An Analysis of the Concept of Patient Participation
ORIGINAL
Blackwell
Malden,
Nursing
NUF
©
0029-6473
XXX
AnBlackwell ARTICLES
Forum
USA
Publishing
Analysis Publishing
of Inc2008of Patient Participation
the Concept
Monika J. M. Sahlsten, PhD, MSc Nursing, BSc Health Service Adm., RN, Inga E. Larsson, MSc Nursing,
BSc Health Service Adm., RN, Björn Sjöström, PhD, RN, and Kaety A. E. Plos, PhD, BSc
The concept of patient participation has an array
of interpretations and lacks clarity. The purpose of
this article is to explore the concept of patient
participation within the context of nursing
practice. The method described by Walker and
Avant (1995) is used. The critical attributes of the
concept are identified. Formation of model,
borderline, and contrary cases exemplifies key
characteristics. Antecedents, consequences, and
empirical referents presented allow for further
refinement of the key attributes defining the
concept. Patient participation in nursing practice
can be defined as an established relationship
between nurse and patient, a surrendering of
some power or control by the nurse, shared
information and knowledge, and active
engagement together in intellectual and/or
physical activities.
Search terms: Concept analysis, collaboration,
involvement, nurse–client relationship, patient
participation, partnership
2 Nursing Forum
Monika J. M. Sahlsten, PhD, MSc Nursing, BSc
Health Service Adm., RN, is at the Institute of Health and
Care Sciences, The Sahlgrenska Academy at Göteborg
University, Göteborg, Sweden; Inga E. Larsson, MSc
Nursing, BSc Health Service Adm., RN, is a doctoral
student at the Institute of Health and Care Sciences, The
Sahlgrenska Academy at Göteborg University, Göteborg,
Sweden, and a Lecturer at the Department of Nursing,
Health and Culture, University West, Trollhättan,
Sweden; Björn Sjöström, PhD, RN, is Professor at the
School of Life Sciences, University of Skövde, Skövde,
Sweden; and Kaety A. E. Plos, PhD, BSc, is a Senior
Lecturer at the Institute of Health and Care Sciences, The
Sahlgrenska Academy at Göteborg University, Göteborg,
Sweden.
Introduction
Patient participation is an essential basis of medical
treatment and nursing care, and the patient’s position
has been increasingly strengthened in recent decades,
both internationally and nationally (Eldh, Ehnfors,
& Ekman, 2004; Nordgren & Fridlund, 2001). The
traditional view is replaced by expectations of an active
patient involved in his or her own care. Despite this,
patients have experienced insufficient participation,
and dissatisfaction and complaints appear to be increas-
ing (Coulter & Magee, 2003; www.pickereurope.org).
Participation is known to reduce stress and anxiety
(Lauri & Sainio, 1998) and increases patients’ motiva-
tion and satisfaction with received care (Williams,
Freedman, & Deci, 1998). However, each patient and
each nurse may have his or her own opinion or ideas
about the meaning and implementation of patient
participation.
Patient participation, despite being widely used
every day, remains an elusive and complex concept,
which is of uttermost importance to nursing. Concepts
are both the foundation of and necessary for advance-
ment of the knowledge base of nursing as well as
being essential for precise communication and critical
thinking (Cahill, 1996). Concepts may be regarded as
Volume 43, No. 1, January-March, 2008
Table 1. Eight Steps of Concept Analysis According
to Walker and Avant (1995)
1. Select a concept
2. Determine the aims of analysis
3. Identify the uses of the concept
4. Determine defining attributes
5. Develop a model case
6. Develop additional cases: borderline and contrary cases
7. Identify antecedents and consequences
8. Define empirical referents
mental constructions of phenomena, which enable a
formation of conceptual definitions allowing examination
to attempt ordering of environmental stimuli
(Walker & Avant, 1995). Concept analysis is a valuable
methodology that can be used to clarify overused
concepts with vague meaning that are prevalent in
nursing practice.
