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Nursing student–patient relationship: Experiences of students and patients
Nurse Education Today (2005) 25, 344–354
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Nursing student–patient relationship: Experiences of students and patients Arja Suikkala a b c
a,b,*
, Helena Leino-Kilpi
a,c
Department of Nursing Science, University of Turku, Finland Diaconia Polytechnic, Helsinki, Finland Turku University Hospital, Finland
Accepted 15 March 2005
KEYWORDS
Summary This study dealt with nursing students’ and patients’ experiences of their relationship. Qualitative data were collected conducting semi-structured interviews with 30 nursing students and 30 patients on medical wards in Finland. The results, analysed using inductive content analysis, revealed student–patient relationships of three types: mechanistic, authoritative and facilitative relationships. Factors promoting or impeding the relationship were divided into studentrelated factors, patient-related factors, length of time together and atmosphere during activity and were found to influence the type and quality of the relationship. The findings also indicate that the relationship has many positive consequences for both students and patients. The results of the study have implications for nursing, pointing out the important role of both staff nurses and nurse educators in supporting students’ learning about individualised patient-centred care. c 2005 Elsevier Ltd. All rights reserved.
Interpersonal relations; Students; Nursing; Patients
Introduction
Despite the central role the nurse–patient relationship plays in professional practice the relationship between the nursing student and the patient has received little attention in nursing research. Research interest has centred mainly on students’ perspective: their experiences, perceptions of and attitudes towards patients and the * Correspondening author. Present address: Yla ¨-Fallin tie 1 E 24, Fin-00690 Helsinki, Finland. Tel.: +358 50 3500755. E-mail address: [email protected] (A. Suikkala).
caring situation, their interpersonal skills and the effects of teaching methods. Very little attention has been paid to patients’ perspective, their role in students’ clinical learning and students’ involvement in their care. Although there is some literature describing the student–patient relationship, there exist no studies with an emphasis on empirical analysis of this relationship and including both perspectives (Suikkala and Leino-Kilpi, 2001). This study aimed at providing insight into the student–patient relationship by describing: (a) the main features of the relationship, (b) activities
0260-6917/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2005.03.001
Nursing student–patient relationship: Experiences of students and patients and actors in the relationship, (c) factors associated with the relationship, and (d) the consequences of the relationship for both students and patients. In collecting information, it is important to include the viewpoints of both students and patients as both of them can be assumed to benefit from the relationship.
Background The central importance of the nurse–patient relationship in nursing care should be emphasized in clinical learning. Although the nurse directs the process, the content of the relationship is patient driven and aims at helping the patient to improve skills in meeting problems and in becoming an autonomous individual (e.g., Peplau, 1988; Gastmans, 1998; see also Leino-Kilpi, 1991). Literature searches from the MEDLINE and CINAHL databases for the 1984–2003 period, using the keywords ‘nurse–patient relations’, ‘nursing students’ and ‘student–patient relations’, yielded few studies that dealt with student–patient relationships, with varying levels of involvement. These studies were descriptive in nature and focused mainly on students’ perspective; the relationship was shown to be associated with students’ professional growth and development (Beck, 1992; Beck, 1993; Seed, 1994). In these encounters, students moved along the novice to expert continuum from being mechanistic and closely focused on doing tasks to having a wider focus seeing the patient as a person (Johnson, 1994; Seed, 1994). Students’ caring actions that took place in a nursing context and were enacted through relationships fostered the development of patient relationships so as to enable students not just to see the patient in an individual personal sense but also take appropriate action in a professional technical sense (Wilkes and Wallis, 1998). Twinn (1995) focused on clients’ perspective in student learning and found that they had different, mutually supporting and more relaxed relationships with students, compared to those with staff. According to her, clients’ willingness and commitment to participate in student learning was based on their perception of students needing clinical experience, especially in practising clinical skills and making clinical judgements. Clients were ambivalent about formally participating in student assessment due to their uncertainty about the criteria used in assessing student performance. A number of factors, such as both students’ and patients’ mutual prejudices and attitudes, have been found to influence the relationship (Morin
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et al., 1999; Granska ¨r et al., 2001; Pattersson and Morin, 2002). Students’ increased confidence in using skills needed to care for patients was quite evidently prerequisite to being able to care about them. Through knowing patients as individuals students gained insight into patients’ circumstances, needs and desires and could provide patientfocused nursing care (Seed, 1994; Fagerberg and Kihlgren, 2001; White, 2003). Also, students’ awareness of their own feelings was important in creating a helping relationship (Johnson, 1994). Further factors worth noting are the importance of staff nurses as role models and their support and guidance (Fagerberg and Kihlgren, 2001; Kotecki, 2002; White, 2003) as well as factors related to ward routines (Seed, 1994; Tuohy, 2002). Students’ progress in acquiring competence through relationships increased their self-esteem and confidence in undertaking the tasks assigned to them and led to more positive perceptions and attitudes (Beck, 1992; Beck, 1993; Seed, 1994; White, 2003). Also, patients seemed to benefit from the therapeutic and social interaction with students (Richards, 1993; Twinn, 1995).
Methods Data collection The participants were a purposive sample of nursing students (n = 30) and patients (n = 30) from one university hospital in Finland. The students were receiving practical training in eight medical wards where the patients stayed for three or more days. All students were studying in a 3.5-year polytechnic degree programme (Bachelor level), which includes basic and professional studies, optional studies, clinical placements and a diploma project consisting of 140 credit units (Ministry of Education, 2000). The clinical placements account for 36–40% of the total education programme. The selection of students and patients was based on the assumption of good informants on the subject matter (Coyne, 1997). Ward managers acted as contact persons and asked, both orally and in an informative letter, about informants’ willingness to participate in the research. The inclusion criterion for the students was that their clinical placement coincided with the interviewed patients’ stay on the ward. Patients were selected if they had experience of students, agreed to participate and were physically and mentally capable of being interviewed. After obtaining written consent, an appointment with the interviewer (AS)
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was made, the study was re-explained and possible questions were answered. Approval from the principals of four polytechnics and the hospital ethics committee was obtained. All students and patients taking part in the study were informed about the aims of the study. Anonymity and confidentiality, as well as the right to interrupt participation in the interview at any time, were guaranteed (Polit and Hungler, 1995). The semi-structured interview used was designed for purposes of this study, based on a literature review (Suikkala and Leino-Kilpi, 2001), and consisted of four themes: main features of the relationship, activities and actors in the relationship, factors associated with the relationship, and consequences of the relationship. The audiotaped interviews were conducted on the wards in a separate room or a patient room in agreement with the participants. Each participant was interviewed once for approximately 1 h (range 30–105 min). A memo was written after each interview to help the researcher plan the next interview and remember the events when analysing data (Catanzaro, 1988).
of a unit of analysis and the context in which a unit of analysis was set in order to categorize it (Berelson, 1952; Holsti, 1969; Catanzaro, 1988; Cavanagh, 1997). The data were organized into themes by culling thoughts and ideas from the text. The themes referring to the same content were grouped into subcategories, drawing comparisons between the data concerning a particular subcategory and other observations. Related subcategories were combined to form categories and, further, main categories (Table 2) (Tesch, 1990; Waltz et al., 1991; Dey, 1993; Robson, 1993).
