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Clinician-patient relationships are central to health care, health systems and medical education. Current educational practice of doctor-patient relationships emerged from an episteme rooted in a biomedical understanding of disease, having epistemic and pedagogical roots in Global North contexts. The thesis offers an analysis of clinician-patient relationships that includes medical ethics, communication skills, and the development of the widely accepted (in Family Medicine) Biopsychosocial model of the clinical consultation. Using a South African clinical postgraduate Family Medicine training programme as a case study, this project answered two central research questions: (i) How do students learn to navigate relationships with patients in this training programme? And (ii) Can we develop an educational model of doctor patient relationships based on local experiences? Mezirow's transformative learning theory, Mbiti's conceptualisation of Ubuntu as an African philosophy, and Foucault's thoughts on structural power provided a conceptual framework. Aim The project aimed to understand the process of student learning about the doctor-patient encounter and to develop a model for teaching about the doctor-patient relationship. Methodology A qualitative longitudinal case study was conducted, drawing data from postgraduate students, educators, and patients. Data was collected from educational, clinical, and reflective activities, and analysed thematically using an inductive approach. Findings The key themes describe students' learning in relation to critical self-awareness, contextual awareness, the dialogic nature of learning, and the impact of transformed perspectives. Patients valued that their patient-hood and personhood were validated, and educators highlighted the theme that vulnerability has pedagogical implications. A new perspective of power dynamics in the clinical encounter is described and an Ubuntu-inspired episteme and pedagogy is synthesised from the findings. Conclusion This decolonial project provides evidence and proposes a model for incorporating an indigenous philosophy (Ubuntu) into mainstream health sciences education. Recommendations are made for educational and clinical practice, as well as future research.

Nursing is uniquely demanding work and occupational stress in the nursing profession has been well-documented. Many theories of stress-related disruptions among helping professionals have been proposed. Although these theories differ slightly in their origin of stress, they share similarities in nurses’ response to the patient relationship. Depersonalization, withdrawal, and avoidance all serve to create relational distance between the nurse and the patient. Despite the prevalence of these responses, there are not any theories on the nurses’ process of disengagement from patient relationships. Using Strauss and Corbin’s (1990) grounded theory method, this study explored acute care nurses’ experience of disengagement in patient relationships. The purpose of the study was to develop a mid-range theory of nurses’ process of disengagement from patient relationships as it occurred in acute care. Through purposive and theoretical sampling, 12 acute care nurses participated in open-ended individual interviews. The process of open, axial and selective coding discovered seven categories related to nurses’ experience of disengagement from patient relationships. These categories were emotional experience, behavioural expression, environmental influences, relational distance, professional identity and work spillover. Although these categories were exclusive, conceptual elements were interwoven into more than one category. The categories were interrelated around the core category, ‘Doing and Being’, and the process of nurses’ disengagement from patient relationships was delineated. Participants in the study experienced dissonance when they were unable to act in accordance to their caring beliefs. Conditions in the work environment, such as the lack of time, the culture of productivity and patient characteristics influenced and promoted their process of disengagement. Disengagement was manifested in the nurse-patient relationship by decreased eye contact, increased physical distance and increased task focused behaviour. These behaviours increased relational distance between the nurse and the patient. Nurses’ experience of dissonance had the potential to foster feelings of professional dissatisfaction and alienation from self, leading to increased turnover behaviour and depression. Implications and recommendations for practice and future research are discussed.

Nursing is uniquely demanding work and occupational stress in the nursing profession has been well-documented. Many theories of stress-related disruptions among helping professionals have been proposed. Although these theories differ slightly in their origin of stress, they share similarities in nurses’ response to the patient relationship. Depersonalization, withdrawal, and avoidance all serve to create relational distance between the nurse and the patient. Despite the prevalence of these responses, there are not any theories on the nurses’ process of disengagement from patient relationships. Using Strauss and Corbin’s (1990) grounded theory method, this study explored acute care nurses’ experience of disengagement in patient relationships. The purpose of the study was to develop a mid-range theory of nurses’ process of disengagement from patient relationships as it occurred in acute care. Through purposive and theoretical sampling, 12 acute care nurses participated in open-ended individual interviews. The process of open, axial and selective coding discovered seven categories related to nurses’ experience of disengagement from patient relationships. These categories were emotional experience, behavioural expression, environmental influences, relational distance, professional identity and work spillover. Although these categories were exclusive, conceptual elements were interwoven into more than one category. The categories were interrelated around the core category, ‘Doing and Being’, and the process of nurses’ disengagement from patient relationships was delineated. Participants in the study experienced dissonance when they were unable to act in accordance to their caring beliefs. Conditions in the work environment, such as the lack of time, the culture of productivity and patient characteristics influenced and promoted their process of disengagement. Disengagement was manifested in the nurse-patient relationship by decreased eye contact, increased physical distance and increased task focused behaviour. These behaviours increased relational distance between the nurse and the patient. Nurses’ experience of dissonance had the potential to foster feelings of professional dissatisfaction and alienation from self, leading to increased turnover behaviour and depression. Implications and recommendations for practice and future research are discussed.