This article presents an analysis of the concept of
patient participation and its relation to nursing by
identifying the meaning of the concept from the
literature. The basic principles from Walker and Avant’s
(1995) model for concept analysis are used to examine,
determine, and define attributes and characteristics of
the concept of patient participation. The model
consists of eight steps used to highlight aspects and
essential attributes of the concept (Table 1). Although
the steps seem to be a linear process, many of them
occur simultaneously. For ease of presentation, each
step will be considered separately.
This concept analysis focuses on the time period
from 1996 to 2005. The analysis is based on research
articles published after the concept analysis of patient
participation performed by Cahill (1996) and the same
methodology is used. The time period Cahill examined
was not explicit but estimated to include up until 1995;
specifics regarding details of the sample are lacking.
In the present concept analysis, the databases used to
search for relevant articles and literature were CINAHL
and MEDLINE with patient participation used as a
key term.
Nursing Forum Volume 43, No. 1, January-March, 2008
Selection of Concept
The concept of patient participation is central to
nursing practice. It has been emphasized as a good
thing (Tutton, 2005), enabling patients to maximize
their potential for comfort (Bottorff et al., 1998). The
right of patients to participate in planning, decision-
making, and carrying out activities concerning their
care is stressed in nursing as well as public opinion
and legislation (Efraimsson, Sandman, Hydén, &
Rasmussen, 2004). The nurse is expected to play a key
role in facilitating and encouraging patients to par-
ticipate. Despite the concept’s significance in current
nursing practice, it has still not been adequately
articulated and continues to be elusive. A diversity of
opinions exists concerning the way both patients and
nurses view the concept (cf. Eldh, Ehnfors, & Ekman,
2006; Tutton).
Although patient participation has been a widely
researched and debated phenomenon in health
care in the last three decades, there is still an array
of interpretations. The lack of clarity associated
with the concept may have resulted in patient
participation becoming a nursing tokenism (Roberts,
2002).
Aims of Analysis
In striving to attain conceptual clarity, the analysis
may make it possible to promote a single vocabulary
for discussion while understanding what the parameters
of patient participation are. Accordingly, the aim of
the analysis is to identify and explore the attributes of
the concept, and to clarify and elucidate the meaning
and nature of the concept of patient participation
within the context of nursing practice. It may provide
a pattern for challenging and criticizing the concept
within the context of nursing practice. This concept
analysis also intends to illuminate the role of the nurse
in relation to patient participation and highlight the
skills, knowledge, and experience nurses require to
practice.
3
An Analysis of the Concept of Patient Participation
Uses of the Concept of Patient Participation
Walker and Avant (1995) claim that this step should
include as many uses of the concept as can be found.
These include consulting dictionaries, thesauri, and
examined articles.
According to the Concise Oxford English Dictionary,
the word participation means to be involved and to
take part in (Soanes & Stevenson, 2004). The term is
derived from the Latin participare, which means share
in, and is based on pars, part- + capere (take). Merriam–
Webster OnLine states that participation means the act of
participating and the state of being related to a larger
whole (www.webster.com). Oxford Reference Online
provides further explanation: involvement, part, con-
tribution, and association (www.oxfordreference.com).
According to Reference.com, participation as ownership
means sharing something in common with others. In
finance, it is an ownership interest in a mortgage or
other loan. Participation is also used as a synonym of
profit sharing, an incentive whereby employees of a
company receive a share of the profits of the company
(www.reference.com). There are several synonyms
of participation: alliance, association, attendance, commu-
nion, cooperation, experience, interest, and membership
(www.thesaurus.reference.com).
The term participation has been discussed in differing
contexts. Collective or indirect participation practiced
as lay participation in research, formulation of policy,
and the commissioning of services (Allen, 2000), or as
a third-party parent, close relative, or carer (Roberts,
2002). Individual participation may be practiced in, for
example, health care and promotion, mental and social
care (e.g., Lammers & Happell, 2003; Obeid, 2000), and
in different situations; for example, discharge planning
(Efraimsson, Sandman, Hydén, & Rasmussen, 2004;
Jewell, 1996; Roberts, 2002), decision-making in treat-
ment/care (Caress, Luker, & Akrill, 1998; Henderson,
2002; Sainio & Lauri, 2003; Sainio, Lauri, & Eriksson,
2001), and bedside reporting (Timonen & Sihvonen,
2000). The meaning of the term has also been explored
(Eldh et al., 2004, 2006; Tutton, 2005) and instruments
4 Nursing Forum
to measure participation have been tested and con-
structed (Caress et al.; Latvala, Saranto, & Pekkala,
2004; Ramfelt, Lützen, & Nordström, 2005). Participa-
tion in medical treatment decisions has received the
greatest attention (Guadagnoli & Ward, 1998; Wellard,
Lillibridge, Beanland, & Lewis, 2003).
