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1 | I NTRODUCTION
Meeting the fundamental care needs of patients is essential for op-
timal safety, recovery and positive experiences in any healthcare
setting (Kitson et al., 2010). Patient participation is one of the fun-
damental care aspects and is increasingly recognized as a key com-
ponent in healthcare. Of all healthcare professionals, nurses spend
the most time with patients, which places them in a unique position
Received: 18 November 2021
|
Revised: 25 March 2022
|
Accepted: 7 May 2022
DOI : 10.1111 /ja n.15 329
ORIGINAL RESEARCH:
EMPIRICAL RESEARCH – QUALITATIVE
Nursing leadership to facilitate patient participation in
fundamental care: An ethnographic qualitative study
Wilmieke Bahlman- van Ooijen1 | Elise van Belle2,3 | Arnold Bank4 |
Janneke de Man- Van Ginkel5,6 | Getty Huisman- de Waal1,3 | Maud Heinen3
This is an op en access article under t he terms of t he Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cite d, the use is non-com mercial and no modificat ions or adaptations are made.
© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
1Depar tment of surgery, Radboud
University Medical Center, Nijmegen,
The Netherlands
2Nursing Science , Julius Center for Health
Science s and Primary C are, Universit y
Medical Center Utrecht, Utrecht
University, Utrecht, The Netherlands
3Scientific cente r for Quality of
Health care (IQ Healthcare), Radboud
University Medical Center Nijmegen,
Radboud Institute for He alth Sci ences,
Nijmegen, The Netherlands
4Depar tment of Nursing St aff, Tergooi
Hospital, Hilversum, The Netherlands
5Nursing Science , Depar tment of
Gerontology and Geriatrics, Leiden
University Medical Centre, Leiden,
The Netherlands
6Nursing Science Program in Clinical
Health Sciences, University Medical
Center Utrecht, Utrecht University,
Utrecht, The Netherlands
Correspondence
W.G. Bahlman- va n Ooijen , Depar tment
of surger y, Radbou d University Medical
Center Nijmegen, The Netherlands, Geert
Grooteplein Zuid 10, 6525 GA Nijmegen,
The Netherlands.
Email: wilmieke.vanooijen@radboudumc.nl
Abstract
Aims: To explore and describe hospital nurses' perceptions of leadership behaviours
in facilitating patient participation in fundamental care.
Design: An ethnographic interview study.
Methods: Individual semi- structured interviews with 12 nurses with a bachelor's or
master's degree working at a university medical centre were conducted between
February and April 2021. The interview data were analysed using thematic analysis.
Results: Six themes were derived from the data: (1) nursing leadership; (2) patient par-
ticipation; (3) using patients' preferences; (4) building relationships; (5) task- focused
nursing; (6) need for role modelling.
Conclusion: Nurses indicated leadership behaviour to facilitate patient participation
in fundamental care as inviting patients to participate and eliciting and supporting
patients' preferences. Although nurses also regarded leadership as motivating col-
leagues to act and enhancing evidence- based practice, they appeared not to practise
this themselves about patient participation. Role modelling was indicated as a need
for improvement.
Impact: The findings established that not all leadership behaviours mentioned were
used in practice about patient participation in fundamental care. Role modelling and
the use of evidence- based practice are needed to increase patient participation.
Further research will be necessary to develop and test leadership interventions to
improve patient participation in fundamental care.
KEY WORDS
ethnography, fundamental care, nurses, nursing leadership, patient participation, patient-
centered care, qualitative research
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BAHLMAN-VANOOIJEN et al.
to enable and encourage the par ticipation of patients in their care
(Tobiano, Bucknall, et al., 2016). Nonetheless, little is known about
how nurses effectively encourage patient participation in hospital
care. Dedicated nursing leadership is key to promote and suppor t
working approaches that improve patient- centred, fundamen-
tal care, including patient participation (Conroy, 2018; Pentecost
et al., 2020).
1.1 | Background
Recent developments in healthcare, such as increased complexity
of patient care, an ageing population, an increase in several chronic
illnesses, a worldwide nursing shortage and the current COVID- 19
pandemic, emphasize the crucial role of nurses (World Health
Organization, 2020). Nurses play a vital role in providing healthcare
services, and they have a significant influence on nurse- sensitive
outcomes, such as medication error, falls, pneumonia, urinar y
tract infections, unjustified restraints and pressure ulcers (Dubois
et al., 2013). The hear t of the nursing profession has been justly de-
scribed as the delivery of Fundamental C are (Kitson et al., 2010). The
FoC Framework (FoCF) encompasses physical, psychosocial, and
relational aspects that are required by every patient regardless of
their clinical condition (Alison Kitson et al., 2013). The nurse– patient
relationship forms the core of the FoCF and is about approaching pa-
tients in an individual manner, developing trust with patients, being
able to focus on them, anticipating their needs, getting to know
them and assessing the quality of the relationship (Feo et al., 2017).
Nurses who successfully address these relational elements of care
work effectively to meet patients' needs (Feo et al., 2017).
Fundament al nursing care is deeply entwined with patient-
centred care, which is promoted in hospitals internationally as a cor-
nerstone for high- quality healthcare. Patient- centred care focuses
on respect for patients' individuality, values, perspectives, knowl-
edge and autonomy and is characterized by shared responsibility
and communication (Hughes et al., 2008). Delivering patient- centred
care includes patient participation, wherein patients are part icipating
as respected and autonomous individuals (Alison Kitson et al., 2013).