Nursing is uniquely demanding work and occupational stress in the nursing profession has been well-documented. Many theories of stress-related disruptions among helping professionals have been proposed. Although these theories differ slightly in their origin of stress, they share similarities in nurses’ response to the patient relationship. Depersonalization, withdrawal, and avoidance all serve to create relational distance between the nurse and the patient. Despite the prevalence of these responses, there are not any theories on the nurses’ process of disengagement from patient relationships. Using Strauss and Corbin’s (1990) grounded theory method, this study explored acute care nurses’ experience of disengagement in patient relationships. The purpose of the study was to develop a mid-range theory of nurses’ process of disengagement from patient relationships as it occurred in acute care. Through purposive and theoretical sampling, 12 acute care nurses participated in open-ended individual interviews. The process of open, axial and selective coding discovered seven categories related to nurses’ experience of disengagement from patient relationships. These categories were emotional experience, behavioural expression, environmental influences, relational distance, professional identity and work spillover. Although these categories were exclusive, conceptual elements were interwoven into more than one category. The categories were interrelated around the core category, ‘Doing and Being’, and the process of nurses’ disengagement from patient relationships was delineated. Participants in the study experienced dissonance when they were unable to act in accordance to their caring beliefs. Conditions in the work environment, such as the lack of time, the culture of productivity and patient characteristics influenced and promoted their process of disengagement. Disengagement was manifested in the nurse-patient relationship by decreased eye contact, increased physical distance and increased task focused behaviour. These behaviours increased relational distance between the nurse and the patient. Nurses’ experience of dissonance had the potential to foster feelings of professional dissatisfaction and alienation from self, leading to increased turnover behaviour and depression. Implications and recommendations for practice and future research are discussed. / Education, Faculty of / Educational and Counselling Psychology, and Special Education (ECPS), Department of / Graduate

Little is known about how people evaluate credence attributes, that is, those attributes which the consumer often cannot fully evaluate even after purchasing and consuming the product. And yet consumers struggle to evaluate quality in several important product categories dominated by credence attributes such as food safety, medical services, legal services, and pharmaceuticals, among others. The dissertation explores the processes by which people form quality evaluations of services high in credence attributes and the consequences of those evaluations. Drawing on the service quality, dual-process social information processing, expert-novice and risk literatures, I develop a conceptual model to illustrate how skill and motivation moderate the ways people seek and integrate observable information to infer unobservable quality. The influence of quality evaluations on outcome, satisfaction, value, and loyalty is mapped. The model is tested in the context of a classic credence service, health care services with two large datasets using structural equation modeling. Study 1 draws on an existing patient satisfaction database (6,280 records) to measure the sources and consequences of quality evaluations. Study 2 validates Study 1 findings and extends those findings to show the moderating roles of product expertise and perceived risk on quality evaluation processes. The second study is tested with 1,379 consumers (patients) drawn from an online consumer panel. The research suggests service quality in this context refers narrowly to the attributes of the core product (here, the physician‘s medical competence); interpersonal and organizational quality are associated with value, satisfaction and loyalty, rather than overall quality. Two paths to quality evaluations appear to exist. In the first, consumers integrate evidence of the physician‘s capabilities, practices, and prior outcomes to reach evaluations of technical quality. In the second path, consumers rely on a trust heuristic in which observed interpersonal and organizational quality signals are used to build trust in the physician; that trust, in turn, influences perceptions of technical quality. The trust heuristic appears to be used when the stakes are low and, counterintuitively, when the stakes are high, just when superior evaluations are most needed.

It has been well established, in the literature, the association between low health literacy rates and poor health outcomes. With the increase of technology dependence, more people are using the internet to look up health information. Research has shown that shared decision making between providers and patients can improve patients' health outcomes. This research aims to examine whether electronic health (eHealth) literacy impacts patient-provider relationships. This research will also examine how geography specifically state residency impacts eHealth literacy rates. Data collected from a national sampling of online health and medical information users who participated in the Study of Health and Medical Information in Cyberspace (N=710) is used to construct structural equation models from SPSS AMOS v. 20.0. After path analysis, the results shown that white males with higher education were more likely to have higher eHealth literacy rates and that eHealth literacy rates are associated with better self-care, higher patient satisfaction and increased trust in provider. Also, state residency does not have an impact on eHealth literacy rates. eHealth literacy will be significant in patient-provider relationships. Program development should be established on focusing on eHealth literacy across the lifespan. Also, it will be important to review federal policy on technology disbursements in order to achieve national goals on eHealth literacy rates.

