Patient Participation in Nursing Care: Views From Ghanaian Nurses, Nursing Students, and Patients

Abstract

Previous studies on patient participation reported inconclusive benefits of patient participation in health care. Consequently, the World Health Organization is actively highlighting the need for the participation of patients and their families in their care. The aim of this study was to explore the views of nurses, nursing students, and patients on patient participation in Ghanaian hospitals. Sixty-five participants made up of 15 patients, 25 registered general nurses, and 25 undergraduate nursing students were involved in the study. Data collection was done through interviews and focus group discussions. Content analysis was utilized in analyzing the data to generate four main categories. These categories were as follows: (a) meaning of patient participation in Ghana, (b) patient participation encouraged more during discharge education, (c) patient participation in nursing care higher in private and smaller hospitals, and (d) perceived facilitators and inhibitors of patient participation in nursing care. Participants in this study indicated that patient participation in nursing care meant involvement of patient in treatment decisions and nursing care procedures. Participants agreed that patient participation in nursing care was mostly encouraged during discharge education. Participation was perceived to be higher in private and smaller hospitals. Wealth and higher education were perceived as facilitators of patient participation while workload and high patient acuity were perceived as inhibitors.

Introduction

The concept of patient participation in nursing care is seldom researched in Ghana. Previous studies in other jurisdictions have reported different views on patient participation. Many of these studies have reported inconclusive benefits of patient participation. Some researchers have also reported different views and understanding of patient participation by various categories of health workers such as physicians and laboratory technicians. The different views on the meaning and benefits of patient participation may be due to the universal application of patient participation, even though interactions between patient and various categories of health workforce may be different in various geographical regions. Consequently, the World Health Organization (WHO; 2005, 2006, 2009) is actively highlighting the need for the participation of patients and their families in their care. Although there are 96 hospitals in the Ashanti region that serve various communities (Ghana Health Service [GHS], 2017; Ghana Statistical Service [GSS], 2018), there are inadequate empirical data on the nature of patient participation within these hospitals. This study was aimed at exploring the views of nurses, nursing students, and patients on patient participation within Ghanaian hospitals located in the Ashanti region.

Literature Review

Literature review covers the following areas: meaning of patient participation in health care and benefits of patient participation in health care.

Meaning of Patient Participation in Health Care

There is no clear definition of patient participation in the literature. Many researchers have found the meaning of patient participation to be vague (Jansen & Hanssen, 2017; Ninson, From, & Lindwall, 2018). There are different views that currently exist on the concept of patient participation. The views on patient participation are different within different jurisdictions and among different disciplines within the health-care system (Vahdat, Hamzehgardeshi, Hessam, & Hamzehgardeshi, 2014). In one view, researchers consider patient participation as the person’s participation or engagement in treatment decisions about him or her (Gallivan, Burns, Bellows, & Eigenseher, 2012; Longtin et al., 2010), while in another view, patient participation means performance of tasks by patients based on doctors’ and nurses’ instructions (Soleimani, Rafii, & Seyedfatemi, 2010; Vahdat et al., 2014). Ninson et al. (2018) related the concept of patient participation to learning, caring relationships among patient- and health-care workers. A recent scoping review by Halabi et al. (2019) found that patient participation meant patient engagement and involvement as partners in decision-making regarding their health care. Moreover, various terminologies have been used interchangeably to represent the concept of patient participation. Client involvement, patient collaborations, patient partnership, client empowerment, and client-centered care are mostly used interchangeably to represent patient participation (Longtin et al., 2010).

A study by Kvangarsnes, Torheim, Hole, and Öhlund (2013) concluded that patient participation should be understood in relation to specific settings. Involvement of patients admitted in hospitals has three levels: involvement during admission, at the point of discharge, or after discharge from hospital (Andiric, 2010; J. Smith & Liles, 2007). This study explored aspects of patient participation within Ghanaian hospitals from nurses, student nurses, and patients’ point of view.