Sahlsten et al. (2008) defined patient par ticipation as an established
relationship between nurses and patients, a surrender of power or
control by the nurses, shared information and knowledge, and ac tive
engagement together in intellectual or physical activities (Sahlsten
et al., 2008). The definition establishes the nurse– patient relation-
ship as the core of effec tive patient participation, which is also at
the centre of the FoCF (Feo et al., 2017). Examples of participation
in nursing care involve acknowledging patients as partners, who par-
take in planning and managing self- care, through a dialogue attuned
to patients' preferences and experiences as well as to profession-
als' exper tise (Oxelmark et al., 2018; Tobiano, Marshall, et al., 2016).
Patient participation has numerous beneficial effects, including im-
proved patient satisfaction, safety, therapy adherence, reduced pa-
tient anxiety, shortened hospital stay and enhanced quality of care,
which leads to better healthcare outcomes (Vahdat et al., 2014).
Despite these advantages, nurses seem reluc tant to enable pa-
tient par ticipation in nursing care (Theys et al., 2020). In the litera-
ture, several challenges in patient participation are described, also at
the patient level, such as the patients' physical condition, different
cultural backgrounds, language, health literacy and characteristics
related to the nature of the work, such as nursing routines, and tra-
ditional culture of not involving patients (Oxelmark et al., 2018). The
need to maintain control over care, reluct ance to engage in deep
conversations, fear of being seen as unprofessional by patients and
even fear of repercussions from physicians hinders nurses from fa-
cilitating patient participation in hospital care (Theys et al., 2020).
Patients experience a lack of participation in their care, and whilst
they would like to be more involved in it, they feel restricted in their
opportunities for participation owing to an imbalanced relationship
in which nurses hold the power (Tobiano, Bucknall, et al., 2 016). The
biomedical model of care still dominates over more patient- centred
psychosocial models, resulting in lower patient participation (van
Belle et al., 2020). Therefore, true patient participation is seldom en-
couraged, although there seem to be ample opportunities for it (van
Belle et al., 2020).
The established benefit s of patient- centred care emphasize the
need to improve patient participation and to generate more insight
into how this could be achieved. Previous research suggests that
dedicated nursing leadership is needed to enhance fundamental
nursing care, including patient participation (Pentecost et al., 2020).
Conroy (2018) indicated that nursing leadership has the potential
to influence the nurse– patient relationship and the active involve-
ment of patients, for example by role modelling expected behaviour
(Conroy, 2018). Whilst an unambiguous definition of nursing lead-
ership is lacking, there is a consensus that it requires competencies
such as innovating, inspiring, supporting and teaching, along with
a concern for improving the qualit y of care (Heinen et al., 2019).
It focuses on delivering excellent patient care and concerns top-
ics such as collaboration with professionals, implementation of
innovations, enhancing evidence- based practice, and reflection
(Northhouse, 2014). Nursing leadership has the potential to improve
patient safety, patient s atisfaction an d reduce adverse events (Wong
et al., 2013). However, the literature shows that as yet not much
research has been done into how nurses working in direc t patient
care use leadership behaviours to achieve a systematic and consis-
tent approach to patient participation (Conroy, 2018). Therefore,
it is necessary to further explore how these nurses use leadership
behaviour to facilitate patient participation in fundamental nursing
care in order to create opportunities for improvement.
2 | THE STUDY
2.1 | Aims
The aim of the study was to explore and describe hospital nurses'
perceptions of leadership behaviours in facilitating patient participa-
tion in fundamental care.
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BAHLMAN-VANOOIJEN et al.
2.2 | Design
A n ex p l o r at o r y et h n o g r ap h i c qu al i t a t i v e de si g n wa s us e d to ob ta i n in -
sight into nurses' perceptions of leadership and patient participation
in fundamental care. This design was chosen to explore and describe
the perceptions of a culture sharing group (Creswell, 2018). The
study was conducted and reported according to the Consolidated
Criteria for Reporting Qualitative Research (COREQ) checklist (Tong
et al., 20 07) and the Standard for Reporting Qualitative Research
(SRQR) (O'Brien et al., 2014).
2.3 | Sample/Participants
The study was conducted in a university medical centre (UMC) in the
Netherlands with the study population consisting of nurses. Nurses
meeting the following inclusion criteria were eligible for participa-
tion: (a) Dutch- speaking, (b) possessing a bachelor's (BSc) or master's
degree (MSc), (c) working in a nursing ward and (d) providing direc t
care to patients for at least 8 h per week. Nurses working in wards
with specialities such as maternity care, paediatrics, and critical care
were excluded from par ticipation because in these specialized wards
the relationship with the patient is formed differently on account
of the typical character of these wards. Physician assistants and
nurse practitioners were excluded from participation because they
do not provide direct bedside care. Convenience sampling of nurses
was used in t wo different ways. First, the members of the Nursing
Science Group (NSG) of the UMC were invited to participate in the
interviews. The NSG is an innovative group of about 40 nurses with a
master's degree who are partially working in nursing research. Their
aim is to share knowledge and exper tise on research, implementa-
tion and evidence- based practice, to improve interprofessional col-
laboration, functioning of nursing teams and quality of care. Second,
the managers of clinical wards and the members of the NSG of the
hospital provided the names of nurses with a bachelor's degree who
might be willing to participate. In total, 31 personalized email invita-
tions were sent to nurses. Six respondent s did not meet the inclusion
criteria, and three respondents declined to participate because they
were busy or on sick leave. Nine nurses did not respond to the email
invitation, and one participant withdrew from the study because of
health- related problems. Finally, 12 nurses were included (Figure 1).