The present concept analysis reveals that studies of
patient participation in nursing care are still not
congruent regarding definition, elements, and processes
(e.g., Gallant, Beaulieu, & Carnevale, 2002). This lack
of clarity is amplified by the use of several terms:
patient/client/consumer/user involvement or collab-
oration (e.g., Langton, Barnes, Haslehurst, Rimmer, &
Turton, 2003) and partnership (e.g., Henderson, 2003).
Patient/client seems to refer to current recipients of
health/mental/social care. Consumer participation
appears to be used interchangeably with user participa-
tion (Lammers & Happell, 2003). However, Langton
et al. claim that there is a difference: consumer relates
to the right to make choice and user is a broad term
that involves a current or potential healthcare recipient.
Patient participation seems to include and be used
interchangeably and synonymously together with user
involvement (Anthony & Crawford, 2000; Doherty &
Doherty, 2005; Evans et al., 2003; Hickey & Kipping,
1998). The term collaboration seems to have diminished
in significance and is seldom used. One possible expla-
nation of the use of several terms can be derived from
governments’ and decision-makers’ different denomina-
tions of patient participation in policy documents.
Patient participation in the context of professional
nursing practice can be related to a few definitions.
Jewell (1996) identifies patient participation as repre-
senting a philosophical approach to patient care and
also as a practical component of patient care. The
philosophical approach includes: “individual or holistic
care, realistic plans based on negotiation, a positive
outcome for patients and encouraging patients to be
active rather than passive during their hospital stay”
(p. 916). The practical component involves: “using the
nursing process, seeing what the patient wants, seeing
what the patient wants regarding discharge, self-care
Volume 43, No. 1, January-March, 2008
i.e., physically take part in care, and informing patients
during their hospital stay” (p. 916). Henderson (2000)
concludes that patient participation means being
involved in the decision-making process concerning
the delivery and evaluation of the patient’s own care.
Determining means treating patients as individuals,
taking into account patients’ opinions, and giving
them control with regard to their own care. Tutton
(2005) defines patient participation as a dynamic process
that changes over time and is integral to the work of
nurses and carers. This process is carried out through
facilitation, partnership, understanding the person,
and emotional work. Partnership is seen as an essential
process that underpins participation by identifying the
values and beliefs on which negotiation is based. Staff
may make decisions for patients but these decisions
are participatory through this dynamic process.
Patient participation can also be described in terms
of elements and processes. Allen (2000) claims that it is
vital to be aware of the differences between the “role”
and “task” elements of patients’ participation and to
keep them distinct. Failure has resulted in conceptual
confusion and faulty assumptions of increased partic-
ipation in tasks implying parallel changes in the role,
i.e., greater power for the patient. Sainio, Lauri, and
Eriksson (2001) state that patient participation relates
to being involved in decision-making or expressing
one’s views on different treatments. It includes
sharing information, communicating feelings and
symptoms, and compliance with nurses’ and physicians’
orders. According to Eldh et al. (2004), patient participa-
tion is to be confident, and to comprehend, seek, and
maintain a sense of control and recognition of one’s
own responsibility as a patient. From a nurse perspective,
participation is more about patients getting indi-
vidually adjusted information so they can act (Eldh
et al., 2006). To sum up, patients experience participation
as something that they have and accept—a personal
active attitude; whereas nurses experience it as some-
thing that they give to the patient—they activate.
