Power to the People: Contributions to the Involvement in Decision-Making About Nursing Care in Hospital Settings

Abstract

Involving the person throughout the nursing process, since the initial assessment to the diagnostic nursing activity, the care planning, the implementation of interventions and the final assessment, will allow them to become partners in the care, to explore their experiences in the transition process, and to respond to their needs, considering their preferences, values and culture. These statements are emphasised by the World Health Organization (2015), with the publication of the “WHO global strategy on integrated people-centred health services 2016–2026”, which advocates a future in which people have access to health care that meets their needs and preferences, in a secure, effective, timely, efficient and high-quality manner. In this sense, the World Health Organization (2015) establishes the involvement of people as strategic, with a view to improve health outcomes through the co-production of care, where shared decision-making and personalised care plans are described as potential policy options and interventions to support this strategy.

In order to discuss this issue, it is important to clarify: what is decision-making in nursing? Decision-making in nursing care is guided by the nursing process. This process is considered a systematised approach, based on critical thinking, the principle of person-centered care and evidence-based practice, being guided by five stages: initial assessment, diagnostic activity, care planning, implementation, and final assessment. Initial assessment involves the collection of subjective and objective data, through interviews and the collection of measurable data. Subsequently, the formulation of nursing diagnoses (clinical judgement about human responses to real or potential health problems of individuals, families, or communities) allows for the planning and implementation of nursing care. Care planning allows for the implementation of personalised, timely, and outcomes-oriented care. At this stage, objectives and outcomes to be achieved are formulated, based on the previously formulated nursing diagnoses. Implementation is the stage that involves delivering the nursing interventions outlined in the care plan. The final evaluation is crucial, highlighting the outcomes that are sensitive to nursing care. This evaluation requires adapting the care plan, which is a dynamic and continuous process (Toney-Butler and Thayer 2023).

As a theoretical basis to understand the importance of people's involvement in decision-making about nursing care, several perspectives, theories and models can be adopted, of which the Transitions Theory can be highlighted for its comprehensiveness and commonalities with the Nursing Process. Changes in people's health can be the cause of transition processes, known as health-illness transitions. The theory also proposes developmental, situational, and organisational transitions. The nature of transitions is also characterised by patterns and properties. In terms of patterns, transitions can occur simply (a single transition) or multiple times (sequential or simultaneous), for example, a person who experiences the diagnosis of a chronic illness and parenthood will be experiencing a health-illness transition and a situational transition, by taking on a new role in society—the parental role (Meleis et al. 2000).

Transition processes are complex and multidimensional, with awareness, involvement, change and difference, time interval and critical points and events representing properties of the experience of a transition process. Awareness refers to the perception, knowledge, and recognition of the transition, as well as the degree of congruence between what is known about the process and the responses and perceptions of the people experiencing the transition. Involvement is characterised as the degree to which the person is committed to the processes associated with the transition. Involvement is associated with the level of awareness because if there is no awareness, the person's involvement will be compromised: no person becomes involved in their transition process if they are not aware of how they are experiencing it. Subsequently, change and difference are considered properties of transitions, once all transitions begin with changes and generate changes, and recognising and attributing their meanings is essential to understanding transition processes. All transitions require time and persist for a period, despite the difficulty in pinpointing their beginning and end. Finally, in terms of critical points and events, some transitions are associated with an obviously identifiable event, such as the diagnosis of a chronic illness, while others may not be so specific (Meleis et al. 2000).

This theory also describes conditions that are considered facilitators or inhibitors of the transition process, including personal, community and social conditions. As regards personal conditions, meanings, cultural beliefs and attitudes, socio-economic status, preparation, and knowledge influence the transition process. Therefore, to understand people's experiences during transitions, it is necessary to comprehend what meanings are attributed to the events that bring about the transition and to the process itself, the advance preparation and existing knowledge, as well as resources (Meleis et al. 2000).

It is essential for nursing to understand how people answer to transitions. People's response patterns to transitions can be translated into process and outcome indicators. Feeling connected, interacting, location and being situated, and developing confidence and coping are the process indicators described in this theory. In summary, these indicators reflect the need to establish relationships, to interact, to feel situated in relation to time, space, relationships and health status, the level of use of resources and the development of strategies and are precursors to a healthy transition. Finally, as outcome indicators, this theory describes mastery and fluid identity, that is, the completion of a healthy transition is determined by the apparent mastery of the skills necessary for the transition and the reformulation of identity (Meleis et al. 2000).

One view of the transposition of this theory into practice is that when a person is admitted to hospital due to a change in their condition or the diagnosis of a chronic illness, they are experiencing a health-illness transition, which requires nursing care (Meleis et al. 2000). As involvement is a property of transitions, it is characterised by the person's active participation in this process and is influenced by intrinsic factors (e.g., a person who is not aware is difficult to involve in their health-disease process) or extrinsic factors (e.g., context and resources) (Meleis et al. 2000), the following reflection emerges in relation to the involvement of the person in decision-making about nursing care. To involve the person in the decision-making process about nursing care, it is first necessary to promote their awareness of the health-disease process. Promoting awareness requires building a relationship, time, and an understanding of the changes/differences that are taking place, that is, the properties inherent in transitions are constantly interacting. Therefore, it is believed that involving the person in the diagnostic activity (knowledge of the problem and its evolution) will facilitate the process of awareness (making the person's perception of their condition similar to the real one), and in turn will allow them to be involved in the planning and implementation of care.

With regard to the conditions that facilitate/inhibit the transition process, in the light of the theory, it is possible to reflect on the following: the person's involvement in decision-making about nursing care requires the transmission of information and, consequently, the prospect of an increase in their level of preparation and knowledge (conditions that, if they exist, facilitate a healthy transition). Considering that the meanings attributed by the person to their experience are a facilitative/inhibitory condition for transition and that there is evidence that when the person feels involved in the care, it improves their experience in the hospital context, it is suggested that when nurses involve the person in decision-making about nursing care, they are facilitating the person's transition process. It should also be noted that people's preferences regarding their involvement in decision-making can be influenced by several factors, as shown by Florin, Ehrenberg, and Ehnfors (2008), which facilitate or inhibit this process: gender; education; living condition and occupational status. Therefore, it is emphasised that nurses should assess these preferences so that people can decide according to their own values, from an informed position. In this reflection, it is also possible to highlight the nurse as a central resource in supporting the health transition process, so that the person can achieve maximum well-being and autonomy.

The establishment of a relationship (nurse–person), as well as the person's willingness to interact and show involvement in decision-making about nursing care, can be considered process indicators of transitions, which are considered precursors to a healthy transition. It is therefore up to nurses to promote this involvement of the person in the decision. As a recent qualitative study using people's voices points out, feeling seen and understood, having a good nurse–patient relationship and being in possession of information are crucial for shared decision-making in nursing (Van Der Ploeg-Dorhout et al. 2024).

This reflection adds a solid theoretical basis to the science, allowing us to understand how the person's involvement in nursing decision-making influences transition processes, as this topic (giving people a voice over their health) is an emerging and current one.

D.G.S.M.D.S. was involved in conceptualization and writing – original draft. A.F.S.A. and E.J.F.D.S. were involved in conceptualization, supervision, validation, writing – reviewing and editing.

The authors declare no conflicts of interest.