2.4 | Data collection
Semi- structured, individual interviews were conducted on the basis
of an interview guide by the executive researcher [WO] between
Februar y and April 2021. The interview guide was created on the
basis of relevant literature and by discussing the topics with the re-
search group (EB/MH) (Appendix S1). The interview guide focused
on the following topics: (1) nursing leadership, (2) patient participa-
tion and (3) nursing leadership to facilitate patient participation. The
guide included questions such as: 'How do you understand nursing
leadership?’, ‘What are examples of how you currently practice pa-
tient par ticipation in hospital care?’ and 'How do you show nurs-
ing leadership to enhance patient participation in hospital care?'
The inter view guide was refined after a pilot interview with a nurse
with a master's degree, who had not been included in the study.
Throughout the interview process, the interviewing researcher criti-
cally reflected on the content and procedure of the interviews in the
research group (EB/MH), with the aim to enhance critical reflectivity.
The inter views were held face- to- face at a place preferred by the
participant or were conducted online via Microsof t Teams, mainly
owing to the COVID- 19 pandemic restrictions. Only the researcher
and participant were present at the time of the interview. Directly
after the interview, contextual memos were made, reflecting the be-
haviour of the participant, as well as the setting of the interview. All
interviews were audio- recorded and transcribed verbatim. However,
FIGURE 1 Flow chart of the recruitment of nurses, including reasons for non- participation.
Nurses invited for
participation
(n = 31)
Declined
participation, because
of busyness or illness
(n = 3)
Willing to participate,
but did not meet
inclusion criteria
(
n = 6
)
Willing to participate,
but no possibility to
schedule the interview
No response
(n = 5)
Drop out, because
of health-related
problems
Participants included in
the study
(n = 12)
(n = 4) (n=1)
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BAHLMAN-VANOOIJEN et al.
one interview was not completely recorded due to technical prob-
lems. The transcript of this interview was further elaborated based
on the notes made during the inter view. Transcripts were returned
to the participants for comments and verification. Eleven partici-
pants agreed that the interview was representative of their views.
We added a clarification to the interview with the par ticipant with
whom the interview had not been fully recorded, which was based
on a discussion of the transcription of the interview.
Respondents' demographic data were gathered at the start
of each interview. As part of the demographics participants were
asked to complete the Leadership Practice Inventory (LPI) question-
naire a week before the interview. The LPI is a 30- item validated
questionnaire containing five subscales for practices of exemplary
transformational leadership (Tourangeau & McGilton, 2004). Each
subscale contains six questions with a 10- point Likert response
scale, where higher scores indicated more frequently shown lead-
ership behaviour (Tourangeau & McGilton, 2004). The LPI was used
to determine whether there was a homogeneous sample of nurses
concerning leadership behaviour (Rendle et al., 2019).
2.5 | Ethical considerations
The study was exempted from formal medical ethical review in
accordance with the Dutch Medical Research Involving Human
Subjects Act (File nr. 2020– 7212). All respondents provided verbal
or written informed consent, depending on the means of conducting
the interview (face- to- face or via digital video conferencing).
2.6 | Data analysis
Interview data were analysed using thematic analysis (Braun &
Clarke, 2006). The analysis followed six phases, supported by Atlas.
ti 8.4.20 software (Friese, 2014). First, the entire text was read to be-
come familiar with the data. Second, features of interest with regard
to the study aim were identified by codes. The work in this phase was
conducted independently by two researchers (WO and AB/EB/MH)
to ensure the researchers' triangulation. The assigned codes were
subsequently discussed, and the consensus was reached. After four
interviews, a concept code map was established and applied to subse-
quent interviews by the executive researcher (WO). The codes of the
other interviews were checked by a senior researcher (EB). Comments
were discussed and the allocated codes were adjusted or clarified. In
the third phase, codes were aggregated according to similarities and
potential thematic patterns were examined. Afterwards, in the fourth
phase, the themes were reviewed and compared again with the inter-
view data. In the fif th phase, the themes were fur ther defined and re-
fined. The work in the third, fourth and fifth phases was performed by
the executive researcher (WO), and the final analysis was validated in
the research group (EB/MH). The research process moved from data
collection to data analysis and back until the description was com-
prehensive, as an iterative process. The analysis process continued
until no new information had been identified. Data from the LPI were
analysed using descriptive statistics in Microsoft Excel.
2.7 | Rigour
The rigour of the study was enhanced by the use of different tech-
niques (Lincoln & Guba, 1985 ). The trained interviewer extensively
discusse d the technique an d content of the firs t two interview s in the
research group to ensure accuracy. To enhance transparency, the ex-
ecutive researcher, who is a nurse herself, critically reflected on her
own beliefs by making self- critical memos, which she subsequently
discussed with the research group (EB/MH/AB/JM). Furthermore,
an audit trail was used to trace decisions made during the research
process. To guarantee dependability, data collection and analysis
were undertaken simultaneously in a c yclic manner, contributing to
the explorative nature of the study. Finally, a thick description was
used in the final report to enable the reader to assess whether the
findings are transferable to another setting.
