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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).
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 1371
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
C.A.S. Takman and E.I. Severinsson
1372 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(6), 1368±1374
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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