Benefits of Patient Participation in Health Care

Patient participation is currently recognized as an important component in health care and seen as a means of improving patient care (Longtin et al., 2010; Ninson et al., 2018; Weingart et al., 2011; WHO, 2006). Previous studies have indicated that patient participation is likely to improve patient satisfaction, improve disease management, increase trust, enhance patient–professionals relationships, and improve patient outcomes (Collins, Britten, Ruusuvuori, & Thompson, 2007; Sanders et al., 2013; Weingart et al., 2011). The advantages of patient participation to health outcomes have been inconclusive (Ampofo, Tagbor, & Bates, 2018; Sanders et al., 2013). Patient participation has brought about some positive outcomes for specific procedures and different patient groups (Carlsson, Nygren, & Svedberg, 2018; Lindberg, Persson, Hörberg, & Ekebergh, 2013; Mctier, Botti, & Duke, 2015; Näsström, Idvall, & Strömberg, 2015; Willeboordse, Hugtenburg, Schellevis, & Elders, 2014). Patient participation in medication management, aged care, and pediatric care during hospital admissions is thought to reduce errors in medication, leads to improved relationship between care givers and older persons, and also results in quality child care within health facilities, respectively (Carlsson et al., 2018; Lindberg et al., 2013; Mctier et al., 2015; Näsström et al., 2015; Willeboordse et al., 2014). The conflicting results of benefits of patient participation may be due to the lack of a standard meanings or practice definition of patient participation in the literature (Sanders et al., 2013). Consequently, the WHO (2005, 2006, 2009) is actively highlighting the need for the participation of patient and family in their care.

Materials and Methods

Study Design

Qualitative exploratory descriptive design was used to explore the views of Ghanaian nurses, nursing students, and patients on patient participation in Ghanaian hospitals from January to March 2018. Qualitative exploratory descriptive design allows researchers to understand the experiences of people about a phenomenon (Polit & Beck, 2013). Qualitative explorative descriptive study design was utilized because researchers wanted to have in-depth understanding into the nature of patient participation within Ghanaian hospitals.

Setting

Ghana is a country in West Africa with a current projected population of 30.4 million people and is divided into 10 regions with the Ashanti region being one of those 10 regions (GSS, 2018, 2019). There are 96 hospitals in the Ashanti region (GHS, 2017). Among these 96 hospitals is a university hospital, a teaching hospital, private hospitals, district hospitals, several health centers, polyclinics, and community-based health planning and services strategy compounds (GHS, 2017). The nurse population ratio of the Ashanti region is 605 (GHS, 2017).

Population and Sampling

Two private hospitals, two public hospitals, and two universities were purposively selected for this study. Population in this study included patients, registered general nurses (RGNs), and nursing students who had experiences in surgical, medical, and emergency wards of selected public and private hospitals. Only patients who visited selected hospitals in the Ashanti region for treatment in less than 6 months prior to this study were included. Students who were included were those who were placed in selected hospitals 6 months prior to study. Only nurses who had worked in selected hospitals were included in study. Sixty-five participants made up of 15 patients, 25 RGNs, and 25 undergraduate nursing students were involved in the study. All participants were within the ages of 20 and 89 years.

Data Collection

Data were collected through interviews and focus group discussion (FGDs). Patients were interviewed while FGDs were utilized in collecting the data from undergraduate student nurses and RGNs. Five FGDs were conducted with RGNs with each group constituting five nurses. Five FGDs were also carried out with undergraduate student nurses with each group constituting five students. Semistructured interviews were conducted with 15 patients. Interviews and FGDs were conducted in either English or Twi. Patients who could not speak English were interviewed in Twi. Interview questions were translated into Twi by a language expert for the purpose of interviewing participants who could not speak English. Twi is the local language spoken in the Ashanti regions where data were collected. Questions for interviews and FGDs were developed by research team headed by a nursing professor (Online Appendix 1). Questions for interviews and FGDs were pretested to identify ambiguous questions. Probes were used to elicit further descriptions of views on patient participation. Data were collected within a 3-month period from January to March 2018. Each interview and FGD lasted for about 1.5 hours. Data were saturated after interviewing 15 participants and conducting FGDs with 50 participants. Data were transcribed and stored on a storage device acquired for study purposes. Numbers and alphabets were used to represent participant names: PPI1 (Patient Participant 1 involved in semistructured interview), UGNSFG 5 (Undergraduate Nursing Student Participant 5 involved in focus FGD), and RGNFG 2 (Registered General Nurse Participant 2 involved in FGD). Interviews were carried out in the homes of patients. The FGDs were carried in the conference room of Christian Service University College, where the first author worked. Data collection commenced after permission was granted by the regional coordinating council, hospitals, and universities whose patients, nurses, and students were involved in the study.