3 | FINDINGS
A total of 12 nurses were interviewed (Table 1). The interviews
lasted between 38 and 64 min (mean 52 min). The study participant s
ranged in age from 27 to 40 years, with the majority of nurses being
female. Nurses had been practising for 8.3 years on average. All
nurses had a Bachelor of Nursing degree. Six of them also had a mas-
ter's degree, the majority being in Nursing Science, and they were
all members of the NSG. These nurses worked partly as a nurse and
partly as a nurse scientist , policy advisor or nurse teacher. One of the
participating nurses did an in- service training to be a manager but
still worked as a nurse and did not have a formal role as a manager.
The nurses' self- reported leadership practice (LPI) mean score was
7.4 (range 6.0– 8.9) on a 10- point Likert scale.
On the basis of the interviews, a tot al of 313 codes were identi-
fied, of which 130 codes focused specifically on nursing leadership,
118 codes reflec ted views on patient participation, and 65 codes con-
cerned the actual use of leadership to facilitate patient par ticipation.
On the basis of all codes, the following six main themes were identi-
fied: (1) nursing leadership, (2) patient participation, (3) using patients'
preferences, (4) building relationships, (5) task- focused nursing and
(6) need for role modelling. The first two themes concerned the per-
ceptions of nurses about leadership and participation. The following
themes reflected on how to use leadership behaviours for patient
participation, the relationship as a prerequisite, task- focused care as
hindering, and role modelling as a need for improvement (Figure 2).
3.1 | Nursing leadership
The participant s described a nurse leader as a competent, reflective,
enthusiastic, inspiring, and critical professional, with a helicopter
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view on patient care and who continually aims for improvement.
Nurses emphasized that their leadership behaviours developed
over time, on the basis of work experience and exploration of the
leadership style that suits them best. Nurses described a wide
range of leadership behaviours. Some nurses emphasized enhancing
evidence- based practice as an important part of nursing leadership
and indicated that they played a leading role in quality improvement,
innovation or implementation.
'The protocols we have on the Q portal [digital pro-
tocol database] are nice of course, but they are most
of the time very old and often there is no evidence
given. I tr y, with the protocols we have on the wards,
I try by means of a literature review or in contac t with
the medical doctor to substantiate them, so that we
are really working according to the most recent in-
sights.' (Female/MSc/34 years.)
Nurses regarded motivating colleagues to act as a part of
nursing leadership, for example by keeping each other involved
in quality projects, sharing knowledge, discussing care issues,
asking critical questions, acting as a team, and supervising new
colleagues or students. Furthermore, showing professional pride
about the nursing profession, in general, was regarded as a part
of leadership. Nurses cited examples such as promoting the nurs-
ing profession as a 'serious profession' to the out side world, ad-
vocating more awareness for the delivery of fundamental care,
encouraging professionalization through more nurses receiving
further education, and promoting the nursing profession as one
that is of equal importance as that of physicians. Moreover, nurses
described leadership as supporting patients, for example during
medical rounds, or by organizing a patient or multidisciplinary con-
sultation. In addition, some nurses described leadership behaviour
as delivering patient- centred care, representing patients' inter-
ests, and making them feel safe. Motivating and stimulating pa-
tients in self- care and mobilization to promote their independence
and recover y was also regarded as leadership.
'But I think that ever y nurse can show nursing lead-
ership, like in patient care, by making decisions
together with the patient and finding out, what
does someone [the patient] want. And sometimes,
n12
Male/female, n3/9
Age, mean in years (range) 32 ( 27– 4 0 )
Bachelor's degree/Master's degree, n6/6
Years of work experience as a nurse, mean (range) 8.25 (2.5– 15)
Clinical ward where the participating nurses were working, n
Surgical departments 5
Internal departments 6
Other departments 1
Years of work experience on current clinical ward, mean (range) 7.50 (2.5– 15)
Hours of work per week in patient c are, mean (range) 25 (8– 36)
Positions of MSc nurses next to patient care, n
Nurse scientist 3
Nurse policy advisor 1
Nurse teacher 1
Hours of work per week in position next to patient care, mean (range) 19 (12– 27 )
Result of the Leader ship Practice Inventory (LPI), mean (range) 7.4 (6.0– 8.9)
TABLE 1 Nurse characteristics
FIGURE 2 Themes about the use
of leadership to facilitate patient
participation in fundamental care.
Prerequisite: Building Relationships
Facilitating:
Need for
Role Modeling
Defining:
Nursing
Leadership
Hindering:
Task-Focused
Nursing
Defining:
Patient
Participation
How: Using Patients’ Preferences
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BAHLMAN-VANOOIJEN et al.
that clashes with the treatment policy that is pre-
scribed by the doctors. And that you also stand for
the patient and dare to represent them.' (Female/
MSc/28 years)
3.2 | Patient participation
Most nurses viewed patient par ticipation mainly as ensuring active
patient involvement in care and more personal control for patients.
Nurses described seeking an equal collaboration with patients, writ-
ing their daily reports together and having conversations to deter-
mine patients' preferences and needs as examples of how to ensure
the active involvement of patient s in their care.
'Yes, I think also providing patients' own control, I
think. But also having a conversation with the patient.
What do you want? How do you see this? How do you
experience this? What is the meaning of quality of life
for you, you know, and does this [treatment policy]
fit? Empathize with patients' perspectives and iden-
tify what is right for them.' (Female/BSc/32 years)
Furthermore, nurses indicated that involving family in care also en-
abled patient participation, for instance by offering rooming- in, which
facilitates family involvement in physical care and decision making.
