Qualitative research on factors affecting nurse-patient relationship under the background of COVID-19

doi:10.21203/rs.3.rs-1450032/v1

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Qualitative research on factors affecting nurse-patient relationship under the background of COVID-19

https://doi.org/10.21203/rs.3.rs-1450032/v1

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Background

Nursing-patient conflict is a worldwide medical dispute problem. Over the years, nursing-patient conflict has not been effectively alleviated. However, the contradiction between medical staffs and COVID-19 patients of China has almost completely disappeared.

Objectives

To explore factors alleviating contradiction between nurses and COVID-19 patients, which might provide an efficient way to improve medical staffs and patients relationship.

Methods

Semi-structured online interviews were conducted with 10 nurses who personally cared for patients in COVID-19 from the Chongqing medical rescue team to Hubei province. The whole interview was videotaped and transcribed to word, which return to the interviewee within 24 hours to confirm. Data were analyzed using NVivo11 coding by more than two researchers.

Results

Economy, expectation, emotion, communication, and media are the main factors that alleviating contradiction between nurses and COVID-19 patients.

Conclusion

Under the influence of certain factors, there is a high probability that the conflict between nurses and patients can be alleviated under daily circumstances. Free medical care, emphasis on online communication, uniform and publicly publicized disease guideline pairs, positive health care provider coverage, and increased nurse-patient trust may be important factors in improving the nurse-patient relationship in COVID-19.Further population-based intervention studies in the five areas are recommended.

COVID-19

Nurse

Nurse-Patient

Qualitative Research

The medical staffs and patients conflict is a medical dispute problem in China and even the whole world. By 2015, about 73 million outpatient visits nationwide has occurred 70,000 medical disputes and it has seriously affected the diagnosis and treatment efficiency of outpatient clinics(Zeng, Zhang, Yao, & Fang 2018). The increasing number of violent incidents between medical staffs and patients in hospitals has even led to the death of medical personnel(Deng et al. 2018). Nursing-patient conflict, as a kind of medical staffs and patients conflict, also deserves attention. In recent years, there have been serious medical disputes worldwide. In the study of nurses in the West, 76.0% have experienced nurse-patient violence, and physical violence accounts for 63.7%. In developing countries, more than 50% of nurses face verbal and physical abuse from patients(Kumari et al. 2020;Speroni, Fitch, Dawson, Dugan, & Atherton 2014). Violence incidents in medical occupations have always attracted attention. As the world’s largest developing country, China’s nurse-patient contradiction is also not optimistic(Hesketh, Wu, Mao, & Ma 2012). According to media statistics, from 2000 to 2020, there were 345 workplace violence incidents in medical institutions, and the most serious one was that 54 incidents ended in the murder of victims(Zhang, Li, Yang, & Jiang 2021).

A large number of scholars have conducted studies on medical staffs and patients conflict, which have been alleviated but have not been fundamentally resolved. There are many influencing factors of medical staffs and patients conflict, mainly related to cost, expectation(Chen et al. 2020), trust, communication(Harbishettar, Krishna, Srinivasa, & Gowda 2019), media(Sun et al. 2018), etc. Based on these research results, the state initiated major healthcare reforms, proposing ways of increasing the allocation of health resources to the primary healthcare system, promoting a tiered diagnostic system, and emphasizing payment reforms(Gong, Chen, Gao, Su, & Chang 2019), the corresponding measures for chronic disease management and elderly health care(Meng, Fang, Liu, Yuan, & Xu 2015;Yip et al. 2012)are also put forward. However, there are still some problems such as lack of insurance coverage, rising medical costs, unbalanced access to medical information(Younger 2016), etc. But the contradiction between medical staffs and patients has not been fundamentally alleviated. In February 2020, the COVID-19 epidemic broke out in Wuhan, Hubei Province, China. After that, medical support teams from all over the country rushed to Wuhan for medical treatment. COVID-19 has had a major impact on all levels of society, and while the pandemic has put many negative pressures on the health care system, it has also affected society’s perception of health care workers, who are called heroes in many cities and celebrate their hard work through media publications and nightly cheers. It is worth noting that, unlike non-COVID-19 patients, in just 2 months, the medical staffs and patients conflict in COVID-19's room has been greatly eased or even disappeared. Patients' trust and respect for medical staff have been significantly improved, their compliance and tolerance of medical behaviors have changed, and the medical staffs and patients relationship has been improved(2019). Our study aims to investigate what impact this pandemic has on the nurse-patient relationship, which might provide an efficient way to improve medical staffs and patients relationship.

