered according to the order in which they were

performed. For example (RN-F7) means that the respon-

dent is a registered nurse, female and that it is interview

number seven.

RESULTS

Three categories of description emerged of the health care

professionals' way of experiencing their encounters with

patients. The ®rst two categories of description show

encounters with patients where the health care

professionals feel that they can understand the patients'

expressions of suffering. The third category of description

shows encounters where the health care professionals

experience dif®culty in understanding patients' expres-

sions of their suffering.

C.A.S. Takman and E.I. Severinsson

1370 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(6), 1368±1374

1. A gain in personal knowledgeand understanding of the patients' different `ways'of communicating experienced suffering

This category describes when the health care professional,

by being open to the patient's different levels of commu-

nication, is gaining a personal knowledge of the patient on

an individual level. The patient is giving the health care

professional an insight into his life as a whole, when he

communicates his feelings and thoughts according to his

life situation in his environment, and to his medical

condition. In the human to human encounter the patient is

able to express his own feelings, and the health

care professional is open and attentive and has the ability

to understand. The health care professional can, in

the encounter, share and interpret information for the

purpose of selecting individual interventions. The health

care professionals can feel that their interventions are

positive for the patient, which in turn gives them a feeling

of positive con®rmation. In caring, which includes

repeated encounters with in- or outpatients, this form of

relation with the patient will be important in forming

individualized care. The following quotations illustrate

this category:

When you get to know your patient, the whole will be more

important for success than just the symptoms¼it will deepen the

relation (P-M3).

One day he says: `Well, now, soon I will sail away on the great

ocean' and he wondered if I could sail with him¼and he was so

ill, he had big wounds¼we both knew that this was what he was

talking about¼that this was his way to say that he was going to

die¼ I felt that he trusted me¼it was like a warm transmission

from his hand (EN-F9).

He was hemiplegic and cared for in a ward-room, where he

enjoyed the company of three other patients¼the three other

patients were dressed to have breakfast. We saw how unhappy he

became, when he couldn't manage to get out of his bed on his

own, and we helped him to get out of the bed, to have breakfast

together with the other patients (RN-F7).

Regarding the patient as an individual in the encounter

makes it easier for the health care professional to be open

to the patient's manner of expressing his suffering as well

as willing to give him individual care.

2. Making the patient feel con®dent

This category describes the situation when the health care

professional is striving to make the patient know that he is

in focus for the health care professional, in order to make

him feel calm and con®rmed in their encounter. This is

because the patient can, for example, feel anxious before

an examination, or of being left alone during the exami-

nation. The medical diagnosis or the hospital environment

can be experienced by the health care professional as

making the patient feel uneasy:

I'm trying to spend the ®rst 10±15 minutes together with the

patient when he has just arrived, in order to con®rm him, so he is

feeling that someone is seeing him, giving him a trustful contact

(RN-M2).

He was worried and asked me if I could follow him and

be seated by his bedside and hold his hand during the

examination (EN-F10).

3. Focusing on the medical problems,not understanding the patients' different `ways'of communicating experienced suffering

This category describes when the patient's experiences of

his situation are not seriously taken into account, because

the health care professional is focusing on the medical

problem and the medical treatment decided. There are

descriptions of encounters with very sick patients as well

as encounters with patients suffering from innocuous

illnesses. It can even be that the health care professional is

trying to understand the patient in the contacts with him,

but fails due to focusing on the patient's medical disease

when the patient shows no interest in talking about this.

The patient's experiences are not taken into account in the

planning of his treatment, because the health care

professional does not understand the patient's way of

communicating his suffering. When the health care

professionals feel that they have nothing particular in

common with the patient, it is harder to understand the

patient's way of expressing his suffering. When the patient

is becoming more ill, this focus on the medical disease

might increase the dif®culty in meeting the patient:

I remember talking to him, but having dif®culty in getting contact

with him. He was acting up and was dif®cult to understand, very

depressed, but I didn't perceive him as depressed. He asked me if

he could have some sedative drugs, but I told him he couldn't, it

was in line with the treatment planned for him (P-M8).