Sharing information about the course of hospitalization and treatment
options was mentioned as another means of enabling participation, to
ensure that patients made informed choices. Making use of the unique
experiences of patients was also indicated. Nurses mentioned that they
sometimes experienced a conflict between the patients' preferences
and experiences and their own expertise or treatment policy on, for ex-
ample, medication use, manner of physical care or frequency of mobili-
zation. S ome nurses regarded the expertise of the patie nt as paramount,
only making exceptions for unsafe care. Other participants described
the medical treatment guidelines as more important, whereas others
preferred to find a compromise. Nurses also regarded suppor ting self-
care as enhancing patient participation. They indicated that they dis-
cussed the patients' preferences for the manner and timing of washing
or mobilization, provided that this suited the nurses' own planning.
'One supports self- management and self- care partici-
pation. It is your task as a nurse to encourage patients
to be involved and to help themselves.' (Female/
MSc/29 years).
Nurses mentioned several developments in the near future that
might have an impact on the demand for patient participation in care,
such as a more patient- centered approach, more multidisciplinary
collaboration, and greater use of technology. They elaborated that
patients will be more assertive and critical and will take the lead,
which requires more multidisciplinary collaboration between patients,
nurses, and other healthcare professionals. Nurses believed that
technology will lead to more opportunities for patient participation,
for example, patients using devices to monitor their own nutritional
status or level of activity.
'I think that patient participation will become more
and more important owing to technical develop-
ments. We will ask more of a patient. Sometimes,
we will appeal more to their own responsibilit y. So,
I think that patient participation goes hand in hand
with nursing leadership, how we c an support patients
but also with technical advancements and other new
developments.' (Male/BSc/28 years).
3.3 | Using patient preferences
Some nurses indicated that they use leadership behaviours to ini-
tiate patient participation by informing patients to take more per-
sonal control, mainly with regard to formulating their needs of the
day and making daily appointments about washing or mobilization.
Furthermore, nurses described being aware of their own role and
responsibility to invite patients to share preferences or expectations
as part of leadership behaviour. Thereby, nurses described empha-
sizing towards patients that they do have a say in their own care and
during the disease process they are going through.
'Well, any way, being aware that you can ask a ques-
tion about how they [patients] wish to participate
in their care that day. That is a part of leadership.'
(Female/MSc/36 years)
'Well, by saying to patients you know, you can, you
can have a say in your own disease process. You can
tell the doctor that you do not see this [treatment]
happening.' (Male/BSc/40 years)
Nurses described several exemplary practices in which they use
their leadership behaviour to promote patient participation. In their
contacts with the patient, some nurses indicated that they deviated
from the protocols or treatment plans to create more room for their
patients' preferences and to prioritize patients' wishes above the daily
ward structure.
'A certain protocol, guideline, or care plan does not
fit everyone. But if you notice, together with the pa-
tient, that the next step in a care plan is too early or
does not fit, you discuss which alternatives exist and
what the patient could do or wants instead.' (Female/
MSc/29 years)
During the physicians' round, nurses described asking critical
questions to physicians in accordance with their patients' needs, and
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BAHLMAN-VANOOIJEN et al.
reminding physicians to involve their patients. In working with their col-
leagues, nurses regarded working together as a team to realize patients'
preferences as important, for example by discussing who is able to sup-
port a patient if they would like to be washed in the afternoon and the
nurse does not reall y have time at that part icular moment. Fur thermore,
nurses indicated discussing patient cases including their personal goals
during team meetings, although this was not often the case.
'And if you are struggling with involving patient s you
should also discuss this together. The nurse manager
of course can also have a cer tain role in this, but I
think that also, actually there is a role for every team
member.' (Female/MSc/29 years).
Nurses regarded nursing leadership and patient participation as
inextricably linked and described that leadership is important to facil-
itate par ticipation. However, they felt that the level of leadership be-
haviour for patient participation is rather disappointing in colleagues.
Some nurses indicated unfamiliarit y about the meaning and practice of
nursing leadership for patient participation in daily care.
'I notice that inexperienced colleagues achieve less
patient participation, because they are not yet able to
show leadership. They cannot rely on their expertise
and knowledge, and then they work more to achieve
the goal and do not take the patient with them in this
process.' (Female/MSc/40 years).
'So, if we, when you ask ever yone, do you, do you
think that it should [showing leadership to involve pa-
tients], they say yes, we have to do that, this is what
we stand for. But are we doing it really? I think that is
still really a bit disappointing.' (Female/BSc/28 years)
3.4 | Building relationships
Nurses indicated that building a relationship with patients was pre-
requisite to showing leadership as well as to facilitate patient partici-
pation. Nurses described showing leadership by deliberately making
time to build up a relationship with patients, which would lead to im-
proved patient participation and positive experiences in healthcare.
Nurses highlighted the need for getting to know the patient, taking
time for informal and meaningful dialogue, active listening, giving
undivided attention, feeling responsible, empathizing with patients,
signalling and responding to patients' needs, and creating a comfort-
able, safe and trusted environment. The participants also described
the need for equal partnership between patients and nurses.