Data Analysis

Qualitative content analysis was used in the analysis of data. Data were analyzed manually by the research team headed by a professor of nursing. Holloway and Wheeler’s (2010) data analysis format was utilized in analyzing the data. This format uses the following phases: validating data, transcription, cleaning, and coding data (Holloway & Wheeler, 2010). Similar codes that were identified during reading of transcripts were grouped to form categories.

Rigor

A pretest ensured that ambiguous questions in interview guide were modified and made clearer for participants. The researchers had prolonged interaction with patients, RGNs, and student nurses to ensure in-depth understanding of findings that emerged. The research team headed by a professor of nursing discussed field notes to ensure the correct interpretations of data. Data transcriptions and coding were done by the research team to ensure that the right views on patient participation were reported. Member checking and peer debriefing were carried out by the research team during data analysis to validate the data from participants. Member checks and peer briefings facilitated understanding into patients, RGNs, and undergraduate nursing students’ views regarding patient participation in nursing care. Researchers went back to patients, RGNs, and undergraduate student nurses to find out whether categories formulated represented their opinions. Personal biases and assumptions were handled by bracketing because almost all researchers in this study were professional nurses in Ghana and have worked in various hospitals in Ghana. Researchers’ personal knowledge and assumptions of patient participation did not interfere in the formulation of categories in this study.

Ethical Consideration

Ethical approval was granted by the Committee on Human Research Publication and Ethics at the Kwame Nkrumah University of Science and Technology. Administrative permission was sought from the Ashanti regional coordinating council, selected universities, and hospitals. Issues of confidentiality and anonymity were fully explained to participants after which they signed informed consent forms. Codes rather than names were used to represent the participants. The names of selected hospitals and universities were also concealed for ethical reasons. Participants were reassured that any withdrawal from study would not attract any sanctions. The study caused no harm to participants.

Results

Sixty-five participants including 45 females and 20 males aged between 20 and 89 years were involved in this study. Fifteen participants were patients, 25 were undergraduate nursing students, and 25 were RGNs. Thirty participants were married while 35 participants were either single or divorced. Fifty-five participants were Christians, while 10 were Muslims. The following four categories were generated from data: (a) meaning of patient participation in Ghana, (b) patient participation encouraged more during discharge education, (c) patient participation higher in private and smaller hospitals, and (d) perceived facilitators and inhibitors of patient participation in nursing care.

Meaning of Patient Participation in Ghana

The majority of participants expressed their opinions on the meaning of patient participation in nursing care. Participants indicated that they considered patient participation in nursing care as involvement of patient in treatment decisions and nursing care procedures. Patient participants said their ability to get involved in nursing care largely depended on the respect they are shown by nurses and information that is provided to them:

Patient participation is getting involved in my care. I usually get involved when I see the respect is mutual, otherwise I don’t say or do anything. Sometimes you feel you can express yourself in the decision-making process about your health with nurses who are tolerant and respect patients’ views. (PP 10)

Participation in nursing care is taking part in care and listening to instructions from nurses on what we must do. I think we are supposed to contribute to the decisions about our care too. That is patient participation in my view. For me personally, I need enough information from nurses to get involved. If I know what I need to do to support my care, why not? (PPI 7)

Many patients said that they participated by performing tasks that nurses asked them to perform during treatment. Patients did not take initiative on their own regarding participation because they believed nurses were competent in their jobs and knew what to do at every point in time:

I participate when nurses ask me to assist in doing something during a procedure or treatment. I get better understanding on what they want me to do if they ask and explain to me. I try to do exactly what they ask me because I know it is their job and they know what they are doing. I don’t assess what they do because I don’t have knowledge on those things. (PP 8)

Well if they don’t ask anything of me, I don’t take actions on my own because I feel it might not be the right action. But if any nurse gives me a specific instruction, I just obey and do it. That is my way of getting involved and I know they are trained. (PP 9)

Many nurses expect their patients to get involved in their care by asking questions, disclosing all necessary information that will assist in effective implementation of nursing care, and helping during nursing procedures. Many nurses indicated that only patients who were more educated met nurses’ expectations of questioning:

I think patient participation is when patients contribute to their care by asking questions during our treatment. I think they can ask questions about things that are not clear to them. Asking question may help us nurses clarify issues. Unfortunately, we don’t have many clients questioning us and what we do, though sometimes those with higher educational degrees do. (RGNFG 2)

Patient participation is when patients that come to us get involved in their care by asking questions of the things we do for them. I think they can get involved by asking more questions. But here our patients don’t ask questions so much. You sometimes have those who are more educated with higher degrees asking questions. The illiterates usually don’t ask questions. (RGNFG 8)