Obeid (2000) states that user participation is a
dynamic process, moving beyond only having a voice,
Nursing Forum Volume 43, No. 1, January-March, 2008
being involved in evaluation and towards actual
planning of care services and delivery. It includes a
person-centered philosophy, such as an equal rela-
tionship and sharing with a supportive facilitator.
Wellard et al. (2003) notes consumer participation such
as sharing information, opinions, and decision-making
power. It should not be limited to a question of shared
clinical decisions, but instead involve a general
involvement with individuals in everyday aspects
during their hospital stay.
Patient participation can be related to difference in
attitude. Jewell (1996) claims that the control profes-
sionals have over their practice affects the level of
active patient participation. It is the nurse’s commitment
to participation that makes it happen. Hickey and
Kipping (1998) report on a participation continuum
from consumerist to democratization approach. This
includes four positions of transferring decision-making
power to the user: (i) information/explanation, and
(ii) consultation with no such transferring, (iii) partner-
ship including joint decisions, and (iv) user control,
i.e., power is redistributed so the user makes the
decision whether to involve someone else.
Roberts (2002) reports that the most applicable
levels of participation are currently informing,
consultation, and placation, denoted as tokenism, and
suggests a passive role for participants. Three types of
people in relation to participation are identified: those
who (i) express their views and opinions or state their
preferences without prompting—these people displayed
the greatest willingness to participate but still preferred
experts to have the final say; (ii) express their views
and opinions or state their preferences when invited to
do so—these people could either wish to play an active
role or respond to the role they felt was expected; and
(iii) accept the decisions that are made—these people
preferred professionals to act on their behalf.
Lammers and Happell (2003) stipulate that consumers
should be given the opportunity to participate in
accordance with individual interest, attributes, need,
and ability. Sainio and Lauri (2003) and Eldh et al.
(2004) confirm that level of participation needs to be
5
An Analysis of the Concept of Patient Participation
an issue for dialogue between nurses and patients
because preferences change over time and phases of
the disease and treatment. Discussing the issue is essential
because Caress et al. (1998) allege that some patients
exceed their preferred level of participation. Passivity
may be the result of fear or perceived lack of knowledge.
When patients prefer a passive role, which appears to
be well considered and genuine, health professionals
should respect this preference.
The degree of patient participation depends on sev-
eral factors, internal as well as external. The internal
factors that have been identified are the patient’s
physical ability, willingness and ability to make
rational decisions (Jewell, 1996), attitude towards
self-care, cultural backgrounds, desire to be a “good”
patient, level of medical knowledge, and previous
hospital experience (Henderson, 2002). Age, marital
status, and time since diagnosis also exert an influence
(Sainio & Lauri, 2003). Not understanding and not
being accountable are experienced as not participating
at all (Eldh et al., 2004). The external factors that affect
a patient’s desire to participate are that nurses provide
information (Sainio & Lauri), encourage questions,
use everyday language, and focus on and spend more
time with the patient (Timonen & Sihvonen, 2000).
A number of factors have been identified as restricting
participation: conflict between patient and carer and
overprotection by nurses (Jewell, 1996), limited
communication between nurses and patients, task-
oriented nursing labor, environmental constraints
limiting patients’ privacy (Wellard et al., 2003), and
when patients lack an equal relationship, respect, and
information (Eldh et al., 2006). Professionals not
attuned to the concerns of the patient and his or
her individual needs, and who literally silence or
disregard the patient’s wishes, produce nonparticipation
(Efraimsson et al., 2004).
Determined Defining Attributes
This step identifies the characteristics of the concept
that repeatedly appear when the concept is defined or
6 Nursing Forum
described (Walker & Avant, 1995). These characteristics
have been grouped to obtain a clear picture of what
comprises the concept of patient participation.
The defining attributes of the concept of patient
participation within the context of nursing practice are:
1. An established relationship. The most distinctive
attribute that emerged from the literature both
explicitly and implicitly is an existing relationship,
which seems to be required according to the defini-
tions and uses of the concept. Participation entails a
good, mutual, trusting, respectful, connected rela-
tionship, with associated affective terms implying
that it is established (e.g., Allen, 2000; Eldh et al.,
2004, 2006; Henderson, 2000; Roberts, 2002; Sainio
et al., 2001; Sainio & Lauri, 2003; Tutton, 2005;
Wellard et al., 2003).