He is getting more ill. When we ®rst met he could walk and see

well, but now he can only see a little and he has wounds on his

toes¼I feel sorry for him and ®nd it dif®cult to meet him (EN-F10).

I sensed the whole time that he observed me in my work with

him, as if he watched all the details when I gave him the

injections. He didn't want to talk so much about his illness.

However he got worried about details, for example how people

encountered him. The food should be served at special times and

in special ways, he was very strict with¼to keep the timetable

with injections and such (RN-F4).

There are outpatients with uncomplicated medical problems,

whom I meet for just ®ve minutes¼ In cases where it is dif®cult to

understand the patient's problems¼it can be patients who are

experiencing their problems in another way than I do (P-M3).



Consequences of having the patients' medical problems

in focus in the encounter could be that the conversation

led by the health care professional mainly concerns these

in the contacts with the patient. This seems to contribute

to health care professionals' inattentiveness to the

patient's manner of expressing his suffering.

DISCUSSION

The aim of this study was to describe health care profes-

sionals' way of experiencing their encounters with in- or

outpatients in acute medical care hospitals. Data was

collected by audio-taped individual interviews and tran-

scribed verbatim. Three qualitatively different categories,

describing health care professionals' way of experiencing

the encounter with in- or outpatients, were found: 1. A

gain in personal knowledge and understand the patient's

different `ways' of communicating experienced suffering;

2. Making the patient feel con®dent; and 3. Focusing on

the medical problems, not understanding the patients'

different `ways' of communicating experienced suffering.

Categories of descriptions 1 and 2 relate to the health care

professionals who, unprejudiced in the encounter, expe-

rience that they can understand the patient's expressions

of suffering. The category of description 3 shows

encounters where health care professionals are trying,

but not succeeding, in understanding the patient's

experiences of suffering.

It can be the case that it is the health care professional's

apprehension of the patient's supposed experience of

suffering that is taken into account in the encounter with

the patient. In this material it is possible to see examples

of the encounter which were described in the introduction

of this paper. For example, category of description 1

focuses on the health care professionals' ability in the

encounter to understand the patient's experiences of

suffering. This is in line with Radwin's (1995) and

Lindholm & Eriksson's (1993) research, where health care

professionals used their understanding of the patient's

feelings to select individual interventions and to show

compassion for the patient's suffering. According to Ford

(1990) and Taylor (1992), a caring encounter is an

encounter where the nurse is open to the patient and is

sensing the patient's vulnerability while relating as

human to human. This way of relating could be seen in

the categories 1 and 2.

Peterson (1988) observed limitations of care given by

nurses. Although the nurses showed a theoretical know-

ledge of psycho-social care, their practical work was

dominated by meeting the patients' needs for physical

nursing care, administration of medications, and techni-

cal procedures. The language used by nurses in their

interactions with patients was examined by Hewison

(1995). Through participant observation, Hewison (1995)

noticed that nurses had a great deal of verbal control

over the interactions, which were super®cial, routinized

and task-related. This is similar to category 3. Applying

the philosopher Buber's (1990, 1997) thoughts to the

encounter between health care professional and patient

should mean that, when the health care professional is

focusing on the patient as a subject and the patient's

experiences of his situation, and suffering is made clear

and taken into account by the health care professional,

the patient becomes a You in relation to the health care

professional, who becomes an I. This way of relating to

the patient is what could be seen in the categories 1 and

2. On the other hand, if the health care professional is

concentrating on the medical problems and at the same

time is not aware of the patient's own experienced

suffering according to his situation, the patient might

become an It in the eyes of the health care professional

(Buber 1997), as could be seen in the category 3. Clarke

& Wheeler (1992) studied six registered nurses' experi-

ences of the meaning of care. Their results are similar to

the present study in the sense that the nurses had a high

focus on interpersonal aspects, such as being supportive,

as well as having trust and respect for their patients.