Patient participation is when patients get involved in their care through questioning to help us to care for them. They need to question treatment decisions and nursing care activities. It is then that we can explain issues to them. Not much of the involvement by questioning is seen in our facility. (RGNFG 11)

Patient Participation Encouraged More During Discharge Education

The majority of patients indicated that patient participation in nursing care was mostly encouraged during discharge of patients. Patients are usually involved when they are being educated on how to comply with their medications. Education on other means of preventing the disease are usually given less emphasis:

Patient participation in nursing care happens mostly during patient education on discharge. Sometimes nurses take us through how to take our drugs at home during discharge. As for the prevention they don’t usually tell us a lot about that one but mostly on how to take our medications. They will usually allow us to ask question on things we don’t understand in terms of the medication. I wish they could tell us more about how to prevent our diseases from getting to us. (PPI 3)

I think here our participation is expected when we are being discharged. Not much of our involvement during the time we are on admission. But when we are about to go home, we are involved to understand how we are supposed to take our medications. May be the same level of involvement can be encouraged in us during the whole time we are in the wards. (PP 4)

Nursing students also observed that patient participation mainly occurred during discharge education of patients. Students observed during placements that education is usually concise due to the busy nature of the various wards or nursing units. They indicated that not many nurses educated patients on prevention of their diseases. They observed that education during discharge was mostly about complying with medications:

Since the time I have been going to the hospitals during placements, I don’t see much involvement of patients in their care. Usually participation occurs during discharge. Even that, it is usually concise because the nurses are usually busy. Some nurses do better than some nurses. Some are interested in prevention, but many too are not really interested like that. Those who care about prevention will usually tell the patients more during discharge education. That is what I have observed. (UGNSFG 5)

The participation isn’t so much but we usually see it happening during discharge where there is usually a discussion between patient, relatives and nurses about how to take medications at home. I think it will be nice if the patients can be involved when they are on admission, if it is possible. (UGNSFG 25)

Patient Participation in Nursing Care Higher in Private and Smaller Hospitals

The majority of patients pointed out that patient participation in nursing care was higher in private and smaller hospitals. Patients explained that workload in private and smaller hospitals was less when compared with public hospitals which were usually bigger. The reduced workload in private hospitals made it easier for nurses to involve patients in decisions making about their nursing care. This expression can be found in the following statements by participants:

I have visited some small hospitals and big hospitals on different occasions. There is always a difference in how they involve us as patients. The smaller ones have more time for us. They will usually take their time to explain issues to you. The bigger hospitals don’t usually do that. The nurses in the bigger hospitals are always busy. Even public hospitals which are not busy all the time don’t have their nurses engaging us all the time. Maybe they feel they will be paid anyway whether they engage us or not. I prefer going to the smaller hospitals because of their customer care like patient engagement, but when they refer me, I need to go to the bigger one. (PPI 2)

Patient participation in terms of how nurses involve us is better in smaller hospitals. I will always prefer the smaller private hospitals. In the big public hospitals nurses usually are busy. Those who are not busy don’t have the culture of engaging us so much in decisions about our nursing care. The private ones don’t usually have many patients so the nurses involve you in their care. They will take their time to explain issues to you. Maybe the private people want profit so they have good customer care. As for the public hospitals, they are paid from the government so they don’t really care about those things. I wish participation can be high in the public and bigger hospitals too. (PPI 5)

Many nurses said that private hospitals were more interested in providing good customer care toward their clients and usually engaged clients in their nursing care procedures. Although some public hospitals had smaller numbers of patients at certain times, nurses were not seen involving patient in nursing care. The nurses believed that they would still be paid salaries whether they engage in customer care practices such as patient participation or not:

Before I started working in … , I was working in … which is a smaller hospitals. As for … hospital you know the patients are usually not many. So you can take your time to involve patients in your nursing care. But in … Our patients are so many. Customer care in terms of patient involvement must also be good in the private hospitals so that we can attract many patients for better pay. The case is a bit different for public hospitals which are sponsored by the government. Sometimes, there is really no time to spend involving the patients so much in nursing care in the public hospital. I wish we could do that here but the situation here does not permit. Our pay also comes whether we do it or not. (RGNFG 9)

