In this paper, a phenomenological study will be outlined in which Total Hip Replacement (THR) patients’ experiences of using a Standardised Nursing Care Plan (SNCP) in lay language as a peri-operative teaching material were explored. The nurses in the orthopaedic unit where this SNCP was implemented were encouraged to discuss the plan with patients on admission, and then continue doing so throughout their hospital stay. This method was considered to potentially provide an opportunity for enhancing patient involvement and partnership between patients and nurses, in line with a person-centred approach. Before turning to the details of the SNCP intervention, however, some theoretical and practical context is in order.

In contemporary health care, person-centred care is strongly endorsed by professionals in the field as well as policy makers [1-3]. Central to such care is viewing patients as unique individuals from a holistic perspective and taking into account their needs and preferences. The concepts patient-centred care and client-centred care, for which the term person-centred care has become a common denominator or an umbrella term [4, 5], both highlight patient involvement and partnership. Evidence shows that with professional support, patients can become active partners in their care [6-8], and that such involvement can be beneficial to them [7, 9, 10] and contribute to empowerment [11]. A therapeutic relationship and the involvement of patients in planning and negotiation of their care are prominent attributes in the conceptual analysis of partnerships [12, 13]. Yet providing patients with information about their planning of care when it is mainly pre-determined by health care professionals, such as through the use of SNCPs or clinical pathways (CP; also known as ‘critical pathway’), is not addressed in these analyses in particular. These plans and pathways have been developed for organising evidence-based care for well-defined groups of patients, such as patients with the same medical diagnosis, patients undergoing similar medical treatment, or patients with similar nursing problems [14, 15]. The main difference between CP and SNCP is that SNCP is formulated according to the nursing process, within which nursing diagnosis, goals, and interventions are outlined [14]. CP is multi-disciplinary, and the outline component of health care is placed in an appropriate timeframe that provides a continuum of care in which expected outcomes are clearly identified [15]. In SNCP, nursing diagnosis, outcomes, and interventions are often outlined in nursing terminology, which allows for their integration in electronic health records [16, 17].

Although they contain important information about patient care and conditions, it is both odd and implicitly paternalistic that SNCPs and CPs have been used to a very limited extent as a medium for patient teaching. This is evident by the fact that only a few studies have been published during the last two decades about the use and impact of CP as teaching material for patients from the patients’ own perspectives. Moreover, no studies have been conducted, to the best of our knowledge, about the use of SNCP for the same purpose. This is in stark contrast to the vast literature that exists about SNCP and CP more generally [15-18].

Studies by Clarke [19] and Nemeth et al. [20] conducted near the turn of the millennium were among the first to explore the impact of the use of a patient version of CP as an educational tool for patients. These CPs were designed for stroke patients and cancer patients who underwent surgery for their conditions [19]. The patients in the studies deemed that the CPs in question were easy to read and comprehend, and helped them to better understand their surgery [19], condition, and treatment [19, 20], as well as to keep track of their progress [20].

In 2012, Ryhänen et al. [21] developed and evaluated an internet-based patient pathway as an educational tool for breast cancer patients. This tool was based on CP for this patient group and the theory of empowering knowledge, including six knowledge dimensions or content areas. These areas aimed at empowering patients in terms of enabling them to gain control over their illness and improve their wellbeing and health [21-24]. The patient pathway was evaluated by patients after being used in their treatment. Their evaluation showed that the language, structure, and technical characteristics were deemed significantly better than the content, suggesting that the empowerment dimension of patient education needed further development.

Later, Ryhänen et al. [25] evaluated the effect of the same patient pathway on a breast cancer empowerment process through a randomised trial. The intervention group used the patient pathway as well as the usual teaching for patients with breast cancer, while the control group had the same teaching but did not use the pathway. The results showed that there was a non-statistical difference between the groups regarding the three outcome measures: quality of life, anxiety, and side effects, which were used to measure empowerment. More positive results were found on the effects of online patient pathways for patients undergoing minimally invasive parathyroidectomy through a randomised trial study by Neary et al. [26]. They found that patients undergoing this surgery and using a website with an interactive patient pathway (intervention group) were more satisfied with the website than patients in a control group, undergoing the same surgery, who utilised a website in which an interactive patient pathway was not included. More specifically, the patients in the intervention group were more satisfied than those in the control group with regard to overall impressions and the organisation, usefulness, and specifications of the information.