Interviewees
Main features of the relationship
The mean age of the students was 26 years (range 20–42); 87% of them were women and 40% had some previous professional qualification. Most (77%) were second-year students; 5 were first-year and only 2 third-year students. The mean duration of the clinical placements was 5 weeks (range 3– 8). The students had a relationship with an average of 10 patients (range 2–30) according to their own estimations. The mean age of the patients was 68 years (range 40–90); 66% of them were women and 57% had no vocational education. The mean duration of the hospital stays was 7 days, ranging from 1 day to 3 weeks. Many patients had been on the same ward several times before. The average number of student relationships reported by the patients was 2 (range 1–10).
In a mechanistic relationship students focused on their own learning needs, intent on acquiring knowledge and technical skills. This relationship, in which students bore no responsibility, was externally directed by daily routines and supervising nurses’ advice and directions for performing physical acts of care. Students and patients did not know each other and there was no, or very little and task-related, interaction between them. In an authoritative relationship the focus was on what students assumed to be the best for the patients. Even though it was possible for patients to make decisions and direct care, the relationship was governed by students’ initiative and their perceptions and knowledge of patients’ needs and of problem-solving methods. Knowing each other superficially meant that students did not know patients well enough to act in a patient-oriented way. Patients knew students by name and were interested in getting to know them personally. Interaction, initiated by either party, was related to patients’ needs, care and instruction and also had characteristics of informal conversation. A facilitative relationship was characterized by mutuality, focusing on the common good for both students and patients. Shared views concerning action were based on co-operation in which equality, respect and appreciation, mutual encouragement,
Data analysis The interviews, transcribed verbatim, were analysed using qualitative content analysis. The data were analysed inductively and the categories were constructed directly from the data (Table 1). In coding the data the unit of analysis was a complete idea or thought, ranging from a single word to several sentences related to the content
Results There emerged three types of relationships, which were, in ascending order of involvement: mechanistic relationship, authoritative relationship and facilitative relationship. Consideration will at first be given to the main features of the relationship, then to the activities and actors in the relationship (see Table 2), factors associated with the relationship and its consequences.
Example of the content analysis process, considering the main features of one of the main categories: facilitative relationship
Quotations
Theme
Subcategory
Category
Main category
‘‘I understand what patients say and they understand me’’ ‘‘We both are quite similar people’’
Reciprocity
Common good of both student and patient
Facilitative relationship
‘‘I do as I’d like to be done to myself’’
Mutual understanding Being at the same level Respect for each other Patient being inspired by student Charity
‘‘I always try to think what’s the best for the patient’’
Acting in patient’s interest
‘‘Adult patients can themselves decide about their own care’’
Patient making decisions concerning own care
‘‘I’ve got to know my primary nurse student’’ ‘‘I’ve got to know my patient very well’’
‘‘The sort of relationship in which both respect each other’’ ‘‘The student inspires the patient’’
‘‘I feel a little sad when the patient leaves’’ ‘‘I really look forward to her smile and greeting me in the morning’’ ‘‘I always try to be my true self with the patient’’ ‘‘One day I was weeping in the room and the student came when I pressed the call bell and I told her what I need and poured it all out’’ ‘‘There develops a trusting relationship in which both can talk more’’
Equality Respect and appreciation Encouragement Caring Best for patient considering his or her individual needs Active participation by patient
Guided by patient’s expectations and requirements concerning care
Getting to know individual student Getting to know individual patient Student missing patient Patient missing student
Knowing student as a person Knowing patient as a person Attachment
Personally knowing each other
Being oneself
Genuineness
Expressing feelings
Conversation dealing with personal and emotional issues
Open and confidential interaction
Confiding
Conversation including confidential information
Nursing student–patient relationship: Experiences of students and patients
Table 1
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Table 2
Student–patient relationship: main categories, categories and subcategories
Characteristics of relationship: categories and subcategories Main features of the relationship
Activities and actors in the relationship Student
Type of relationship: main categories Authoritative relationship
Facilitative relationship
Focus on student’s learning Acquiring knowledge Acquiring technical skills
Student’s assumptions about what is best for patient Student’s knowledge of good care Student’s values concerning care
Common good of both student and patient Reciprocity Equality Respect and appreciation Encouragement Caring
Directed externally according to staff nurses’ routines Tasks performed according to daily routines Delivery of care under direct supervision Performance of tasks as ordered by nurses
Directed by student’s perceptions of patient needs and care methods Student’s initiative in patient care Patient needs assessed by student Patient care planned and decisions taken by student
Directed by patient’s expectations and requirements of care Best for patient considering his or her individual needs Active participation by patient
Not knowing each other Patient not knowing student Patient not recalling student’s name Student not knowing patient Student not knowing patient’s problems
Knowing each other superficially Patient knowing student by name and sight Student knowing patient in terms of certain health problem Little emotional involvement
Knowing each other personally Patient knowing student as a person Student knowing patient as a person Attachment
Perfunctory interaction Conversation between supervising nurse and student Conversation between supervising nurse and patient Limited conversation about tasks performed
Talking centred on care issues and some chatting Conversation dealing with facts Conversation dealing with practical issues Conversation dealing with issues of everyday character
Open and confidential interaction Genuineness Conversation dealing with personal and emotional issues Conversation including confidential information
Observes role models and follows nurses’ advice Acts as an observer Regards nurses as role models Listens to nurses’ explanations Acts according to nurses’ orders and directions
Plans and provides care and patient education Acts as a helper Collects information Makes decisions Attends to patient’s needs Acts as an advisor Discusses Answers questions Gives information Clarifies Teaches Gives advice
Attentive to patient’s wishes and needs and acts according to them Acts as a listener Gives consideration to patient’s personal opinions, wishes and needs Responds to requests Acts as an advocator authorized by patient
Practises technical skills by performing tasks Acts as a technical skills trainee Concentrates on technical performance Performs single tasks or sets of tasks Attends promptly to patient’s physical needs
Activates patient Coaxes Motivates
Supports patient’s use of own resources Reassures Comforts Encourages Is attentive with regard to patient’s feelings and concerns
A. Suikkala, H. Leino-Kilpi
Mechanistic relationship
Contributes to student’s learning Acts as student’s learning resource Gives orders and directions to student Gives feedback Encourages student
Directs own care as concerns own health and care Acts as an expert in own care Expresses wishes and needs related to care Expresses feelings, thoughts and concerns Takes an active part in care and decision making
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caring and empathy were evident. The relationship was governed by patients’ expectations and requirements of care. Patients’ active involvement in and sense of responsibility for their own care and the feedback given by them guided nursing care. Students and patients knew each other personally and the relationship was described as warm and close with mutual attachment and encouraging humour. The relationship was based on a genuine interest in each other as individuals and, through the open and confidential interaction, offered patients an opportunity to work through their own feelings.