Participation is actually better in smaller hospitals. The workload is most of the time too high in bigger hospitals. In smaller hospitals, the patients are usually few and so you can spend time talking with them usually when they are being discharged. You can take your time to educate them on their medications and how to prevent the re-occurrence of their diseases. But I also think that some nurses in bigger public hospitals feel they don’t have to work extra to get paid. The government will pay anyway whether more patients come or not. (RGNFG 16)

Nursing students were of the view that patients in public hospitals also need similar level of care regarding their participation in nursing care. Undergraduate nursing students indicated that management of public hospitals should find ways of paying enough attention to their clients as occurs in smaller and private hospitals:

I have been placed in both a smaller hospital like … and a bigger hospital like … and I see a big difference in terms of how patients participate in their nursing care. In the bigger hospitals, the participation is less but in smaller and private hospitals, the participation is more. Maybe it is because in smaller hospitals the patients are few. More patients are also encouraged to come back so that smaller private hospitals can get money to pay their staff. I think we should try for the patients in the bigger hospitals too. Maybe it is because they will be paid even if they don’t satisfy the patients through patient participation. (UGNSFG 21)

I have gone for clinical in both smaller hospitals and bigger public hospitals. In the case of private and smaller hospitals, you see that participation of patients in their care was fairly ok but in the bigger hospitals, the patients are more and participation was less. Many patients in big public hospitals also have much more serious conditions and so the participation is usually less. Hospital management and Nurses should do well to involve patients in public hospitals too. (UGNSFG 17)

Perceived Facilitators and Inhibitors of Patient Participation in Nursing Care

Many participants expressed their views on facilitators and inhibitors of patient participation of nursing care in Ghanaian hospitals. This category had four subcategories: wealth as facilitator of patient participation in nursing care, education as facilitator of patient participation in nursing care, workload as inhibitor of patient participation in nursing, and high patient acuity as inhibitor of patient participation in nursing.

Wealth as facilitator of patient participation in nursing care

The majority of participants intimated that people who were wealthy participated more in their nursing care. Many wealthy patients were also more informed about their disease conditions and could contribute more to their nursing care. Many participants linked wealth to having enough knowledge on disease conditions:

The patients who are richer are able to contribute to their care. Maybe the wealthy patients are more educated and informed about their conditions and therefore are able to contribute to their nursing care. Those who are poor don’t really participate much. (RGNFG 23)

I have a doctor that I pay to come check me at home. He has told me a lot about my condition so I usually ask a lot of questions and make sure I am part of whatever they are doing about my problem when I am in the hospital. It is my body so I need to know what is happening. That is very important to me. (PPI 14)

I have realised that when we go to the hospital, we see people who are rich participating more in their nursing care. I think there is some relationship between having enough money and having knowledge. I think the rich people are more exposed because of their money. Some have stayed outside Ghana and therefore are more confident about taking part in their nursing care. (UGNSFG 221)

Education as facilitator of patient participation in nursing care

Patients who were educated with higher degrees asked more question about their care. Some educated patients read about their conditions and wanted to know more about their disease conditions. Many participants in this study related higher levels of patient participation to higher educational levels:

You know I am a teacher so I have read a few things about my problem. I am able to relate more to the things that are being done for me. I am aware of some things about my condition so when I see that things are not going like that I usually seek for clarification. I am not afraid to do that because I am educated to the university level and I teach students as well. (PPI I5)

I have not been to school so I don’t want to be asking too many questions. I may ask needless questions. I don’t really know about the care they give so I cannot contribute very much. I wish I knew some things about my condition so that I can contribute. Sometimes I wish I could read so that I know about my problem in my folder or something. (PPI 12)

So far I see that those who are government workers like teachers, lecturers and nurses participate more. Maybe it’s because they have some ideas about their conditions. Maybe we need to encourage those who are poorer or illiterates to also be part of their care. (RGNFG 25)

Well it is easier for the more educated patients with higher degrees to take part in their nursing care. I don’t see a lot of the uneducated patients or illiterates taking part in their care but I do see more participation especially during discharge education from those who are educated especially those who work in offices in the country. (UGNSFG 8)

Workload as inhibitor of patient participation in nursing care

The majority of participants indicated that workload led to the inadequate involvement of patients in their nursing care. Workload in many instances was due to high numbers of patients or less numbers of nurses to match patient numbers. Workload was particularly high in public and larger hospitals:

Some places are good in involving patient in terms of patient participation. I was operated some time ago and was put in the surgical unit of a smaller facility. We were only 10 in the ward so the nurses had time for us. They explained almost everything to us. That place is different from other places like out-patient department and emergency unit. As for the emergency ward they don’t have time for patients because of their busy schedule and the many numbers of patients. The nurses too are not many for the patients there. The work is usually more than other places. (PP 15)