2.1. Aim and objective

The purpose of this qualitative study is to explore the influencing factors of the nurse-patient relationship in COVID-19 and provide a new reference for alleviating the contradiction between medical staffs and patients.

2.2. Design

This survey is based on 10 online face-to-face semi-structured qualitative interviews, to gain a deep understanding of providing ideas to alleviate the contradiction between nurses and patients.

2.3. Participants

The interviewees were 10 nurses from the medical team supporting Wuhan in Chongqing and directly caring for COVID-19 patients. They came from the emergency department or respiratory medicine department of the Chongqing medical team.

2.4. Data collection

To avoid contact with the risk of infection, all interviews are conducted by online video. The interview lasted about 60 minutes. We developed an interview guide incorporating open-ended questions including the basic information of the interviewee, the patient's medical expenses, the patient's trust in medical staff, tolerance, expectations, nurse-patient emotions, nurse-patient communication, media influence, factors that cause nurse-patient conflicts, and suggestions for improving nurse-patient conflicts. Online interview whole course video recording, keep the interview video, to transcribe the interview content, proofread the written material, and return to the interviewee within 24 hours to confirm Interviewees are coded by coders after they are confirmed to be correct. NVivo 11 software is used to classify the data, make the coding scheme, and constantly check and modify the data code. Finally, the data code is continuously checked and modified. The interview ended when the data reached information saturation and information redundancy.

Interviewee information is shown in Table 1, and the interview outline is shown in Appendix A.

Table 1

Interviewees' characteristics
Characteristics	Interviewees (n = 10)
	n	%
Gender
Male	1	10%
Female	9	90%
Highest degree
Bachelor's degree	5	50%
Master's degree	5	50%
Position
Nurse	3	30%
Head nurse	3	30%
Deputy Chief Nurse	3	30%
Chief Nurse	1	10%
Working years
1-20years	7	70%
21-40years	3	30%
Hospital departments
Emergency, Critical Care Medicine, Respiratory Medicine	4	40%
Other departments	6	60%
Support Hubei time
20-30days	4	40%
31-50days	4	40%
51-70days	2	20%

3.1. Communication

3.1.1. Form of communications

Compared with ordinary patients, the communication time between patients and medical staff in COVID-19 is longer, and the communication of illness is more comprehensive.

"I think it would give him more time to communicate with other people," she says. "You give the patient time, you communicate with the patient, the patient gives you feedback, and the patient is more likely to put up with you."(nurse,8)

3.1.2. Changes in communication methods

Online communication during COVID-19 has become a new way of communication. Ordinary patient communication is limited, while there are more online communication methods between patients and medical staff in COVID-19 besides face-to-face communication, which exists in almost every ward.

"We pull every patient and medical worker into a Wechat group to find out what every patient’s needs are promptly and do our best to address them."(nurse,5)

"Nurses communicate more with their patients to reduce the chance of nurse-patient conflicts, and if face-to-face communication is reduced in the future, there are many chances for the nurse-patient relationship to develop to a malignant degree."(nurse,8)

3.1.3. Peer education

All patients in COVID-19 were not accompanied by their families during hospitalization, and the hospitalization time was longer than that of ordinary patients. The communication time and ways between patients increased. When there was a conflict between nurses and patients, persuasion between patients played a positive role.

"Other patients would talk to him and say, you don't want to do this, you know? Persuasion among patients will work positively, not negatively as you have now."(nurse,8)

3.2. Expected value

3.2.1. Comparison of patients' expectations of medical effects

The average patient always expects a better medical result, the expectation value to the medical effect is on the high side. But COVID-19 patients understanding of the new epidemic is more fitting the reality.

"Maybe his expectations are too high, he thinks I am a consumer, I pay money, then I have to meet the expectations I want, then is to make me the patient fully recovered as before."(nurse,2)

"If it can't be achieved now, it can be said that it will immediately reduce your fever, or kill the virus immediately and recover immediately, so most patients can understand it."(nurse,2)

3.2.2. Disease Guidelines

The treatment of the COVID-19 disease is published in the whole country, the treatment plan is open and transparent, there are a large number of popular science workers to interpret the medical treatment plan, to ensure that non-hospital residents and patients can understand. The average patient has few nationally consistent treatment plans; patients have little access to treatment plans, and even when they do, patients who lack medical knowledge are hard to read.