'Having a relationship is really import ant, or at least
[ensuring] that patients feel that they have an oppor-
tunity to discuss something. If they only see me com-
ing and leaving in two seconds, and that is the only
contact we have, I do not believe, when I imagine I am
a patient, that I would feel safe discussing a sensitive
topic.' (Female/MSc/29 years)
'The moment you start with it, then you start work-
ing on this trusting relationship, that can lead to pa-
tient par ticipation. So it is, again, that you bring some
nursing leadership, by giving that patient a bit more
trust, and building a relationship with each other so
that they can maybe trust you sooner, whereby you
can feel strengthened, and think, hey, I am actually
more aware, do I have to stand up for this patient, or
will they manage themselves, it really has an impact
on myself. It is an integral process I think.' (Male/
BSc/40 years)
Furthermore, nurses indicated demonstrating leadership aimed at
facilitating patient participation by communicating with patients about
treatment policy or care processes in an open, honest and clear man-
ner, to ensure that patients have opportunities to pose questions, dis-
cuss ambiguities and participate in their care.
'I think that transparency creates participation.'
(Male/BSc/28 years).
3.5 | Task- focused nursing
Nearly all nurses were convinced that the existing and strong focus
on task completion hinders showing leadership in patient participa-
tion. Nurses explained that they acted often from a pragmatic per-
spective to prioritize the order and fixed daily structure of the day
instead of integrating patients' needs. T ime and work pressure with
respect to task completion were considered by nurses as barriers to
showing leadership behaviour and enhancing patient participation.
'Yes, I think we, as nurses, tend to think about our
own interests and [about] tasks that have to be done,
and we really like to tick these boxes on our list. Yes,
I think that we are on the right track seeing patients
as partners, but there is still a lot of potential [for im-
provement].' (Female/MSc/29 years).
'We are too much used to our own struc ture. In our
daily structure, we do medicines and vital signs at 8
o'clock, and afterwards activities of daily living, and
at half past ten we drink cof fee and continue with the
medical round with the physicians. […] But I think it
is more a habit. So, we have not organized our pro-
cesses in a way that we can be flexible.' (Female/
MSc/29 years).
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BAHLMAN-VANOOIJEN et al.
Some nurses indicated that they were questioned by colleagues
when they had not completed all their tasks at the end of their shift,
even though this occurred because of their patients' preferences.
'I regularly see that some patients need to receive
temazepam rectally in the evening, and then some-
times the patient says: 'I do not want to go to sleep
yet.' Should I reply, 'Even so, I am going to administer
it to you right now'? No, my answer is: 'Please give me
a signal when you want to sleep and then my night-
shift colleague will come.' And then, during handover,
I see my nightshift colleague thinking, why do I still
have to do that? I thought, why are you sulking that
you still have to do that, when this is patients' wish?'
(Female/BSc/28 years).
3.6 | Need for role modelling
Nurses described several necessar y changes evolving around role
modelling to facilitate leadership about patient participation. They
indicated that more knowledge in nurses about the meaning and dif-
ferent ways of patient par ticipation, as well as communication and
coaching skills, are amongst the first things that will be necessar y to
improve leadership and patient participation.
'I think I would like to highlight again what we stand for
and what patient participation exactly means, and what
we think is important about it . […] But, I think there is
a role for awareness, you have different degrees of pa-
tient par ticipation I think, and I think that maybe a bit
more awareness is needed.' (Female/BSc/28 years).
Further, it was indicated that patients need to be better informed
by nurses about how they actually can participate in their own care
during hospitalization. Therefore, more attention and emphasis on
these aspects will be required during the nursing intake interview,
for example by asking patients about their personal goals. One of the
nurses described a 'preoperative education day' as a good example of
preparing patient s for admission. On such a day, the patient s receive
information about their hospitalization, which help them to understand
what to expe ct during admissi on. This could lead to m ore active patient
involvement, for example about mobilization, use of medication, and
nutrition. Nurses also indicated the need to formulate a shared vision
of patient participation at the ward level, so that all nurses will model
patient participation in the same way.
'I think what could help us is a shared vision on pa-
tient par ticipation. When you share this vision with
each other, everyone supports this vision, and we
promote it in the same way. Right now, I think that ev-
eryone just does whatever they think is best.' (Male/
BSc/33 years)
Nurses indicated that they need someone to set the tone for the
ward in showing leadership behaviour for patient participation. A few
nurses described how they felt they could be a role model themselves,
for example by showing how to make partnerships with patients to
realize making shared decisions, paying extra attention to reporting
psychosocial care and nursing care plans, and holding other nurses ac-
countable for showing leadership and enabling participation.
'I can take, of course, a clearer leading role, together
with other nurses who partly do this already, to cre-
ate a small group in which we motivate other nurses
on the ward, to have a conversation in that way
and report in that way [in medical files].' (Female/
MSc/34 years)
4 | DISCUSSION
The results of this qualitative study provided insight into nurses' per-
ceptions of how they use leadership behaviour to facilit ate patient
participation. Six themes were identified: nursing leadership, patient
participation, using patients' preferences, building relationships,
task- focused nursing and need for role modelling. First, the results
about nursing leadership and patient participation are discussed as
separate concepts in the light of the international literature, fol-
lowed by the additional identified themes, in which nursing leader-
ship related to patient participation in fundamental care is discussed.