Some of the wards are less busy so we try to involve the patients. But as for places like emergency ward and critical care units, you don’t get time to finish your work so it is difficult to have a lot of time for patient engagement. We are not many, but our patients are many. We wish we could, but it is difficult because of the workload in some wards such as intensive care unit and emergency unit. (RGNFG 18)

Different situations show different levels of patient participation. When you are placed in wards where there is less work or less patients, you see that nurses try to have time to talk to the patients especially during discharge education but in wards where there is a lot of workload, things are different. Less workload or less patients can encourage patient participation. (UGNSFG 15)

High patient acuity as inhibitor of patient participation in nursing

Patient participation was also lower in cases where there were a lot of critically ill patients. Some departments such as emergency departments and intensive care units (ICUs) had lower patient participation due to the nature of critically ill patients within the emergency department and ICU:

Participation is better in wards that have less critically ill patients. The last time I was in the emergency department I realised that the nurses did not have time to involve us. It was not because they didn’t want to but most of the cases were serious and needed attention of the few nurses. Their patients are very ill so they are always busy around. They did not have a lot of time to talk to me during that time. (PPI 24)

We try to involve the patient but sometimes it becomes difficult when we have a lot of very sick people we have to attend to. Sometimes the patients themselves are sick to the extent that they are even unconscious, so it is difficult to involve them. We know we have to involve their relatives in that case but relatives are not allowed always to be around especially in intensive units. (RGNFG 19)

As for the involvement of patients in their care, it depends. When you have cases that are seriously ill, you may not be able to involve them so much. Many of them are usually not in the shape for their involvement in nursing care. Participation is better when the workload in a ward or on a day is low and you have less acute cases. Unfortunately that is not the case in emergency unit or ICU. (RGN10)

When we go to the different wards, we see different levels of participation in the different wards. In wards where there are a lot of acutely ill patients, you will not see a lot of patient participation. The workload is too heavy in places where there must be continuous monitoring of patients such as ICU. (UGNSFG 13)

Discussion

This study explored the views of patients, RGNs, and undergraduate student nurses on patient participation within Ghanaian hospitals. The views of patient participation are discussed in line with categories extracted from data.

Meaning of Patient Participation in Ghana

Practicing nurses, student nurses, and patients indicated in this study that patient participation in the Ghanaian context meant involvement of patients in treatment decisions and nursing care procedures. Although no single definition of patient participation was found in the literature, many researchers in patient participation agree that there must be some level of patients’ involvement in their care regarding the use of the term patient participation within the hospital setting (Halabi et al., 2019; Heggland, Mikkelsen, & Hausken, 2013; Soleimani et al., 2010; Vahdat et al., 2014). According to Heggland et al. (2013), there are four models of patient involvement in their treatment decisions: paternalistic model, nonpaternalistic model, shared model, and informed model. In the paternalistic model of patient participation, decisions regarding patient care are taken by health professionals on behalf of the patient. Nonpaternalistic model is where all decisions regarding treatment are taken by patient with health professionals as their agents. In shared model, health status, treatment options, and outcomes of treatments are shared between patients and their health professionals while informed model is where patients are given information to decide on treatment options available to them. Involvement of patient in treatment and care decisions in this study was found to be more paternalistic as participants believed their health professionals were trained and were the best people to decide the treatment and care they should be given. Patients therefore did not ask many questions of the care or treatments. Patients wanted to perform tasks during their care only when they were given instructions by nurses caring for them. Although there are mixed results of impact of patient participation on health outcomes (Clayman, Bylund, Chewning, & Makoul, 2016), there are strong ethical and moral grounds for patient involvement (Beier, Schweda, & Schicktanz, 2019) in health care especially at a time when health care is moving away from paternalistic models of care (D’Agostino et al., 2017; Jo Delaney, 2018). Reports from WHO (2013) and Institute of Medicine (2005) have described the exclusion of patients in health care as unacceptable. Practicing nurses in this study expected patients to ask questions regarding their care while many patients interviewed also expected nurses to give them instructions on how to participate in their care. Training in communication skills may be necessary to help address such gaps in communication in order to encourage patients to participate in their nursing care (D’Agostino et al., 2017). Description of the meaning of patient participation as patient involvement in care alone may not be enough. Education of nurses, nursing students, and patients on patient participation may help in moving toward shared, informed, or nonpaternalistic models of patient participation in Ghana.