The interest in this subject arose as a result of the first author’s collaboration with nurses at an orthopaedic ward in designing SNCPs for patients undergoing similar operations. The SNCPs consisted of nursing diagnoses and interventions stated according to the classification systems of NANDA [27, 28] and Nursing Intervention Classification (NIC) [29, 30]. Nursing objectives were also stated in the SNCPs. One of those plans was for patients undergoing THR. Moreover, it was decided to write a patient version of the SNCP that the patients could retain throughout their hospital stay. To begin with, a patient version of the SNCP was written for THR patients and sent to them with other pre-operative teaching materials prior to their admission to the orthopaedic unit.

To begin addressing the absence of research about patients’ perspectives of such use of a nursing care plan, it was decided to conduct a phenomenological study through which patients’ experiences could be studied deeply from an open and broad perspective [31]. Accordingly, the aim of the study reported here is to explore the meaning that THR patients ascribe to the lived experience of reading and retaining a nursing plan in lay language. This plan will be referred to as an open nursing care plan (ONCP) in the paper.

The main finding of the study was that the THR patients acquired knowledge from the text of ONCP, which was found understandable and meaningful, as it empowered most of them to gain control over or cope with the consequences of the operation and treatment connected to it.

The prominence of the extent to which participants seemed to acquire knowledge from the text of the ONCP has not been reported on before, as the main impact of using a patient version of a care plan as teaching material for patients. However, the result from the present study showing that ONCP in lay language was found understandable and helpful is supported by three studies showing that patients found patient versions of their CP easy to read, understandable, and useful [19, 20, 26]. The patients’ satisfaction with the lay language in the care plan indicates that use of the plan was in line with a person-centred approach in which such language use and understanding are distinct features [5].

The fact that the acquired knowledge empowered the participants in the present study to gain increased control over or cope with their health situation is another significant finding. This is in accordance with Gibson [34], who defines empowerment as ‘a process of helping people to assert control over the factors that affect their health’ (p.359). Apparently, the participants directed the knowledge they acquired from the ONCP towards managing the problems associated with the THR operation. This indicates that they used problem-focused coping, which is directed at managing or altering problems that cause distress [35]. Such an overall empowering impact of using SNCPs or CPs as teaching material has not been supported previously. Yet this aspect of CPs had been explored in particular in two recent studies [21, 25] but without definitive conclusions.

Four areas of knowledge were found to be particularly important and meaningful for the participants in the present study. The first of those was knowledge about treatment, which parallels the salience of ‘content’ in the biophysiological dimension of empowering knowledge [22, 23] where the treatment and physical signs are addressed. The knowledge area, ‘What nurses and nursing assistants do’, emphasised in the current study, concurs with ‘Help with managing consequences of the treatment’, which is addressed in the functional dimension of empowering knowledge [22, 23]. The participants in the present study remarked that they had learnt from the ONCP that the nurses observed them, and this was of particular importance to them as it enhanced their security, as it meant nurses were monitoring their conditions.

The finding that the participants learnt from the ONCP what nurses do agrees with a stated purpose of the nursing process, which is to demonstrate the roles of nurses, such as their surveillance role [36], which was addressed in the present study. Strangely enough, this finding is not corroborated by the previous literature regarding care plans. In the functional dimension of empowering education, action and moving on during treatment periods, and patient participation in those processes, are both addressed [22-24]. These two areas contain information about what patients are supposed to do, which was an issue that the participants in our study found to be of importance.