Patient
Observes student’s actions as an outsider Acts as a passive object of performed tasks Is an outside observer of student’s care activities Does not participate in care activities
Participates in care by asking for help or advice Tells student about health problems Asks for help Asks for advice
Expresses no opinions concerning care Acts as a recipient of care and advice Does not give orders or directions Expects student to make decisions
Activities and actors in the relationship In a mechanistic relationship students were passive observers listening to nurses’ explanations and regarding nurses as role models. Further, they were active trainees of technical skills, concentrating on performing single tasks or sets of tasks well according either to nurses’ orders or to a nursing plan, with a nurse or on their own. Patients were passive objects benefiting from the activity with whom students practised technical skills. Patients were excluded and had the role of outsiders quietly observing students’ actions. In an authoritative relationship students were patients’ active helpers and advisors, having the expertise and know-how needed for planning and carrying out patient care and clarifying matters with patients. Students’ efforts to act in a patient-oriented way involved collection of information, through discussions with patients, about their condition, help needed and effectiveness of care. Students helped patients meet their needs and taught them to solve problems by giving information, advice and answers to their questions and activated them by coaxing and motivating. Despite the opportunities to guide their own care, patients were passive recipients of help and advice who did not express their own opinions concerning care, or the preconditions for doing so did not yet exist. Patients’ activity involved asking for help and advice concerning health and care, while students were expected to make the decisions. In a facilitative relationship students were listeners and advocators who showed a genuine interest in and understanding of patients’ welfare by giving consideration to patients’ personal opinions and wishes and responding to their requests. Students supported patients’ use of their own resources by relating to them gently and empathically and giving comfort and encouragement. As
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patients’ advocators students communicated patient-related information to other team members. Patients as experts in their own well-being had an active and responsible role in care and decisionmaking insofar as allowed by their resources. As a learning resource, patients advised students on issues related to illness and care and gave them positive and encouraging, though quite subjective, feedback.
Factors associated with the relationship The categories of the factors with a promoting or an impeding effect on the establishment of a well-functioning relationship were student-related factors, patient-related factors, length of time spent together and atmosphere during the activity (Table 3). Successful outcome in terms of a well-functioning relationship was associated with students’ interest in patients, personality traits characterized by a predominantly positive frame of mind, combined with a high self-esteem and an ability to cope with feelings, an accepting and respectful attitude towards patients and realistic, humanoriented learning objectives. Other promoting factors included students’ previous qualification and theoretical and practical knowledge and skills. Extroverted patients with a positive disposition and feelings and those recovering well, capable
Table 3
of self-care and compliant with treatment were seen as ideal patients. Positive and unprejudiced attitudes towards students and their know-how were also seen as promoting factors. Long clinical placements of students and long stays of patients on the ward as well as the primary nursing system offered an opportunity to spend enough time together to develop a good relationship. Good role models offered by staff nurses and their supportive supervision and encouraging feedback were mentioned as preconditions for successful patient relationships. Impeding factors were contrary to promoting ones or consisted in an absence of the latter. Students’ personality characterized by shyness and reticence, negativity combined with a low self-esteem and an inability to deal with feelings and stress, negative or stereotyped attitudes towards patients or caring situations and task-orientated learning objectives had impeding effects on the relationship. Lack of knowledge, skills and experience, manifested as a fear of failure and of harming patients, also had an impeding effect. Further factors seen as impeding were introversion and negativity in patients. Relational problems also occurred with seriously ill patients and patients in pain, or with mental or social problems or problems of intimate nature. Patients’ negative or stereotyped attitudes towards students and their know-how and patients’ inability to accept their illness and non-compliance were seen as
Factors promoting or impeding good student–patient relationships
Promoting factors
Impeding factors
Student-related factors Personality characterized by positive frame of mind Positive expectations and attitudes Intellectual and interpersonal competence
Student-related factors Personality showing tendency to negativity Negative or stereotyped expectations and attitudes Lack of intellectual and interpersonal competence
Patient-related factors Personality characterized by positive frame of mind Favourable demographic and diagnostic characteristics Positive expectations and attitudes
Patient-related factors Personality showing tendency to negativity Unfavourable demographic and diagnostic characteristics Negative or stereotyped expectations and attitudes
Length of time together Patients’ long hospital stays Students’ long clinical placements Primary nursing system
Length of time together Patients’ short hospital stays Students’ short clinical placements High workload Functional nursing system
Atmosphere during activity Good role models offered by staff nurses Supportive supervision relationship Positive and encouraging feedback from staff nurses
Atmosphere during activity Bad role models offered by staff nurses Lack of supportive supervision relationship Negative feedback from staff nurses Lack of privacy during patient care
Nursing student–patient relationship: Experiences of students and patients
increased compliance was also mentioned as a positive consequence by some patients.
impeding. Short stays by both students and patients on the ward, high workloads, functional nursing system, unsatisfactory staff nurse-student supervising relationship and lack of privacy in caring situations were also mentioned as impeding factors.