"We have a new crown patient guidelines, we will be based on this guide, according to the actual situation of the patient to set him an approved drug, and will not consider whether the patient has medical insurance, he is not family difficulties, this drug it can not afford and so on the kind of. This means that the nurse is completely freed up to focus on treating patients."(nurse,8)

3.3. Media

Media workers walked with medical staff during the epidemic and reported more frequently and comprehensively on nurses and patients. The reports on the medical staff of patients in COVID-19 are closer to the facts, and there are more positive reports.

"From what I saw during the outbreak, the media reports were very real and there was no blurring."(nurse,11)

"Because when we went to Wuhan at that time, three Chongqing TV reporters followed us, which is equivalent to a live feed of our work at any time."(nurse,2)

3.4. Economic factors

3.4.1. Patient's medical consumption views

COVID-19 patients' concept of medical expenses has changed. Before the epidemic, patients thought that medical care was omnipotent, and they could get good medical results by spending money, putting themselves in the position of consumers, and the nurse-patient relationship was unequal. During the period of COVID-19, this concept was corrected, patients' cognition of disease and the medical level was more objective.

"When patients come in, they always think I’m a consumer who paying for it, and you should give me an effect that I want to have. And now people are thinking that maybe the respect between people is a little bit better than before."(nurse,2)

"Then in this particular case, his expectations and we have a certain gap in real life, but through our communication to make his expectations a little bit lower, to achieve this effect."(nurse,2)

3.4.2. Medical expenses

Non-COVID-19 patients need to bear all or part of the medical expenses, and sometimes give up the best treatment plan because of economic stress. Sometimes patients choose the best treatment plan and pay high medical expenses, but the medical results do not meet expectations.

"Because often the family goes all out, he hopes to get a good result. But we know that there are many areas of medicine, we have no effective way to solve, so it is possible to do everything possible, including putting all his savings and even borrowing money to cure diseases, and he hopes to get a good result, at the end, when it didn’t work out, he thought it was a waste of money and a waste of time."(nurse,10)

All medical expenses of patients in COVID-19 are borne by the state, and patients do not have to bear the pressure brought by medical costs. Patients use the best treatment plan, and even if the medical results fail to meet expectations, it is more acceptable. In addition, the situation that medical staff urges patients to pay fees has been completely avoided.

"All medical care was free, and all medicines, no matter how expensive they were, were used, at no cost to him."(nurse,8)

"Patients in COVID-19 suddenly get worse, and patients and their families can accept some of them slowly."(nurse,5)

3.5. Emotional factors

3.5.1. Trust

The trust of patients in COVID-19 is generally higher than that of ordinary patients.

"We all follow the guidelines. In fact, his trust is quite high, because he knows that it should be a country."(nurse,8)

"Communication isn’t equal. It isn’t. There is a systematic professional education at the level of the nurse, and then all of the behavior follows the norms, follows the standards. But the patient is different. Because of his lack of medical expertise, the patient will have a distrust of the nurse. He wants to reach the same level of communication with the professional, and he will understand it through various channels, trust can be hard to build if you don’t have the time or energy to communicate with each other when the information isn’t equal."(nurse,9)

3.5.2. Attention under special circumstances

Under the epidemic situation, the attention of patients in COVID-19 is much higher than the usual attention.

"It is a kind of attention, because after he is infected, the government, the local community, the designated hospitals, and headquarters will register him, including its disposal process and COVID-19 treatment. After the improvement, he will return to the community and be picked up by a special person. He is specially registered and followed up. These concerns are very high."(nurse,10)

4.1. Communication

Effective communication between nurses and patients can significantly improve medical results(Leask, Hooker, & King 2010). The common form of nurse-patient communication is mainly limited to face-to-face communication. The communication time is limited and the form is single, and the communication efficiency between nurses and patients is not high. What makes medical malpractice lawsuits increase is the poor treatment effect, the decrease of patients’ trust and satisfaction with nurses, and the poor compliance of patients to treatment plans (Gerber 2016). Due to the special treatment environment in COVID-19, on the basis of traditional face-to-face communication, the communication between patients and medical staff has increased the way of network real-time communication, that is, App chat. Breaking the lack of time and space limitations of face-to-face communication significantly improves the efficiency of nurse-patient communication as they offer the same interaction quality and satisfaction level as regular face-to-face consultations. The prevalence of online communication has accelerated changes in nurse-patient communication patterns during COVID-19 treatment. With the rapid adoption of video-based "tele-medicine"(Newcomb et al. 2021) and the continuous development of network technology, the new nurse-patient communication model has sufficient technical support, which will also become an opportunity to improve the nurse-patient relationship. On the other hand, some studies have found that peer education among patients in COVID-19 can improve the nurse-patient relationship (Newcomb et al. 2021). Family members are prohibited from accompanying in wards in COVID-19. At the same time, the hospitalization time of patients in COVID-19 is generally longer than that of other ordinary patients, and the communication time between patients in COVID-19 is longer and the communication degree is deeper.