Finally, the aspect of patients’ potential responses to treatment, addressed as important in the present study, can be found in the experiential dimension of empowering knowledge, where it is outlined as feelings concerning illness and how illness or operations can affect such experiences [22-24]. The participants’ opinions that they had acquired important knowledge from the ONCP about their potential responses to treatment is not supported in the current literature, however. Yet, this knowledge aligns strikingly with NANDA nursing diagnoses, which are defined as human responses to health conditions or life processes, as well as susceptibility for that response, either by an individual, family, group, or community [28]. Nurses have used NANDA nursing diagnoses in North America for diagnosing clients for around 50 years, and they have been used in many other countries in the past decades [16, 28]. Thus, it reflects somewhat paternalistically on previous standard practice that this is the first study in the current literature which suggests that patients actually know what nursing diagnosis is about.

The knowledge obtained from the ONCP and the other teaching materials improved the participants’ psychological wellbeing by reducing the disempowering psychological effects of the operation, such as anxiety and insecurity. Except for one study, this impact of SNCP or CP has not been noted previously in the literature. The exception is one study [19] that showed that the use of a patient version of CP for cancer patients decreased their anxiety. However, it is well established that written pre-operative teaching material reduces patient anxiety and fear [37]. Still, no research was found that showed a direct relationship between pre-operative education and security. Assuming that security is the opposite of increased anxiety to some extent already supports the view that an ONCP increases security.

Most participants found that the detailed descriptions in the ONCP contributed to their physical progress and their participation by mobilising their abilities. According to Gibson [34], the mobilisation of resources is, indeed, part of the empowering process. These findings have not been confirmed in studies of the use of SNCPs or CPs as teaching materials. They are supported to some extent in research on pre-operative teaching [38], but these results vary between studies [37].

The finding that the ONCP was used as a tool to keep track of care confirms the results of a study by Nemeth et al. [20]. They revealed that a patient version of a multidisciplinary care plan for ischemic patients, consisting of icons and comments, served as a tool for the patients to keep track of care. Yet, this finding has not been confirmed in either recent studies where the use of SNCPs or CPs for educational purposes has been explored, or in the literature regarding peri-operative teaching. By helping patients keep track of care, the ONCP seems to have served the purpose of the care plans, which is to provide continuity of care [36]. Judging from the literature, traditional peri-operative teaching material does not provide patients with such continuity.

The most prominent communicational impact of the ONCP, namely more open and free communication, has not been confirmed in the current literature regarding patient teaching or the use of SNCPs or CPs as teaching material. However, there are striking similarities between this finding and the general assumptions of critical theory that creating conditions for unconstrained communication contributes to empowerment [39, 40]. However, our study showed that the nurses did not discuss the ONCP with the patients, as had been intended, but mainly used it as written teaching materials. The participants felt that the ONCP should be used as a tool for communication and evaluation. Arguably, the participants were here asking for an empowering dialogue and a partnership with health care professionals, enabling them to gain increased control over their situation. This indicates that the ONCP has important under-utilised empowering potential.

Some participants felt they were not prepared enough for how their feelings would develop when the discharge approached. There are interesting similarities between these findings and the results of a study by Szöts et al. [41], which showed that knee-replacement patients most often had unrealistic expectations regarding their abilities and behaviour after discharge, which often resulted in distress. Both of these studies indicate that knowledge about potential responses to health situations is of considerable importance for patients. The general opinion among the participants that the ONCP and other teaching materials should be added to the care plan seems logical, because often the same information was repeated in the different teaching materials. Furthermore, the participants’ suggestion that pictures should be added to the care plan is supported by prior studies that demonstrate the importance of providing education in visual and textual forms [42].

This study suggests that a patient version of standardised care plans can act as an important educational tool for patients that can empower them to manage their health situations. These results can encourage health care professionals to find ways to use care plans as an educational tool for patients in their practice.

Continued use of the already implemented ONCP for THR patients on the respective orthopaedic ward was recommended in light of its overall empowering impact on the patients. Yet, our study clearly showed that improvements were needed in terms of some content of the ONCP and in enhancing its use in communicating and partnering with patients. Such practice development calls for further research on the use of the plan.