Patient Participation Encouraged More During Discharge Education

Participants in this study indicated that patient involvement or participation in their care was encouraged mostly at the point of discharge. Patient involvement at this point centered on adherence to medications. Although the practice of involving patients in their care at the point of discharge has the potential of providing sufficient knowledge on patients’ and family home care responsibilities (Roumie et al., 2011), it should not be the only stage where patients are involved in their care. Evidence available shows that patients and family may have more needs and concerns before and during admission than during discharge and may wish to express those concerns during the period of admission (Almborg, Ulander, Thulin, & Berg, 2009; J. Smith & Liles, 2007). Many reports have shown that patient participation, patient safety, patients’ rights, patient-centeredness, and patient empowerment are intricately linked (Castro, Van Regenmortel, Vanhaecht, Sermeus, & Van Hecke, 2016; Hwang, Kim, & Chin, 2019; WHO, 2013). It is therefore essential to encourage patient everywhere to be knowledgeable and vigilant during treatment and care (WHO, 2013). One way of identifying a patient's needs in a holistic nursing care is to involve him or her during the time of admission. Hospital managers and nursing schools in Ghana should help create health-care environment where patients and nurses see themselves as partners in health-care delivery. Hospital managers could organize workshops on patient participation within Ghanaian hospitals to improve knowledge of nurses and other health providers on patient participation. Nursing schools could update their curricula with important concepts of patient participation that will ensure that current nursing students engage their patients in better participation. This will provide opportunities for patients to express important needs that will lead to identification and management of such needs.

Patient Participation Higher in Private and Smaller Hospitals

Participants in this study indicated that patient participation in private hospitals and smaller hospitals was better when compared with participation in public hospitals which were bigger. Similarly, a study of patient satisfaction within private and public hospitals in Ethiopia found higher satisfaction levels in private hospitals (Tateke, Woldie, & Ololo, 2012). Factors that led to the higher patient satisfaction in the private hospitals in Ethiopia included met expectations of clients, adequate duration of consultation, adequate competence of health providers, a good welcoming approach, and a positive body language (Tateke et al., 2012). The higher levels of patient participation in private hospitals in Ghana may be due to the fact that most private health facilities in Ghana need to attract customers to be able to raise the necessary revenue to pay their workers and maintain their facilities. Staff of public hospitals in Ghana are usually paid monthly by the state irrespective of the number of clients attended to. The pay of public hospital workers could be linked to performance appraisal procedures in order to improve care provided to clients within public hospitals.

Higher patient participation in private and smaller hospitals may be also influenced by the fewer numbers of clients within private hospitals in Ghana. Participants indicated that workload in public hospitals which were usually bigger was higher than that of smaller hospitals. Higher workloads within public hospitals could be resolved by the state employing more nurses to support the current manpower within public hospitals. However, it is important for public and larger hospitals to train their staff in customer care and patient participation. This will be in the interest of patients because some researchers have found some advantages of patient participation such as improved relationship between care givers and patients, improved quality elderly and pediatric care, and reduction in medication errors within hospitals (Carlsson et al., 2018; Lindberg et al., 2013; Mctier et al., 2015; Näsström et al., 2015; Willeboordse et al., 2014). Other parts of the world are succeeding in implementing patient participation by incorporating it into professional standards for health professionals (WHO, 2013). Patients in Ghana may benefit from the concept of patient participation if it is incorporated into professional standards of nursing in Ghana.