2. A surrendering of some power or control by the nurse.
The level of control nurses have affects the degree
of patients’ participation; commitment is crucial
and makes it happen (Jewell, 1996). Participation
entails equality, negotiation, and responsibility, which
appear as associated terms (e.g., Eldh et al., 2004,
2006; Henderson, 2000; Jewell; Obeid, 2000; Tutton,
2005; Wellard et al., 2003). Self-care and other
activities the patient can manage are allocated and
responsibility follows. Nurses become empowerers
and supportive facilitators (Obeid).
3. Shared information and knowledge. Participation
requires meaningful information and knowledge
exchanged between nurse and patient. This entails
obtaining the patient’s opinions, expectations, and
experiences and providing individually adapted
information/knowledge (e.g., Eldh et al., 2004;
Henderson, 2002; Kettunen, Poskiparta, & Karhila, 2003;
Sainio et al., 2001; Sainio & Lauri, 2003; Tutton, 2005).
4. Active mutual engagement in intellectual and/or physical
activities. Participation requires activation by both
nurse and patient throughout all aspects of the
nursing process. Inviting, encouraging, and supporting
are crucial. The patient’s willingness is associated
with a number of factors; for example, ability,
Volume 43, No. 1, January-March, 2008
 health status, attitudes, and trust (e.g., Caress et al.,
1998; Henderson, 2002; Jewell, 1996).
Developed Model Case
The development of a model case starts at the same
time as the development of the list of defining attributes,
(Walker & Avant, 1995). This model case is a constructed
“real life” example of the use of the concept including all
critical attributes. It serves to provide “evidence” of
what the concept definitively is. This model case received
careful consideration by testing it on thoughtful
colleagues, as proposed by Walker and Avant.
The Model Case
The model case serves to provide evidence of what
the concept of patient participation definitively is.
Jenny is a patient in an orthopedic ward. Since the
first day, her primary nurse has regarded Jenny as
an equal partner, activating her to participate in all
aspects of her nursing care. The nurse starts in
Jenny’s frame of reference and uses open-ended
questions to explore expectations, wishes, and
opinions. They also discuss what they expect of
each other. In their regular talks, they get to know
each other and trust and respect develop. Jenny par-
ticipates in planning, formulating goals, performing
activities, and evaluation of her own nursing care.
The nurse continually provides information and
knowledge adjusted to Jenny’s needs and Jenny,
in turn, volunteers experiences, values, and beliefs.
This generates informed choices and together they
negotiate acceptable agreements. Jenny has reached
understanding and a sense of control of her own
situation.
Developed Additional Cases
Additional cases are constructed to help to decide
what “counts” as a defining attribute of the concept
Nursing Forum Volume 43, No. 1, January-March, 2008
and what does not. It enables identification of what is
and what is not an incidence of the concept in question.
The Borderline Case
This is an example or instance that contains some of
the critical attributes of patient participation, but
which differs substantially in one of the criteria
(Walker & Avant, 1995).
Borderline case of the concept of patient participation:
Klara is a patient in a rehabilitation ward with
discharge to home imminent. Because of a temporary
remaining disability, Klara will need homecare help
daily. A discharge planning conference is scheduled
and her primary nurse prepares Klara. They discuss
Klara’s need for help and questions to be asked.
The conference starts with the nurse encouraging
Klara to describe her wishes regarding anticipated
needs. Klara uses her list of notes and starts with a
description of her current health status and the
nurse helps to fill in the blanks. Information regarding
the resources the care system could offer is accur-
ately presented by the coordinator for homecare in
the municipality. Specific questions from Klara
about, for example, how many and when homecare
aids would come, receive unspecific answers. The
nurse decides when Klara needs homecare without
taking her wishes into account. Klara grows quiet
and is subjected to pressure to accept. Finally, Klara
accepts because the nurse appears to know what is
best.
The Contrary Case
Walker and Avant (1995) claim that this case
illustrates what the concept is not.
