Researchers improve the dialogue between nurses and patients
‘Dialogue’, ‘co-creation’, ‘collaboration’ and ‘citizen engagement’ have become buzzwords with a taken-for-granted positive value. Practices under the banner of the buzzwords have proliferated across diverse fields. Citizens, patients and employees are enlisted in collaborative decision-making on everything from urban renewal to social housing initiatives and their own health care. Among the buzzwords, the most popular in Denmark anno 2018 is ‘co-creation’. It signals the purest process whereby all participants take part on an equal footing in all stages. For example, nurses in the ‘Active Patient Support’ programme in Region Zealand are not meant to tell citizens what to do and citizens are not merely ‘involved’.
Instead, citizens and nurses together co-create ways of dealing with chronic illness that support citizens’ self-care. In the ‘Active Patient Support citizens with chronic illnesses receive regular telephone counselling from their own personal support nurse over a period of up to nine months.
On the face of it, this sounds great, but how does it work in practice, and can nurses be both receptive to suggestions and make use of citizens’ input when they must simultaneously act on the basis of their professional experience and knowledge? And if this is possible, what kind of toolbox should they use to co-create in the best way possible? Researchers from Roskilde University are examining this in close detail together with citizens participating in the Active Patient Support programme and nurses working on the programme. The region’s main motivation for commissioning the research project was to strengthen the programme’s adherence to principles of ‘person-centredness’ so that counselling conversations open up for the voices of citizens - expressing citizens’ experience-based knowledge and preferences.
»Our project is first about understanding the process and the tensions that arise when people participate in co-creation process with different starting- points. The nurses have the professional knowledge, but citizens know themselves and their own illnesses better. Ideally, dialogue across these two sets of knowledge can lead to better ways of tackling their illnesses in their everyday lives. When we have gained an understanding of the co-creation process in practice, we can create better dialogic tools and improve the nurses’ communication with citizens,« explains Louise Phillips, professor of communication at Roskilde University.
There is a risk that co-creation is used as a form of manipulation, but this is not how it has to be
Louise Phillips is responsible for the research project together with her colleague, postdoc Michael Scheffmann-Petersen and in collaboration with Region Zealand’s unit, ‘Production, Research and Innovation’ (PFI) which, among other things, aims to ensure that more patients experience high quality in their meeting with the healthcare system.
Power is always in play
The buzzword status of ‘co-creation’ means that there is a tendency to romanticise practices as straightforward, totally inclusive processes. It is implied that all participants participate on an equal footing. In practice, some perspectives dominate co-creation while others are marginalised or totally excluded. In the worst-case scenario, co-creation serves to legitimate pre-determined outcomes, and involvement becomes mere window dressing, passing off ‘top-down’ decision-making processes as ‘bottom-up’ democratic ones.
It is also an illusion to think that it is possible to get rid of the tensions in co-creation. Power is always in play, Louise Phillips points out. Some kinds of knowledge are weighted more heavily than others. For instance, the creation of a patient’s treatment process can end up being based solely on the doctor’s professional judgement and healthcare experience and not on the patient’s experience with his or her own illness process.
»There is a risk that co-creation is used as a form of manipulation, but this is not how it has to be. Instead of just convincing patients that they need to exercise more, nurses can open up for patients’ own voices, expressing experience-based knowledge. In this way, patients’ own knowledge is harnessed as nurses and patients collaboratively create ways of tackling patients’ illnesses in their everyday lives,« says Louise Phillips.
Raising awareness of different conversational modes
In their research, Louise Phillips and Michael Scheffmann-Petersen has worked together with nurses from the Active Patient Support project in order to determine when and how co-creation works or runs into problems. Among other things, the researchers and the nurses have discovered that nurses often adopt three different conversational modes in counselling conversations with citizens, and relations between these modes has an impact on the co-creation process. The modes are:
• The inquiry mode where the nurse inquires about the citizen’s’ illness and relevant aspects of her life• The caring support mode where the nurse shows empathy and provides support
• The sparring partner mode where the nurse invites the citizen to cooperate in order to find the best solution for them.
»One of our most important results is that the nurses in our workshops have a greater ability to reflect on and understand how they adopt and switch between these different modes and what impact this has on the co-creation process,« says Louise Phillips.
If the nurse adopts one role too frequently in relation to the individual citizen, things can fall apart.
Louise Phillips offers an example where a citizen had a bad experience with a doctor, but one day, she had a positive experience. The nurse repeatedly asked what was different about the positive experience so that the patient could learn from it. The nurse stuck to the inquiry mode and forgot everything about the caring support and sparring partner modes. At one point, the patient got so tired of the many questions that she ended up becoming angry ruining the conversation and scuppering co-creation.
»We analysed how the different roles influenced the conversation with the citizen and how shifting between different modes helps to further co-creation between counselling nurses and citizens. There is no ‘one size fits all’ solution, but reflecting on the different modes and how they shape the conversation provides the nurses with tools for dialogue,« explains Louise Phillips.
Research in itself is also co-creation
The research project itself is also structured around the same scaffold as the Active Patient Support programme. Researchers do not act as if they have all the answers, but instead engage in co-creation with the counselling team of nurses and citizens participating in the programme. Together, they arrive at insights that inform a communication model for refining counselling practices.
»Here we are also analysing the tensions that arise during the research process in the tension between between opening up for the voices of nurses and citizens and steering the process towards closure in the form of a communication model that can further develop the Active Patient Support programme.This analysis offers insight into co-creation in collaborative research - an insight that we hope to use to improve research practice,« says Louise Phillips.
Louise Phillips and Michael Scheffmann-Petersen have, together with colleagues in the research group Dialogisk Kommunikation (Dialogic Communication) at Roskilde University, been part of writing the book ‘Dialog og samskabelse: metoder til en refleksiv praksis’ (‘Dialogue and co-creation: methods for a reflective practice’) which has been published in November 2018 by Akademisk Forlag. The book is intended for researchers and practitioners who work with co-creation, for example, in municipalities or regions.