Discussion The aim of the study was to provide insight into the nature of nursing student–patient relationships. The data were collected using a semi-structured interview. A sample size of 30 students and 30 patients was estimated as adequate for saturation of data. This was reached, similar matters becoming repetitive in the last interviews (Catanzaro, 1988). The results of this study are largely consistent with those found in previous research. Firstly, earlier studies have shown that there is a shift in students’ relationships with patients from observation and practising of technical skills and seeing patients as objects towards regarding them as individuals and the relationship as one in which both parties present themselves as they really are, accepting each other with their potentialities and limitations (Sadala, 1999; Kotecki, 2002). It seems that knowing each other personally and a reciprocal connection (Beck, 1992; Twinn, 1995; White, 2003) with mutual respect, trust and equality (Granska ¨r et al., 2001) are essential for development of a facilitative relationship. Secondly, the patients in our study had quite a passive role in relationships with students. Few patients take the opportunity to direct their care or contribute to students’ learning (Morgan and
Consequences of the relationship The relationship had mostly positive consequences for both students and patients (Table 4). Students’ personal and professional growth was described as increased maturity as human beings and as nurses and as development of their personal and professional values. Students’ improved competence was reflected in higher levels of skills and theoretical and practical knowledge in nursing. Their feelings of having succeeded in the areas of knowledge, skills and patient relationships as well as their strengthened career motivation with trust in their own abilities and appreciation for their own role in nursing were related to increased confidence and self-esteem. Despite many positive consequences, feelings of failure because of lack of competence were also evident among some students. The relationship had positive consequences for patients’ state of health and self-care, also seen as their satisfaction with students’ genuine presence and with the help and assistance given whenever needed to make them feel physically and mentally well. A more rapid recovery through
Table 4
Consequencies of the relationships
Positive consequencies
Negative consequencies
Student’s personal and professional growth Growing as human being and nurse Development of personal and professional values Improved know-how in individualized patient care, technical skills, communication and co-operation with individual patient Expanded theoretical knowledge base
Student’s feelings of failure Feelings of not having succeeded in technical skills and know-how Feelings of not having succeeded in interpersonal skills with patients
Student’s increased confidence and self-esteem Feelings of success regarding knowledge and skills Feelings of success regarding patient relationships Trust in own abilities and possibilities Strengthened motivation for nursing as career Increased appreciation of own role in nursing Patient’s improved state of health and self-care Satisfaction with student’s genuine presence Being helped whenever needed More rapid recovery through increased compliance
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–
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352 Sanggaran, 1997; Hills, 1998; White, 2003). However, some are willing to participate in students’ assessment, although many feel it difficult to give negative feedback to students (Twinn, 1995) or lack the necessary professional background for making such assessments (Andresen and McDermott, 1992). In addition, mechanistically or authoritatively performed interventions by staff nurses and students often seem to gain undue predominance in the relationship and hamper the development of individual and patient-centred relationships. Thirdly, the relationship was influenced by student-related and patient-related factors, length of time spent together and atmosphere during activity. The relationship seems to be largely determined by students’ and patients’ preconceptions and stereotypes about one another (see Peplau, 1997) and needs, desires and personal qualities of both of them (Morse, 1991). For instance, students’ characteristics and modes of professional behaviour and patients’ perception of personal self and their personal feelings are associated with the nature of the relationship established and of nursing care activities (Morin et al., 1999). Lack of confidence and the newness of the experience cause students uncertainty, limiting the action taken (see Cooke, 1996; Fagerberg and Ekman, 1997; Sadala, 1999; Hjo ¨rleifsdo ´ttir and Carter, 2000; Allcock and Standen, 2001; Granska ¨r et al., 2001; Tuohy, 2002). Students can indeed either centre exclusively on satisfying their personal learning needs, or focus on patients’ needs and expectations (Granska ¨r et al., 2001). Patients’ willingness to contribute to students’ learning seems to involve giving students an opportunity to gain clinical experience; some ambivalence has been found in this willingness, however (Twinn, 1995). In addition to efforts to overcome obstacles to a good relationship, long clinical placements (Richards, 1993) and the support and encouragement given by staff nurses (Dunn and Hansford, 1997; Fagerberg and Kihlgren, 2001; Kotecki, 2002; White, 2003) have been seen as important. Finally, the relationship has many positive consequences for both students and patients. It gives students an opportunity for personal and professional growth as students gain confidence in encountering the patient instead of just following rules or acting according to routines (Beck, 1992; Beck, 1993; Arnold, 1997; Granska ¨r et al., 2001; White, 2003), learn to accept their limitations and find meaning in their own lives (Eifried, 2003). Students’ role in promoting patients’ recovery and capability for self-care by showing an accepting attitude towards and a genuine interest in patients and giving them advice and instructions
A. Suikkala, H. Leino-Kilpi has also been pointed out by Twinn (1995) and Sadala (1999). There are no generally agreed ways to establish the credibility of qualitative research findings. In this study, the trustworthiness of the research process was established by estimating its confirmability, dependability, credibility and transferability (Catanzaro, 1988; Robson, 1993; Miles and Huberman, 1994; Marshall and Rossman, 1995). Each stage of the research process was documented. The first author collected and analysed the data from the tape-recorded interviews, transcribed verbatim, trying to maintain a neutral stance during these stages. The results of the analysis were confirmed by coding the data twice, at different points in time (Berelson, 1952; Appleton, 1995; Krippendorff, 1980). The investigator, an outsider in the organisation, was acquainted with the subject matter, which contributed to the creation of a confidential atmosphere and to understanding of the context of the research setting (Patton, 1990). However, interviewees might have reported things they assumed the investigator expected to hear instead of revealing their own thoughts. Feedback from informants could have been used to ensure creditability, but this was not feasible (Catanzaro, 1988; Appleton, 1995). The conclusion of transferability to other similar contexts can be made, based on the descriptions of the sample, settings and processes (Robson, 1993; Miles and Huberman, 1994). In generalizing the study findings, cultural differences must be considered. Although a more heterogeneous sample could have yielded different findings, the present results can be considered to have a wider relevance with respect also to other clinical contexts.
Conclusions The present findings have implications for clinical learning, as concerns particularly students’ relationships with patients. Nurse educators and staff nurses can use the information in mentoring students in interpersonal relations, with patients being involved in both learning and treatment. Taking factors associated with the relationship into account contributes to students’ progress towards individual-oriented nursing practice. Further research is needed to obtain more information about the nursing student–patient relationship and its connections with learning and nursing. The next step would be to test the categories that emerged from this study by using a quantitative approach. Research in other
Nursing student–patient relationship: Experiences of students and patients clinical areas could offer a more complete view of the relationship. It would also be important to investigate how high in order of importance interpersonal relationships are ranked by students and supervising staff nurses.
Acknowledgements The authors thank all students and patients who volunteered to participate in this study. Funding for this study was received from the Finnish Nurses Association, the Foundation of Nursing Education and the OKKA Foundation.