A contrary case of patient participation:
Adam is admitted to a surgical ward. Adam meets
different nurses every day and gets no information
or introduction. The first nurse Adam meets draws
7
An Analysis of the Concept of Patient Participation
up the nursing care plan without consulting him.
When performing physical care, the nurse does
things only in her own way and excludes Adam.
The nurse demonstrates that she knows what is best
for Adam, offers no choices, and often makes
decisions “over his head.”
Identified Antecedents and Consequences
According to Walker and Avant (1995), antecedents
are events or incidents that must occur prior to the
occurrence of the concept and are useful for identifying
underlying assumptions. Consequences are those events
or incidents that occur as a result of the occurrence of
the concept and are useful for determining neglected
ideas, variables, or relationships fruitful for new
research directions.
Antecedents
• Recognition on the part of the nurse of patients as
individuals (Allen, 2000; Caress et al., 1998; Eldh
et al., 2004, 2006; Henderson, 2000; Obeid, 2000;
Roberts, 2002; Sainio et al., 2001; Sainio & Lauri,
2003; Tutton, 2005).
• Continuity and limitation of staff to one assigned
nurse (Eldh et al., 2004; Tutton, 2005).
• Nurse and patient identify their role expectations
(Timonen & Sihvonen, 2000).
• A meaningful, mutual interaction between nurse
and patient (Eldh et al., 2004; Roberts, 2002; Sainio
et al., 2001; Sainio & Lauri, 2003; Tutton, 2005).
• Good communication (Allen, 2000; Roberts, 2002)
specified as reciprocal conversation including
affective questions and tentative speech together
with continuers on the part of the nurse (Kettunen
et al., 2003).
• The patient obtains sufficient, appropriate, under-
standable, and meaningful information and
knowledge in order to feel confident (Eldh et al.,
2004, 2006; Mitcheson & Cowley, 2003; Sainio et al.,
2001; Sainio & Lauri, 2003).
8 Nursing Forum
• Recognition on the part of the nurse of the patient
as valuable and equal, and having power, control,
and responsibility (Eldh et al., 2004, 2006; Kettunen
et al., 2003; Lammers & Happell, 2003; Obeid, 2000;
Roberts, 2002; Tutton, 2005; Wellard et al., 2003).
• A willingness on the part of the patient to assume
power, control, and responsibility (Eldh et al., 2004,
2006; Sainio et al., 2001).
Consequences
There is a dearth of empirical studies examining
outcomes of patient participation in nursing care. The
few reported consequences of patient participation are
primarily described as improvements of some sort.
Outcomes of patient participation have not been a
specific research question; these consequences are,
rather, mentioned as findings.
• Increased satisfaction with care and hospital stay
(Henderson, 2000), treatment, influence, and access
to information (Sainio et al., 2001).
• Better treatment results (Sainio et al., 2001).
• Patient empowerment (Allen, 2000; Henderson,
2000; Kettunen et al., 2003).
• A sense of comprehending and being confident
(Eldh et al., 2004).
• Better adjustment to the situation (Roberts, 2002).
• Decreased vulnerability (Henderson, 2000).
• Feeling uncomfortable about the presence of other
patients during participation in bedside reporting
(Timonen & Sihvonen, 2000).
• Increased job satisfaction and raised self-esteem on
the part of the nurse (Obeid, 2000).
• When nurses have the knowledge but are hindered
from implementing patient participation, they may feel
powerless and risk burnout and stress (Obeid, 2000).
Empirical Referents
According to Walker and Avant (1995), the final
step is to determine the empirical referents for the
Volume 43, No. 1, January-March, 2008
critical attributes. Empirical referents are discernible
attributes of actual phenomena that, by their existence,
demonstrate the occurrence of the concept itself. The
few reported studies, which include observations, pro-
vide some referents. These studies involved participant
observation at acute medical, surgical, and extended
care wards (Henderson, 2002, 2003), a cardiovascular
medical unit (Wellard et al., 2003), and a nurse-led
clinic for chronic heart failure (Eldh et al., 2006).
• The nurse displays genuine interest and empathy
for the person and spends time together with him
or her so that they can get to know each other.