Peer education of patients will be a good way to alleviate the conflicts between nurses and patients when patients have conflicts with medical staff. This means that by increasing online communication between patients and increasing peer education among patients, we may significantly improve the existing nurse-patient relationship.

4.2. Disease guidelines

A large number of studies have found that the asymmetry of medical professional information between nurses and patients is an important factor causing the tension between nurses and patients(Frankel, Sung, & Hsu 2005). Disease treatment programs are not uniform, patients have almost no way to obtain the standard treatment programs for their own diseases, and even if they get the treatment programs, they can't read medical expertise, which aggravates the current situation of asymmetric information between nurses and patients.

Novel coronavirus pneumonia unified method for treatment.The treatment of SRAs-cov-2 is uniformly issued by the country, and the treatment plans of different medical institutions are almost the same. And this disease guideline is open to the public and the media is reporting, almost everyone knows its treatment plan.Patients can also easily obtain a complete treatment plan through the Internet, with the help of the majority of medical science workers, almost all non-medical COVID-19 patients can understand the treatment plan. In this special environment, the asymmetry of professional information between COVID-19 patients and medical staff is almost non-existent. The communication between nurses and patients is smoother and trust increases the objective treatment of medical results. Therefore, meeting actual expectations can improve the nurse-patient relationship(Peacock & Hernandez 2020;Wang, Song, Zhang, & Xiao 2017). At present, there are relatively few studies on disease treatment guidelines and the improvement of the nurse-patient relationship. Formulating recognized treatment guidelines for different diseases and disclosing them to patients and focusing on the transformation of medical science, which become an important strategy to improve the nurse-patient relationship. It is worth mentioning that there is no contradiction between standardization and individuation of disease treatment. Personalized treatment on the basis of unified and open disease treatment guidelines can effectively reduce patients' doubts about medical plans, promote medical efficiency and enhance medical effects.

4.3. Media and Emotion

The particularity of patient wards in COVID-19 makes patients more dependent on medical staff, and also makes medical staff have a special sense of mission. The medical model in this environment partially overlaps with the medical model generally recognized abroad, that is fully respects the autonomy of nurses (Parsi & Elster 2015). It is recommended to refer to foreign medical models (Kondro 2010) to increase the autonomy of nurses and ease the contradiction between nurses and patients. Although it provides a new way to improve the relationship between nurses and patients, this model needs to be adjusted according to the actual situation of the country. Some scholars pointed out that when there is a medical dispute, the media is more biased towards patients and medical staff may have untrue negative reports, which may cause distrust of other patients and stimulate nurse-patient conflicts (Peacock & Hernandez 2020). During the COVID-19 outbreak, the media followed the medical staff into the COVID-19 ward to fully report the current situation of medical staff in treating COVID-19 patients. The news was closer to the facts and the reports of medical staff were more positive and increased the trust of both nurses and patients. Effectively alleviate the contradiction between nurses and patients. In order to better improve the relationship between nurses and patients, the supervision of the media can be increased to make news reports closer to the facts and increase positive reports on the medical staff.

4.4. Economy

Research shows that economy is an important factor affecting the nurse-patient relationship (Marrondelabre, Rivollier, & Bois 2015). When treatment results do not meet expectations and higher medical consumption is incurred, nurse-patient conflicts are easily triggered.

In addition, when choosing a treatment plan, patients may give up the optimal treatment plan because of the pressure of medical costs, which may also stimulate the nurse-patient conflict to some extent.Patients can use the optimal treatment plan without financial pressure because all medical expenses for COVID-19 patients in China will be borne by the state. From the economic and medical point of view, even if the treatment results do not meet expectations, patients in COVID-19 are more acceptable than ordinary patients, thus improving the nurse-patient relationship in COVID-19. On the other hand, some scholars have pointed out that whether it is the need for self-financing of Chinese medical institutions or the link between the income of medical staff and medical plans, it will increase the medical expenses of patients and worsen the relationship between nurses and patients. The country fully bears the medical expenses of COVID-19 patients. Both medical institutions and medical staff can focus all their attention on how to treat patients with COVID-19, which can also improve the relationship between patients with COVID-19. In some areas, the infection rate of COVID-19, requiring even longer treatment regimens with drugs that are more expensive and difficult to tolerate, is increasing. Although the exemption of medical expenses for COVID-19 patients is a special policy in a special period, its emergence has indeed proved from reality that the country has used different reimbursement policies for different income groups by increasing the intensity of medical insurance for the past ten years. Irrespective of changing standards and continuous reforms in health service. Efforts to reduce the pressure on patients' medical expenses should always remain the principal direction.