Communicating with the patient as human to human

was also valued. Nurses were reported to develop a

feeling of being under pressure when meeting patients

who were hard to understand, which affected the quality

of care given.

Methodological consideration

This study used a phenomenographic approach. Since it is

of value for the nursing research ®eld to identify

phenomena important for caring sciences, it will also be

of importance to re¯ect on how health care professionals

handle problems or situations in their professional world.

In order to make clear how people act with regard to

different phenomena in the world, we must gain

knowledge in order to understand the ways in which

people experience them, because their acting is in relation

to the world as they experience it. The world is real, `but it

is a described world, a world experienced by humans'

(Marton & Booth 1997 p. 113). To gain knowledge about

health care professionals' experiences, the phenomeno-

graphic approach could be appropriate. However, in order

to get a deeper understanding of the research questions in

this study the use of a phenomenological approach could

have been valuable (Morse & Field 1995). The issues of

validity of the qualitative approach need to be addressed.

Stiles (1993 p. 601) suggested that validity in qualitative

studies refers to `trustworthiness' of the theoretical inter-

pretations of ®ndings, here formed into categories. Kvale

(1989 p. 77) stated that to validate is to investigate by

`continually checking, questioning and theoretically

interpreting the ®ndings'. Limitations of the method used

should be stated when evaluating the validity of



phenomenographic research. Intersubjectivity in this

study was reached in the following way. Both the ®rst

and the second author read the narrated stories several

times. Independently of one another, the ®rst and the

second author reached consensus on the categories. SaÈljoÈ

(1997) is critical of the interview as a method for providing

basic data in phenomenographic research, arguing that it

is of importance to discuss the relationship existing

between experience and discourse. Instead of studying a

phenomenon experienced in a number of qualitatively

different ways, the phenomenographic researcher studies

a `number of ways of talking about a phenomenon that is

perceived as relevant in a particular situation', and this

could be called accounting practice (SaÈljoÈ 1997 p. 178).

There is also the risk in phenomenographic research of

making the object of study abstract, when decontextuali-

zing the utterances from their function in communication

and when forming categories of description, which

implies separating the respondent from what he/she has

said (SaÈljoÈ 1997). To avoid making the object of study

abstract in this study, the categories of description have

been explained in relation to discourse. We do not claim

that the ®ndings can be generalized beyond the health care

professionals included in this study.

Implications for practice

The three categories of description emerging in this study

showed that encounters between health care professionals

and patients can be complex in nature and that health care

professionals might need support in trying to understand

those patients whose `way' of expressing experienced

suffering is unknown to the health care professional. One

way of implementing the research ®ndings to help health

care professionals in clinical practice could be through

clinical supervision. In supervision the health care

professionals can express their feelings and thoughts by

re¯ecting on the care provided (Severinsson 1995). The

knowledge arising from phenomenographic research can

also enhance an understanding that health care profes-

sionals working in the same speciality could experience

phenomena in their professional world in different ways,

which also carries implications for multidisciplinary

training in clinical practice.

CONCLUSION

The health care professionals' way of experiencing their

encounters with in- or outpatients in acute medical care

hospitals could be described as follows: a gain in personal

knowledge and understanding of the patients' different

`ways' of communicating experienced suffering; making

the patient feel con®dent and; focusing on the medical

problems, not understanding the patient's different `ways'

of communicating experienced suffering. We conclude for

further research that there is a need to consider the

patients' experiences of their suffering as expressed in the

encounter. There is a need to support health care profes-

sionals in improving their understanding of patients'

suffering.

Acknowledgements

We are grateful to the enrolled nurses, physicians and

registered nurses who participated in this study and to

Gullvi Nilsson for reviewing the English.

Description of health care professionals' experiences of

encounters with patients in clinical settings.

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Documents

A description of health care professionals’ experiences of encounters with patients in clinical settings