• The nurse encourages and supports the patient to
take on responsibility and control by providing
options to choose and decide.
• The nurse provides information and knowledge
adjusted to the individual’s needs and listens
actively. The dialogue continues until an exchange
of information is complete and where the patient
volunteers information without being asked or is
invited to do so by means of open questions.
• The nurse activates and supports the patient to
cooperate, adjusted to his or her ability, during all
physical activities as well as in planning, imple-
menting, and evaluating the nursing care.
Conclusions
Based on the results from the present study, it may
be possible to form a theoretical definition of the
concept. Patient participation in nursing practice exists
when all the identified attributes are present: an
established relationship between nurse and patient,
the surrendering of some power or control by the nurse,
shared information and knowledge, and active engage-
ment together in intellectual and/or physical activities.
The attributes of the concept of patient participation
within the context of nursing practice have been
identified and explored through a systematic analysis.
More work is required to uncover further details of,
for example, the interaction and the relationship in
Nursing Forum Volume 43, No. 1, January-March, 2008
order to be able to stimulate and optimize patient
participation. The meaning and nature of the concept
of patient participation that has emerged here is only
representative of the current state of the art. Concept
analysis is a never-ending process and when further
knowledge and experiences become available, addi-
tional development will be needed.
The use of concept analysis has aided in clarifying
and elucidating the nature of the concept and has
potentially formed a template for critiquing and
challenging patient participation in nursing practice.
The results may be useful for how implementation of
patient participation is designed and evaluated. It may
help to raise awareness of the complexity of patient
participation and contribute to understanding the
meaning by elucidating adjacent and necessary
qualities, such as individual-centered care, nurse–
patient continuity, and attending to the patient’s
self-image and experience of the situation.
When comparing the present results to Cahill’s
(1996) concept analysis of patient participation, the
defining attributes are mainly the same, although
more detailed. Surrendering power or control to the
patient has a more prominent position. Shared
information and knowledge adjusted to each patient’s
needs seem to be emphasized. Today, active engagement
includes all phases of the nursing process in contrast
to only some. The antecedents of patient participation
appear to have been extended and refined, qualities of
the relationship seem to have been illuminated to a
greater degree. It is obvious that in the case of the nurse,
recognition of the patient as equal and as having control
and responsibility are required. A desire to relinquish
a degree of power seems to be no longer sufficient.
Employing Walker and Avant’s (1995) model and
methodology promotes a systematic approach and, for
the purpose of this analysis, it was successful in
identifying and clarifying the concept. The construction
of cases advocated in this methodology contributed to
more specific and distinct descriptions as opposed to
cases identified from data used in other approaches
(cf. Rodgers, 1989; Schwarts-Barcott & Kim, 1993).
9
An Analysis of the Concept of Patient Participation
Although the tool provided a useful guide, at times it
seemed that information was being replicated only for
the sake of conforming to the needs of the stages in
the analysis. This is in line with comments by authors
also following this approach (Cahill, 1996; Rodgers).
The tool lacks distinct guidelines for certain aspects of
the analysis, such as the need for a literature review
and an explicit validation phase to verify the presence
of the proposed defining attributes of the concept.
Rodgers and Paley (1996), among others, criticize the
methodology for presenting a rigid, static view of the
world. However, Walker and Avant (1995) claim that
“the end product is always tentative” (p. 37). They
also assert that concepts change over time: what is true
today is not true tomorrow. Accordingly, the results
from this analysis should be considered as a starting
point for further development.
Although the analysis was systematically performed,
questions may be raised with respect to the representa-
tiveness of the literature chosen as data for this study.
A more extensive inclusion of data might have been
more elucidating in terms of the meaning of the concept
of patient participation in nursing practice.
Contributions
Conception and design: MS
Data collection, analysis and interpretation: MS, IL
Drafting the article: MS, IL
Revising the article critically for important intellectual
content: BS, KP
Acknowledgements. We would like to thank the
Department of Nursing, Health and Culture Vänersborg,
University West Trollhättan, for its financial support.
Author contact: monika.sahlsten@swipnet.se, with a copy to
the Editor: nursingforum@gmail.com
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