About nursing leadership four domains can be identified in the
literature: the clinical, professional, health system, and health policy
leadership domains (Heinen et al., 2019) . The partici pants of our st udy
described perceptions of nursing leadership that predominately re-
semble the provision of 'good' fundamental care, which corresponds
mostly with elements of the clinical leadership domain. Clinical lead-
ership competencies are focused on promoting health, facilitating
self- care management, optimizing patient engagement, and pre-
venting future decline (Heinen, 2019). These elements recurred in
the perceptions that nurses described with regard to nursing lead-
ership, whereby they mainly described examples of leadership such
as optimizing patient care and engagement. Furthermore, clinical
leaders are expected to act as clinical experts, engage in evidence-
based practice, and collaborate with other healthcare professionals
(Heinen et al., 2019). On a more individual level, a leader act s as a
resource person, preceptor, mentor or role model, demonstrating
critical and reflective thinking (Sievers & Wolf, 2006). Although the
nurses in our study described leadership as motivating and inspir-
ing colleagues to act, this leadership behaviour was mainly focused
on enabling others to act (Tourangeau & McGilton, 2004). Nurses
described only a few examples of how they are modelling the way
themselves, whils this is an important part of leadership behaviour
(Heinen et al., 2019; Tourangeau & McGilton, 2004).
The nurses' perception of patient participation is largely con-
gruent with its description in the international literature. Tobiano,
Marshall, et al., 2016 described activities undertaken by nurses and
1052
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BAHLMAN-VANOOIJEN et al.
patients to promote patient par ticipation, such as nurse– patient
dialogue, sharing of knowledge, and involvement in planning and
managing self- care (Tobiano, Marshall, et al., 2016). Although nurses
initially described a wider spectrum of hypothetical possibilities to
involve patients in care, examples about how they truly exercised
the facilitation of patient par ticipation were limited to informing
patients and encouraging them in physical care. When asked about
setting goals with patients or involving them in other aspects of care,
nurses indicated this was often not the case. Literature suggests
three levels of patient engagement, including consultation, involve-
ment, and partnership (Carman et al., 2013). Reaching a partnership
can be achieved by involving patient s in decision making, but nurses
find it challenging to specify how they do this in practice (Sahlsten
et al., 2008). This was also observed in our study, where the exam-
ples of their actual practice mainly gravitated toward consultation
or perhaps involvement. Therefore, nurses do not seem to achieve
all different levels of patient par ticipation, which is consistent with
previous findings (van Belle et al., 2020).
Nurses indicated that they practised leadership to facilitate pa-
tient participation mainly by inviting patients to participate, using
their preferences, and supporting their needs. This is consistent with
nurses' perceptions about leadership in general as suppor ting pa-
tients' care needs. Nurses and patients have different priorities when
it came to attending to patients' needs (Mudd et al., 2022). Therefore,
the leadership behaviour of nurses is required to achieve prioritization
of patients' needs, such as modelling expected behaviours, setting the
tone for the ward, and providing resources to support the psychoso-
cial fundamental care delivery (Conroy, 2018). The nurses in the cur-
rent stud y described the need for havin g role models and to ac t as role
models themselves. In addition, nurses experienced difficulties about
practising leadership for participation, due to uncertainties about the
meaning and different ways of participation, which seemed to recur in
the described examples about patient participation. It is reported that
nurses experienced a lack of knowledge on how to invite, motivate,
and suitably promote patient participation (Oxelmark et al., 2018).
There is room for improvement by generating more knowledge and
coaching skills in nurses to reach a higher level of patient participation
through true partnership and shared decision making with patient s.
Furthermore, searching, practising and implementing evidence- based
strategies, such as hourly nursing rounds or bedside handovers, could
promote seeing patients as par tners (Tobiano, Marshall, et al., 2016).
Although nurses described enhancing evidence- based practice as
part of nursing leadership, they did not indicate that they actually
practised this about patient participation.
Another challenge nurses described was pressures from daily
routines and their peers as hindering leadership for patient partici-
pation. Task- focused nursing care has been recognized in earlier eth-
nographic studies as a barrier to participation (van Belle et al., 2020).
Interes tingly, none of the nurs es mentioned tas ks, such as suppo rting
patients in their preferences or questioning patients' goals, as part of
their daily routines. Nurses suggested questioning patients' expec-
tations and goals for hospitalization during the nursing intake, which
seems a way to claim time and awareness for patient participation.
Integrating relational and psychosocial aspects in daily care routines
is needed to promote patient participation. More importantly, nurse
leaders are expected to optimize patient engagement, but respon-
dents described that nurses mainly invested time in involving pa-
tients when it suited their planning. This calls for action from nurses
to reroute from task- focused nursing to acknowledging patients'
preferences. Examples of rerouting from tasks were however lim-
ited, which implies that there seems to be an inability to respond in
a patient- centered way to task- oriented thinking. Strengthening the
ability to reroute from the focus on task completion, and changing
behaviours of nurses would show real leadership of nurses in daily
practice. Leadership interventions such as mentoring could be help-
ful in this (Cummings et al., 2021).
The nurse– patient relationship was described as a prerequisite
for executing leadership practices to enhance patient participation.