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354 Seed, A., 1994. Patients to people. Journal of Advanced Nursing 19 (4), 738–748. Suikkala, A., Leino-Kilpi, H., 2001. Nursing student–patient relationship: a review of the literature from 1984 to 1998. Journal of Advanced Nursing 33 (1), 42–50. Tesch, R., 1990. Qualitative Research: Analysis Types and Software Tools. Falmer Press, London. Tuohy, D., 2002. Student nurse–older person communication. Nurse Education Today 23 (1), 19–26. Twinn, S.F., 1995. Creating reality or contributing to confusion? An exploratory study of client participation
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Nurse Education Today intl.elsevierhealth.com/journals/nedt
Nursing student–patient relationship: Experiences of students and patients Arja Suikkala a b c
a,b,*
, Helena Leino-Kilpi
a,c
Department of Nursing Science, University of Turku, Finland Diaconia Polytechnic, Helsinki, Finland Turku University Hospital, Finland
Accepted 15 March 2005
KEYWORDS
Summary This study dealt with nursing students’ and patients’ experiences of their relationship. Qualitative data were collected conducting semi-structured interviews with 30 nursing students and 30 patients on medical wards in Finland. The results, analysed using inductive content analysis, revealed student–patient relationships of three types: mechanistic, authoritative and facilitative relationships. Factors promoting or impeding the relationship were divided into studentrelated factors, patient-related factors, length of time together and atmosphere during activity and were found to influence the type and quality of the relationship. The findings also indicate that the relationship has many positive consequences for both students and patients. The results of the study have implications for nursing, pointing out the important role of both staff nurses and nurse educators in supporting students’ learning about individualised patient-centred care. c 2005 Elsevier Ltd. All rights reserved.
Interpersonal relations; Students; Nursing; Patients
Introduction
Despite the central role the nurse–patient relationship plays in professional practice the relationship between the nursing student and the patient has received little attention in nursing research. Research interest has centred mainly on students’ perspective: their experiences, perceptions of and attitudes towards patients and the * Correspondening author. Present address: Yla ¨-Fallin tie 1 E 24, Fin-00690 Helsinki, Finland. Tel.: +358 50 3500755. E-mail address: [email protected] (A. Suikkala).
caring situation, their interpersonal skills and the effects of teaching methods. Very little attention has been paid to patients’ perspective, their role in students’ clinical learning and students’ involvement in their care. Although there is some literature describing the student–patient relationship, there exist no studies with an emphasis on empirical analysis of this relationship and including both perspectives (Suikkala and Leino-Kilpi, 2001). This study aimed at providing insight into the student–patient relationship by describing: (a) the main features of the relationship, (b) activities
0260-6917/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2005.03.001
Nursing student–patient relationship: Experiences of students and patients and actors in the relationship, (c) factors associated with the relationship, and (d) the consequences of the relationship for both students and patients. In collecting information, it is important to include the viewpoints of both students and patients as both of them can be assumed to benefit from the relationship.
Background The central importance of the nurse–patient relationship in nursing care should be emphasized in clinical learning. Although the nurse directs the process, the content of the relationship is patient driven and aims at helping the patient to improve skills in meeting problems and in becoming an autonomous individual (e.g., Peplau, 1988; Gastmans, 1998; see also Leino-Kilpi, 1991). Literature searches from the MEDLINE and CINAHL databases for the 1984–2003 period, using the keywords ‘nurse–patient relations’, ‘nursing students’ and ‘student–patient relations’, yielded few studies that dealt with student–patient relationships, with varying levels of involvement. These studies were descriptive in nature and focused mainly on students’ perspective; the relationship was shown to be associated with students’ professional growth and development (Beck, 1992; Beck, 1993; Seed, 1994). In these encounters, students moved along the novice to expert continuum from being mechanistic and closely focused on doing tasks to having a wider focus seeing the patient as a person (Johnson, 1994; Seed, 1994). Students’ caring actions that took place in a nursing context and were enacted through relationships fostered the development of patient relationships so as to enable students not just to see the patient in an individual personal sense but also take appropriate action in a professional technical sense (Wilkes and Wallis, 1998). Twinn (1995) focused on clients’ perspective in student learning and found that they had different, mutually supporting and more relaxed relationships with students, compared to those with staff. According to her, clients’ willingness and commitment to participate in student learning was based on their perception of students needing clinical experience, especially in practising clinical skills and making clinical judgements. Clients were ambivalent about formally participating in student assessment due to their uncertainty about the criteria used in assessing student performance. A number of factors, such as both students’ and patients’ mutual prejudices and attitudes, have been found to influence the relationship (Morin
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et al., 1999; Granska ¨r et al., 2001; Pattersson and Morin, 2002). Students’ increased confidence in using skills needed to care for patients was quite evidently prerequisite to being able to care about them. Through knowing patients as individuals students gained insight into patients’ circumstances, needs and desires and could provide patientfocused nursing care (Seed, 1994; Fagerberg and Kihlgren, 2001; White, 2003). Also, students’ awareness of their own feelings was important in creating a helping relationship (Johnson, 1994). Further factors worth noting are the importance of staff nurses as role models and their support and guidance (Fagerberg and Kihlgren, 2001; Kotecki, 2002; White, 2003) as well as factors related to ward routines (Seed, 1994; Tuohy, 2002). Students’ progress in acquiring competence through relationships increased their self-esteem and confidence in undertaking the tasks assigned to them and led to more positive perceptions and attitudes (Beck, 1992; Beck, 1993; Seed, 1994; White, 2003). Also, patients seemed to benefit from the therapeutic and social interaction with students (Richards, 1993; Twinn, 1995).
Methods Data collection The participants were a purposive sample of nursing students (n = 30) and patients (n = 30) from one university hospital in Finland. The students were receiving practical training in eight medical wards where the patients stayed for three or more days. All students were studying in a 3.5-year polytechnic degree programme (Bachelor level), which includes basic and professional studies, optional studies, clinical placements and a diploma project consisting of 140 credit units (Ministry of Education, 2000). The clinical placements account for 36–40% of the total education programme. The selection of students and patients was based on the assumption of good informants on the subject matter (Coyne, 1997). Ward managers acted as contact persons and asked, both orally and in an informative letter, about informants’ willingness to participate in the research. The inclusion criterion for the students was that their clinical placement coincided with the interviewed patients’ stay on the ward. Patients were selected if they had experience of students, agreed to participate and were physically and mentally capable of being interviewed. After obtaining written consent, an appointment with the interviewer (AS)
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was made, the study was re-explained and possible questions were answered. Approval from the principals of four polytechnics and the hospital ethics committee was obtained. All students and patients taking part in the study were informed about the aims of the study. Anonymity and confidentiality, as well as the right to interrupt participation in the interview at any time, were guaranteed (Polit and Hungler, 1995). The semi-structured interview used was designed for purposes of this study, based on a literature review (Suikkala and Leino-Kilpi, 2001), and consisted of four themes: main features of the relationship, activities and actors in the relationship, factors associated with the relationship, and consequences of the relationship. The audiotaped interviews were conducted on the wards in a separate room or a patient room in agreement with the participants. Each participant was interviewed once for approximately 1 h (range 30–105 min). A memo was written after each interview to help the researcher plan the next interview and remember the events when analysing data (Catanzaro, 1988).
of a unit of analysis and the context in which a unit of analysis was set in order to categorize it (Berelson, 1952; Holsti, 1969; Catanzaro, 1988; Cavanagh, 1997). The data were organized into themes by culling thoughts and ideas from the text. The themes referring to the same content were grouped into subcategories, drawing comparisons between the data concerning a particular subcategory and other observations. Related subcategories were combined to form categories and, further, main categories (Table 2) (Tesch, 1990; Waltz et al., 1991; Dey, 1993; Robson, 1993).