4.5. Limitations

Limited by the risk of infection in COVID-19, the scope of interviewees in this study is limited. Only the medical staff who assisted Hubei were interviewed, and the true feelings of patients in COVID-19 about the nurse-patient relationship during the epidemic were not interviewed. The interviewees were not comprehensive enough.

4.6. Implications for nursing policy

Nurse-patient relationship plays an important role in medical treatment. A good nurse-patient relationship brings more spiritual support to patients and promotes the recovery of patients. Unlike the usual nurse-patient relationship, COVID-19 patients have a better understanding of the difficulties of medical staff, and their attitude and compliance with medical staff are relatively moderate. This study provides a new reference and direction for the follow-up study of nurse-patient relationship and the related nursing policy. Nurse-patient relationship plays an important role in medical treatment. A good nurse-patient relationship brings more moral support to the patient and contributes to the patient's recovery. Unlike the usual nurse-patient relationship, the COVID-19 patients have a better understanding of the difficulties of medical staff, and their attitudes and compliance with medical staff are relatively moderate. This study provides a new reference and direction for the follow-up study of nurse-patient relationship and the related nursing policy.

The quality of the COVID-19 nurse-patient relationship is extremely high. Compared with the low-quality existing nurse-patient relationship, economy, communication, disease guide, emotion and media have changed greatly in the nurse-patient relationship in COVID-19, which may be important influencing factors for improving the existing nurse-patient relationship. It is recommended that further population intervention studies be carried out for the five latitudes.

Ethics approval：The Ethics Committee of Chongqing Medical University has reviewed the proposed use of human subjects in this research. We approve papers resulting from the project.The study was initiated in July 2020 and retrospectively registered on March 31, 2021.

Ethics approval and consent to participate: This project has been approved by the Ethics Review Committee of Chongqing Medical University (Document.7). All respondents gave informed consent (Document.8). After review by the ethics committee, the research protocol and informed consent form submitted by this project conform to the principles of medical ethics and the requirements of the Declaration of Helsinki.

Consent for publication: All respondents agreed to be interviewed and published.

Availability of data and materials: All data generated or analysed during this study are included in this published article and its supplementary information files.

Competing interests: No conflict of interest has been declared by the authors.

Funding: The project was approved for scientific research application of the School of Nursing of Chongqing Medical University.

(Project Number: HLJYK202104)

Authors' contributions: Feng PENG, Zhitong CAI and Qiuhua YU contributed to developing the research concept. Zhitong CAI, Qiuhua YU and Yunyun TANG contributed to the coding and thematic analysis of participant transcripts. The final draft was significantly and critically revised for relative scientific content by Zhitong CAI, Feng PENG, Dengya JIANG, Yunyun TANG, Xia JIN and Ziyi ZHANG. All authors approved the final versions of the manuscript. All authors agree to the content of this paper and were involved in writing and revising this manuscript.

Acknowledgements: We would like to thank the Medical staff who participated willingly in this study. They take their precious time to share their experiences and thoughts on the nurse-patient relationship.

Authors' information: The author including Zhitong CAI, Dengya JIANG, Yunyun TANG, Xia JIN, Qiuhua YUand Ziyi ZHANG. The corresponding author is Feng PENG. The first author’s E-mail is [email protected]. The corresponding author’s E-mail is [email protected]. All authors come from Chongqing Medical University,Chongqing, China.

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No competing interests reported.

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Qualitative research on factors affecting nurse-patient relationship under the background of COVID-19

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Abstract

Background

Objectives

Methods

Results

Conclusion

1. Background

2. Methods

2.1. Aim and objective

2.2. Design

2.3. Participants

2.4. Data collection

3. Results

3.1. Communication

3.1.1. Form of communications

3.1.2. Changes in communication methods

3.1.3. Peer education

3.2. Expected value

3.2.1. Comparison of patients' expectations of medical effects

3.2.2. Disease Guidelines

3.3. Media

3.4. Economic factors

3.4.1. Patient's medical consumption views

3.4.2. Medical expenses

3.5. Emotional factors

3.5.1. Trust

3.5.2. Attention under special circumstances

4. Discussion

4.1. Communication

4.2. Disease guidelines

4.3. Media and Emotion

4.4. Economy

4.5. Limitations

4.6. Implications for nursing policy

5. Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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