Perceived Facilitators and Inhibitors of Patient Participation in Nursing Care

Participants in this study reported perceived facilitators and inhibitors of patient participation in nursing care. Wealth and higher education was found to be facilitators of patient participation while workload and high patient acuity were inhibitors. A previous study by Schildmeijer et al. (2018) found clients’ capability to get involved in health care as a facilitator for patient involvement in health care. Patients who were wealthier or had higher levels of education were found in this study to have better capabilities to get involved in their care by asking questions of their health-care providers regarding their nursing care. Patients with higher education degrees were regarded as more involved probably because they were more confident than illiterate patients. The ability to read and write has been found to lead to higher self-esteem and confidence in many people (McArthur, Castles, Kohnen, & Banales, 2016). Some illiterate patients in this study indicated that they got involved in their care only when nurses gave them specific instructions. Smith, Dixon, Trevena, Nutbeam, and McCaffery (2009) found that literate patients with higher degrees would usually want to verify information from health providers by reading and asking questions while illiterate patients perform tasks instructed by nurses without questioning. Evidence available also shows that information sharing between nurses and patients, active communication, and involvement of patients in care planning are the ways nurses can encourage all patients to participate in their nursing care (Tobiano, Marshall, Bucknall, & Chaboyer, 2015). Patients will get involved more if they understood the roles they have to play regarding patient participation in hospitals (Tobiano et al., 2015). In Ghana, 19% of women and 9% of men have never attended any school (GSS, GHS, The DHS Program, & ICF International, 2014). Education of patients is necessary for improved participation in nursing care in Ghana. Studies have shown that education is one of the socioeconomic factors that influences a person’s behaviors and ways of interaction (GHS et al., 2014). In general, the higher the level of education of a person, the more knowledgeable he or she is about health issues and the use of health facilities (GHS et al., 2014). Ghana is currently implementing a policy of free education to the senior high level to enable the state reduce the level of illiteracy in the country. This policy should continue for a longer period of time to enable majority of Ghanaian population to become educated. The high workload and high patient acuity that were found to be inhibiting factors for patient participation could be addressed by employing more nurses into public hospitals because many of these nurses are currently at home without jobs. In cases where public hospitals cannot take on additional nurses to reduce workload, additional patients should be transferred to private hospitals that have the facilities to treat them.

Strengths and Limitations

Although this study seems to be the first in Ghana to explore the concept of patient participation in nursing care, there are associated limitations. The study was qualitative and was conducted in Ashanti region, which is only one of the 10 regions in Ghana. The study did not explore views of other categories of nurses such as psychiatric nurses or midwives or other health professionals such as medical officers or laboratory technicians.

Implications of Study

Findings in this study suggest curricular revisions that could help improve knowledge and practice of patient participation among nursing students in Ghana. In addition, regular workshops on patient participation are recommended to improve knowledge and practice of patient participation among practicing nurses. Our findings may also help develop policies to improve the practice of patient participation within Ghanaian hospitals.

Conclusion

Evidence available through this study depicts views of practicing nurses, nursing students, and patients on patient participation in Ghana. Many patients, undergraduate nursing students, and RGNs described patient participation as the involvement of patient in treatment decisions and nursing care procedures. Participants indicated that patient participation was mostly encouraged during discharged education of patients. Patient participation was found to be better within smaller and private health facilities in the Ashanti region of Ghana. There were both facilitators and inhibitors of patient participation within hospitals in the Ashanti region. Wealth and education were perceived as facilitators of patient participation while workload and high patient acuity were perceived as inhibitors of patient participation in nursing care. The participation of patients in their care can only take place when there is mutual trust and respect between patients and nursing staff. A positive interpersonal relationships should be formed between nurses and patients during patient admissions to encourage patients to participate in their nursing care. Patients should not only be involved in care during discharges because patient participation has benefits during the entire period of hospitalization. Overcrowding of patient within public hospitals can be reduced when more nurses are employed, and extra patients transferred to private health facilities. Overall improvement in educational levels of the Ghanaian population is likely to improve the knowledge of patients and make them participate better in their nursing care. Practicing nurses and nurse academicians could come together to develop a checklist for patient participation in nursing care. This checklist could be helpful in the implementation of patient participation in nursing in Ghanaian hospitals. Practicing nurses can be trained in workshops and conferences on how to improve their practice of patient participation. The advantages of patient participation such as complete medical history from patient and relatives, prevention of medication errors, and prevention of disease complications can be realized if the necessary curricula revisions and education on patient participation can be achieved. Patient participation should be studied in other nursing units such as psychiatry and obstetrics. This will enable researchers to make a comparison of patient participation in general wards such as surgical, medical, and emergency wards and specialized wards such as psychiatry and obstetrics.

Further research is needed in the development of assessment tools of patient participation in the Ghanaian health-care systems. In light of the confusion of roles of patients and nurses in patient participation, researchers could conduct further research to identify and clarify the specific roles of nurses and their clients in patient participation.

Authors’ Contributions

C. A. A. conceptualized the study, collected and analyzed the data, and prepared the manuscript; E. A., A. A., K. A., S. B. A., J. S. A., A. A. B., and C. P. A. conceptualized the study and collected and analyzed the data. J. G. conceptualized the study, analyzed the data, and reviewed the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: All funds for the study were provided by the first author.

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