Interviewees
Main features of the relationship
The mean age of the students was 26 years (range 20–42); 87% of them were women and 40% had some previous professional qualification. Most (77%) were second-year students; 5 were first-year and only 2 third-year students. The mean duration of the clinical placements was 5 weeks (range 3– 8). The students had a relationship with an average of 10 patients (range 2–30) according to their own estimations. The mean age of the patients was 68 years (range 40–90); 66% of them were women and 57% had no vocational education. The mean duration of the hospital stays was 7 days, ranging from 1 day to 3 weeks. Many patients had been on the same ward several times before. The average number of student relationships reported by the patients was 2 (range 1–10).
In a mechanistic relationship students focused on their own learning needs, intent on acquiring knowledge and technical skills. This relationship, in which students bore no responsibility, was externally directed by daily routines and supervising nurses’ advice and directions for performing physical acts of care. Students and patients did not know each other and there was no, or very little and task-related, interaction between them. In an authoritative relationship the focus was on what students assumed to be the best for the patients. Even though it was possible for patients to make decisions and direct care, the relationship was governed by students’ initiative and their perceptions and knowledge of patients’ needs and of problem-solving methods. Knowing each other superficially meant that students did not know patients well enough to act in a patient-oriented way. Patients knew students by name and were interested in getting to know them personally. Interaction, initiated by either party, was related to patients’ needs, care and instruction and also had characteristics of informal conversation. A facilitative relationship was characterized by mutuality, focusing on the common good for both students and patients. Shared views concerning action were based on co-operation in which equality, respect and appreciation, mutual encouragement,
Data analysis The interviews, transcribed verbatim, were analysed using qualitative content analysis. The data were analysed inductively and the categories were constructed directly from the data (Table 1). In coding the data the unit of analysis was a complete idea or thought, ranging from a single word to several sentences related to the content
Results There emerged three types of relationships, which were, in ascending order of involvement: mechanistic relationship, authoritative relationship and facilitative relationship. Consideration will at first be given to the main features of the relationship, then to the activities and actors in the relationship (see Table 2), factors associated with the relationship and its consequences.
Example of the content analysis process, considering the main features of one of the main categories: facilitative relationship
Quotations
Theme
Subcategory
Category
Main category
‘‘I understand what patients say and they understand me’’ ‘‘We both are quite similar people’’
Reciprocity
Common good of both student and patient
Facilitative relationship
‘‘I do as I’d like to be done to myself’’
Mutual understanding Being at the same level Respect for each other Patient being inspired by student Charity
‘‘I always try to think what’s the best for the patient’’
Acting in patient’s interest
‘‘Adult patients can themselves decide about their own care’’
Patient making decisions concerning own care
‘‘I’ve got to know my primary nurse student’’ ‘‘I’ve got to know my patient very well’’
‘‘The sort of relationship in which both respect each other’’ ‘‘The student inspires the patient’’
‘‘I feel a little sad when the patient leaves’’ ‘‘I really look forward to her smile and greeting me in the morning’’ ‘‘I always try to be my true self with the patient’’ ‘‘One day I was weeping in the room and the student came when I pressed the call bell and I told her what I need and poured it all out’’ ‘‘There develops a trusting relationship in which both can talk more’’
Equality Respect and appreciation Encouragement Caring Best for patient considering his or her individual needs Active participation by patient
Guided by patient’s expectations and requirements concerning care
Getting to know individual student Getting to know individual patient Student missing patient Patient missing student
Knowing student as a person Knowing patient as a person Attachment
Personally knowing each other
Being oneself
Genuineness
Expressing feelings
Conversation dealing with personal and emotional issues
Open and confidential interaction
Confiding
Conversation including confidential information
Nursing student–patient relationship: Experiences of students and patients
Table 1
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Table 2
Student–patient relationship: main categories, categories and subcategories
Characteristics of relationship: categories and subcategories Main features of the relationship
Activities and actors in the relationship Student
Type of relationship: main categories Authoritative relationship
Facilitative relationship
Focus on student’s learning Acquiring knowledge Acquiring technical skills
Student’s assumptions about what is best for patient Student’s knowledge of good care Student’s values concerning care
Common good of both student and patient Reciprocity Equality Respect and appreciation Encouragement Caring
Directed externally according to staff nurses’ routines Tasks performed according to daily routines Delivery of care under direct supervision Performance of tasks as ordered by nurses
Directed by student’s perceptions of patient needs and care methods Student’s initiative in patient care Patient needs assessed by student Patient care planned and decisions taken by student
Directed by patient’s expectations and requirements of care Best for patient considering his or her individual needs Active participation by patient
Not knowing each other Patient not knowing student Patient not recalling student’s name Student not knowing patient Student not knowing patient’s problems
Knowing each other superficially Patient knowing student by name and sight Student knowing patient in terms of certain health problem Little emotional involvement
Knowing each other personally Patient knowing student as a person Student knowing patient as a person Attachment
Perfunctory interaction Conversation between supervising nurse and student Conversation between supervising nurse and patient Limited conversation about tasks performed
Talking centred on care issues and some chatting Conversation dealing with facts Conversation dealing with practical issues Conversation dealing with issues of everyday character
Open and confidential interaction Genuineness Conversation dealing with personal and emotional issues Conversation including confidential information
Observes role models and follows nurses’ advice Acts as an observer Regards nurses as role models Listens to nurses’ explanations Acts according to nurses’ orders and directions
Plans and provides care and patient education Acts as a helper Collects information Makes decisions Attends to patient’s needs Acts as an advisor Discusses Answers questions Gives information Clarifies Teaches Gives advice
Attentive to patient’s wishes and needs and acts according to them Acts as a listener Gives consideration to patient’s personal opinions, wishes and needs Responds to requests Acts as an advocator authorized by patient
Practises technical skills by performing tasks Acts as a technical skills trainee Concentrates on technical performance Performs single tasks or sets of tasks Attends promptly to patient’s physical needs
Activates patient Coaxes Motivates
Supports patient’s use of own resources Reassures Comforts Encourages Is attentive with regard to patient’s feelings and concerns
A. Suikkala, H. Leino-Kilpi
Mechanistic relationship
Contributes to student’s learning Acts as student’s learning resource Gives orders and directions to student Gives feedback Encourages student
Directs own care as concerns own health and care Acts as an expert in own care Expresses wishes and needs related to care Expresses feelings, thoughts and concerns Takes an active part in care and decision making
Nursing student–patient relationship: Experiences of students and patients
349
caring and empathy were evident. The relationship was governed by patients’ expectations and requirements of care. Patients’ active involvement in and sense of responsibility for their own care and the feedback given by them guided nursing care. Students and patients knew each other personally and the relationship was described as warm and close with mutual attachment and encouraging humour. The relationship was based on a genuine interest in each other as individuals and, through the open and confidential interaction, offered patients an opportunity to work through their own feelings.