The ability to build a relationship is associated with nursing leader-
ship because it involves the ability to understand and respond to
the feelings of others (Feo et al., 2 017). Relating to patients is also
identified as a method of enabling patient participation (Tobiano,
Marshall, et al., 2016). Feo et al. (2017) described how an estab-
lished nurse– patient relationship consists of five essential relational
elements: developing trust, giving undivided attention, anticipating
patients' needs, getting to know the patient and evaluating the qual-
ity of the relationship. The par ticipants in this study described that
they practised most of these aspects of establishing a relationship,
except for the evaluation of the quality of the nurse– patient relation-
ship. These findings are rather promising, as delivering care centred
on such relationships is challenging (Feo et al., 2017). Even so, there
is still room for improvement about the evaluation of the quality of
the nurse– patient relationship, by talking to patients about their
perception of the relationship, and determining whether patients'
expectations have been met and where improvements can be made
(Feo et al., 2017). Reflection on practice will help to create awareness
of the nurses' current approaches toward their role in engaging with
patients and can lead to nurses acknowledging patients' needs in a
more patient- centred manner. This reflection seems to fit the role of a
nurse leader as a reflective thinking professional (Heinen et al., 2019).
In terms of strengths, this study is one of the few qualitative
studies exploring nurses' perceptions of leadership behaviours for
enhanced patient participation in fundamental hospital nursing
care. Leadership behaviours for fundamental care including pa-
tient par ticipation are not widely investigated in daily practice. This
study provides a preliminar y exploration of the relation between
leadership behaviours and patient participation and provides rich
data based on 12 interviews about this interrelationship, conducted
amongst nurses possessing either a BSc or MSc, working in a wide
range of clin ical wards, and having varying levels of wo rk experience.
5 | LIMI TATIONS
This study also has some limitations that need to be addressed. First,
it could be argued that convenience sampling might have led to some
|
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BAHLMAN-VANOOIJEN et al.
selection bias, as participants were included in their willingness to
participate. Therefore, perhaps only nurses showing stronger lead-
ership behaviour may be involved, which is reflected in an average
to high mean score on the LPI. On the contrary, this fits with the
explorative ethnographic nature of the study and shows how these
experienced nurses describe their leadership behaviours for patient
participation. Second, asking the nurses to fill in the LPI might have
led to giving some direction in discussing leadership behaviours in the
interviews. However, we expect this to have only a limited impact in
getting insight into the perceptions of nurses on how they enact lead-
ership for patient participation, as concepts of the LPI had not been
integrated in the inter view guide. Finally, we acknowledge that we
only had a rather small number of participants, which is however not
exceptional for qualitative research. The perceptions of the partici-
pating nurses seemed to be representative of nurses working in this
health facility.: during the last interview no additional data was found
to further develop the properties of the themes, and only individual
variation existed concerning examples of leadership for participation.
6 | CONCLUSION
Nurses use leadership behaviours to facilitate patient participa-
tion in fundamental care by inviting patients to par ticipate and
eliciting and supporting their preferences. Although nurses de-
scribed nursing leadership also as motivating colleagues to act and
enhancing evidence- based practice, they did not practise this be-
haviour themselves with regard to patient participation. Evidence-
based strategies and role modelling leadership behaviours about
patient participation are needed. Fur ther research will be neces-
sary to develop and test leadership interventions to improve pa-
tient participation in fundamental care, such as mentoring or role
modelling.
AUTHOR CONTRIBUTIONS
All authors have contributed to the conception and writing of the
paper. All authors have had a significant doing in drafting and revis-
ing the article for import ant intellectual content, and have agreed on
the fina l ver sio n. WO, AB, EB, MH: Made substantial co ntributions to
conception and design, acquisition of data or analysis and interpreta-
tion of data. AB, EB, JM, GH, MH: Involved in drafting the manuscript
or revising it critically for important intellec tual content. WO, EB,
AB, JM, GH, MH: Given final approval of the version to be published.
Each author should have participated sufficiently in the work to take
public responsibility for appropriate portions of the content. WO,
EB, AB, JM, GH, MH: Agreed to be accountable for all aspects of the
work in ensuring that questions related to the accurac y or integrity
of any part of the work are appropriately investigated and resolved.
ACKNOWLEDGEMENTS
We would like to thank all nurses who par ticipated in the interviews.
Through their valuable input, we could provide more insight into
the use of nursing leadership to facilitate patient participation in
fundamental care. Open access funding enabled and organized by
ProjektDEAL.
FUNDING INFORMATION
The work has received no grants from any funding agency in the
public, commercial or social- profit sectors. There was no involve-
ment of any funding body in the conception, design and writing of
this paper.
CONFLICTS OF INTEREST
The authors declare that they have no conflicting interests.
PEER REVIEW
The peer review history for this article is available at https://publo
ns. com/pu blo n/10.1111/ jan.15 329.
DATA AVAIL ABI LIT Y S TATEM ENT
Data available on request from the authors. The data that support
the findings of this study are available from the corresponding au-
thor upon reasonable request.
ORCID
Wilmieke Bahlman- van Ooijen https://orcid.
org/0000-0001-9251-4874
Elise van Belle https://orcid.org/0000-0001-5723-4850
Getty Huisman- de Waal https://orcid.org/0000-0003-2811-4176
Maud Heinen https://orcid.org/0000-0001-7536-1327
TWITTER
Getty Huisman- de Waal @getty_huisman
Maud Heinen @MaudHeinen
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SUPPORTING INFORMATION
Additional supporting information can be found online in the
Suppor ting Information section at the end of this article.
How to cite this article: Bahlman- van Ooijen, W., van Belle,
E., Bank, A., de Man- Van Ginkel, J., Huisman- de Waal, G., &
Heinen, M. (2023). Nursing leadership to facilitate patient
participation in fundamental care: An ethnographic
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