Patient
Observes student’s actions as an outsider Acts as a passive object of performed tasks Is an outside observer of student’s care activities Does not participate in care activities
Participates in care by asking for help or advice Tells student about health problems Asks for help Asks for advice
Expresses no opinions concerning care Acts as a recipient of care and advice Does not give orders or directions Expects student to make decisions
Activities and actors in the relationship In a mechanistic relationship students were passive observers listening to nurses’ explanations and regarding nurses as role models. Further, they were active trainees of technical skills, concentrating on performing single tasks or sets of tasks well according either to nurses’ orders or to a nursing plan, with a nurse or on their own. Patients were passive objects benefiting from the activity with whom students practised technical skills. Patients were excluded and had the role of outsiders quietly observing students’ actions. In an authoritative relationship students were patients’ active helpers and advisors, having the expertise and know-how needed for planning and carrying out patient care and clarifying matters with patients. Students’ efforts to act in a patient-oriented way involved collection of information, through discussions with patients, about their condition, help needed and effectiveness of care. Students helped patients meet their needs and taught them to solve problems by giving information, advice and answers to their questions and activated them by coaxing and motivating. Despite the opportunities to guide their own care, patients were passive recipients of help and advice who did not express their own opinions concerning care, or the preconditions for doing so did not yet exist. Patients’ activity involved asking for help and advice concerning health and care, while students were expected to make the decisions. In a facilitative relationship students were listeners and advocators who showed a genuine interest in and understanding of patients’ welfare by giving consideration to patients’ personal opinions and wishes and responding to their requests. Students supported patients’ use of their own resources by relating to them gently and empathically and giving comfort and encouragement. As
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patients’ advocators students communicated patient-related information to other team members. Patients as experts in their own well-being had an active and responsible role in care and decisionmaking insofar as allowed by their resources. As a learning resource, patients advised students on issues related to illness and care and gave them positive and encouraging, though quite subjective, feedback.
Factors associated with the relationship The categories of the factors with a promoting or an impeding effect on the establishment of a well-functioning relationship were student-related factors, patient-related factors, length of time spent together and atmosphere during the activity (Table 3). Successful outcome in terms of a well-functioning relationship was associated with students’ interest in patients, personality traits characterized by a predominantly positive frame of mind, combined with a high self-esteem and an ability to cope with feelings, an accepting and respectful attitude towards patients and realistic, humanoriented learning objectives. Other promoting factors included students’ previous qualification and theoretical and practical knowledge and skills. Extroverted patients with a positive disposition and feelings and those recovering well, capable
Table 3
of self-care and compliant with treatment were seen as ideal patients. Positive and unprejudiced attitudes towards students and their know-how were also seen as promoting factors. Long clinical placements of students and long stays of patients on the ward as well as the primary nursing system offered an opportunity to spend enough time together to develop a good relationship. Good role models offered by staff nurses and their supportive supervision and encouraging feedback were mentioned as preconditions for successful patient relationships. Impeding factors were contrary to promoting ones or consisted in an absence of the latter. Students’ personality characterized by shyness and reticence, negativity combined with a low self-esteem and an inability to deal with feelings and stress, negative or stereotyped attitudes towards patients or caring situations and task-orientated learning objectives had impeding effects on the relationship. Lack of knowledge, skills and experience, manifested as a fear of failure and of harming patients, also had an impeding effect. Further factors seen as impeding were introversion and negativity in patients. Relational problems also occurred with seriously ill patients and patients in pain, or with mental or social problems or problems of intimate nature. Patients’ negative or stereotyped attitudes towards students and their know-how and patients’ inability to accept their illness and non-compliance were seen as
Factors promoting or impeding good student–patient relationships
Promoting factors
Impeding factors
Student-related factors Personality characterized by positive frame of mind Positive expectations and attitudes Intellectual and interpersonal competence
Student-related factors Personality showing tendency to negativity Negative or stereotyped expectations and attitudes Lack of intellectual and interpersonal competence
Patient-related factors Personality characterized by positive frame of mind Favourable demographic and diagnostic characteristics Positive expectations and attitudes
Patient-related factors Personality showing tendency to negativity Unfavourable demographic and diagnostic characteristics Negative or stereotyped expectations and attitudes
Length of time together Patients’ long hospital stays Students’ long clinical placements Primary nursing system
Length of time together Patients’ short hospital stays Students’ short clinical placements High workload Functional nursing system
Atmosphere during activity Good role models offered by staff nurses Supportive supervision relationship Positive and encouraging feedback from staff nurses
Atmosphere during activity Bad role models offered by staff nurses Lack of supportive supervision relationship Negative feedback from staff nurses Lack of privacy during patient care
Nursing student–patient relationship: Experiences of students and patients
increased compliance was also mentioned as a positive consequence by some patients.
impeding. Short stays by both students and patients on the ward, high workloads, functional nursing system, unsatisfactory staff nurse-student supervising relationship and lack of privacy in caring situations were also mentioned as impeding factors.
Discussion The aim of the study was to provide insight into the nature of nursing student–patient relationships. The data were collected using a semi-structured interview. A sample size of 30 students and 30 patients was estimated as adequate for saturation of data. This was reached, similar matters becoming repetitive in the last interviews (Catanzaro, 1988). The results of this study are largely consistent with those found in previous research. Firstly, earlier studies have shown that there is a shift in students’ relationships with patients from observation and practising of technical skills and seeing patients as objects towards regarding them as individuals and the relationship as one in which both parties present themselves as they really are, accepting each other with their potentialities and limitations (Sadala, 1999; Kotecki, 2002). It seems that knowing each other personally and a reciprocal connection (Beck, 1992; Twinn, 1995; White, 2003) with mutual respect, trust and equality (Granska ¨r et al., 2001) are essential for development of a facilitative relationship. Secondly, the patients in our study had quite a passive role in relationships with students. Few patients take the opportunity to direct their care or contribute to students’ learning (Morgan and
Consequences of the relationship The relationship had mostly positive consequences for both students and patients (Table 4). Students’ personal and professional growth was described as increased maturity as human beings and as nurses and as development of their personal and professional values. Students’ improved competence was reflected in higher levels of skills and theoretical and practical knowledge in nursing. Their feelings of having succeeded in the areas of knowledge, skills and patient relationships as well as their strengthened career motivation with trust in their own abilities and appreciation for their own role in nursing were related to increased confidence and self-esteem. Despite many positive consequences, feelings of failure because of lack of competence were also evident among some students. The relationship had positive consequences for patients’ state of health and self-care, also seen as their satisfaction with students’ genuine presence and with the help and assistance given whenever needed to make them feel physically and mentally well. A more rapid recovery through
Table 4
Consequencies of the relationships
Positive consequencies
Negative consequencies
Student’s personal and professional growth Growing as human being and nurse Development of personal and professional values Improved know-how in individualized patient care, technical skills, communication and co-operation with individual patient Expanded theoretical knowledge base
Student’s feelings of failure Feelings of not having succeeded in technical skills and know-how Feelings of not having succeeded in interpersonal skills with patients
Student’s increased confidence and self-esteem Feelings of success regarding knowledge and skills Feelings of success regarding patient relationships Trust in own abilities and possibilities Strengthened motivation for nursing as career Increased appreciation of own role in nursing Patient’s improved state of health and self-care Satisfaction with student’s genuine presence Being helped whenever needed More rapid recovery through increased compliance
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–
–
352 Sanggaran, 1997; Hills, 1998; White, 2003). However, some are willing to participate in students’ assessment, although many feel it difficult to give negative feedback to students (Twinn, 1995) or lack the necessary professional background for making such assessments (Andresen and McDermott, 1992). In addition, mechanistically or authoritatively performed interventions by staff nurses and students often seem to gain undue predominance in the relationship and hamper the development of individual and patient-centred relationships. Thirdly, the relationship was influenced by student-related and patient-related factors, length of time spent together and atmosphere during activity. The relationship seems to be largely determined by students’ and patients’ preconceptions and stereotypes about one another (see Peplau, 1997) and needs, desires and personal qualities of both of them (Morse, 1991). For instance, students’ characteristics and modes of professional behaviour and patients’ perception of personal self and their personal feelings are associated with the nature of the relationship established and of nursing care activities (Morin et al., 1999). Lack of confidence and the newness of the experience cause students uncertainty, limiting the action taken (see Cooke, 1996; Fagerberg and Ekman, 1997; Sadala, 1999; Hjo ¨rleifsdo ´ttir and Carter, 2000; Allcock and Standen, 2001; Granska ¨r et al., 2001; Tuohy, 2002). Students can indeed either centre exclusively on satisfying their personal learning needs, or focus on patients’ needs and expectations (Granska ¨r et al., 2001). Patients’ willingness to contribute to students’ learning seems to involve giving students an opportunity to gain clinical experience; some ambivalence has been found in this willingness, however (Twinn, 1995). In addition to efforts to overcome obstacles to a good relationship, long clinical placements (Richards, 1993) and the support and encouragement given by staff nurses (Dunn and Hansford, 1997; Fagerberg and Kihlgren, 2001; Kotecki, 2002; White, 2003) have been seen as important. Finally, the relationship has many positive consequences for both students and patients. It gives students an opportunity for personal and professional growth as students gain confidence in encountering the patient instead of just following rules or acting according to routines (Beck, 1992; Beck, 1993; Arnold, 1997; Granska ¨r et al., 2001; White, 2003), learn to accept their limitations and find meaning in their own lives (Eifried, 2003). Students’ role in promoting patients’ recovery and capability for self-care by showing an accepting attitude towards and a genuine interest in patients and giving them advice and instructions
A. Suikkala, H. Leino-Kilpi has also been pointed out by Twinn (1995) and Sadala (1999). There are no generally agreed ways to establish the credibility of qualitative research findings. In this study, the trustworthiness of the research process was established by estimating its confirmability, dependability, credibility and transferability (Catanzaro, 1988; Robson, 1993; Miles and Huberman, 1994; Marshall and Rossman, 1995). Each stage of the research process was documented. The first author collected and analysed the data from the tape-recorded interviews, transcribed verbatim, trying to maintain a neutral stance during these stages. The results of the analysis were confirmed by coding the data twice, at different points in time (Berelson, 1952; Appleton, 1995; Krippendorff, 1980). The investigator, an outsider in the organisation, was acquainted with the subject matter, which contributed to the creation of a confidential atmosphere and to understanding of the context of the research setting (Patton, 1990). However, interviewees might have reported things they assumed the investigator expected to hear instead of revealing their own thoughts. Feedback from informants could have been used to ensure creditability, but this was not feasible (Catanzaro, 1988; Appleton, 1995). The conclusion of transferability to other similar contexts can be made, based on the descriptions of the sample, settings and processes (Robson, 1993; Miles and Huberman, 1994). In generalizing the study findings, cultural differences must be considered. Although a more heterogeneous sample could have yielded different findings, the present results can be considered to have a wider relevance with respect also to other clinical contexts.
Conclusions The present findings have implications for clinical learning, as concerns particularly students’ relationships with patients. Nurse educators and staff nurses can use the information in mentoring students in interpersonal relations, with patients being involved in both learning and treatment. Taking factors associated with the relationship into account contributes to students’ progress towards individual-oriented nursing practice. Further research is needed to obtain more information about the nursing student–patient relationship and its connections with learning and nursing. The next step would be to test the categories that emerged from this study by using a quantitative approach. Research in other
Nursing student–patient relationship: Experiences of students and patients clinical areas could offer a more complete view of the relationship. It would also be important to investigate how high in order of importance interpersonal relationships are ranked by students and supervising staff nurses.
Acknowledgements The authors thank all students and patients who volunteered to participate in this study. Funding for this study was received from the Finnish Nurses Association, the Foundation of Nursing Education and the OKKA Foundation.
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