Acute care nurse practitioners (ACNPs) are a new addition to the Canadian health care system, having been introduced in the Canadian health care system in the late 1980s. While some authors have suggested that nurse practitioners offer “something special” to patient care, no evidence to date has substantiated this claim. The findings of this grounded theory study offer a theory (Acute Care Health Professional-Patient Relationship (ACHPPR) Theory) to describe how three types of health care professionals establish relationships with patients in acute care settings (Figure 7). This qualitative study explored relationships that ACNPs, physicians and staff nurses establish with patients in a large urban multi-site university-affiliated hospital. Six quartets (patient, ACNP, physician, staff nurse) were recruited and interviews, using a semi-structured guide were audio-taped and subsequently transcribed verbatim. Each type of relationship was found to have a unique focus; ACNPs focus on making connections with patients, physicians focus on managing patients’ diseases and staff nurses focus on meeting patients’ needs. In order to establish relationships with patients, readiness conditions must be met. Health professionals use strategies to influence the achievement of readiness conditions as well as to move forward with relationship development. Each type of relationship varies in the range of potential intensity that can be achieved, which is influenced by various dimensions. Relational intensity ranges from the uncommon clinical relationship, which focuses on the patient’s disease, through the more typical professional relationship characterized by a comfortable rapport and then finally to the most relationally intense, but rare, personal relationship. If a relationship reaches professional or personal levels of relational intensity, relational products become evident. When comparing these three health professional-patient relationships, similarities and differences have been identified. Analysis of patient interviews yielded themes that substantiate the ACHPPR theory. The ACHPPR theory offers a beginning understanding of the complementary nature of three types of health professional-patient relationships in the acute care setting and has the potential to influence practice, education, theory development and future research related to ACNP-patient relationships.

Acute care nurse practitioners (ACNPs) are a new addition to the Canadian health care system, having been introduced in the Canadian health care system in the late 1980s. While some authors have suggested that nurse practitioners offer “something special” to patient care, no evidence to date has substantiated this claim. The findings of this grounded theory study offer a theory (Acute Care Health Professional-Patient Relationship (ACHPPR) Theory) to describe how three types of health care professionals establish relationships with patients in acute care settings (Figure 7). This qualitative study explored relationships that ACNPs, physicians and staff nurses establish with patients in a large urban multi-site university-affiliated hospital. Six quartets (patient, ACNP, physician, staff nurse) were recruited and interviews, using a semi-structured guide were audio-taped and subsequently transcribed verbatim. Each type of relationship was found to have a unique focus; ACNPs focus on making connections with patients, physicians focus on managing patients’ diseases and staff nurses focus on meeting patients’ needs. In order to establish relationships with patients, readiness conditions must be met. Health professionals use strategies to influence the achievement of readiness conditions as well as to move forward with relationship development. Each type of relationship varies in the range of potential intensity that can be achieved, which is influenced by various dimensions. Relational intensity ranges from the uncommon clinical relationship, which focuses on the patient’s disease, through the more typical professional relationship characterized by a comfortable rapport and then finally to the most relationally intense, but rare, personal relationship. If a relationship reaches professional or personal levels of relational intensity, relational products become evident. When comparing these three health professional-patient relationships, similarities and differences have been identified. Analysis of patient interviews yielded themes that substantiate the ACHPPR theory. The ACHPPR theory offers a beginning understanding of the complementary nature of three types of health professional-patient relationships in the acute care setting and has the potential to influence practice, education, theory development and future research related to ACNP-patient relationships.

Durante minha trajetória profissional experenciando o cuidar de clientes portadores de doença onco-hematológica percebi a luta destes seres humanos pela vida e como a relação enfermeiro-cliente era vital para a realização do cuidado. O enfermeiro interage grande parte do tempo com esta clientela a qual percorre uma trajetória de re-internações e longos períodos de tratamento. Nesse sentido, entendendo que a relação interpessoal como uma condição importante para que o enfermeiro compreenda o outro em sua totalidade e preste um cuidado singular, delimitei como objeto de estudo as relações interpessoais do enfermeiro na ação de cuidar do cliente internado para tratamento onco-hematológico. Para tanto, o objetivo foi compreender o significado das relações interpessoais na ação de cuidar do enfermeiro junto ao cliente internado para tratamento onco-hematlógico. Trata-se de estudo de natureza qualitativa, cujo referencial teórico pautou-se nas concepções da fenomenologia sociológica de Alfred Schutz. O cenário de realização do estudo foi a enfermaria de Hematologia de um Hospital Universitário Federal do estado do Rio de Janeiro e os sujeitos foram todos os seis enfermeiros lotados nessa unidade. Antes da etapa de campo e em cumprimento aos princípios éticos da Resolução 196/96 do CNS que trata da pesquisa com seres humanos, o projeto foi submetido ao Comitê de Ética dessa instituição cenário do estudo, sendo aprovado com o Parecer n 092/11. A captação das falas deu-se por meio de entrevista com a utilização das seguintes questões orientadoras: fale para mim sobre as ações que você desenvolve junto ao cliente internado para tratamento onco-hematológico; o que significam as relações interpessoais na ação de cuidar do cliente internado para tratamento onco-hematológico?; e o que você faz para que esta relação aconteça? A análise compreensiva das falas possibilitou a apreensão das categorias: cuidar através de procedimentos técnicos e científicos, orientando para o enfrentamento da doença e atender o paciente na perspectiva de suas necessidades estabelecendo a relação interpessoal entre enfermeiro e o cliente. O enfermeiro descreve as ações desenvolvidas junto ao cliente em tratamento onco-hematológico como um fazer técnico, rico em procedimentos, que tem em vista apoiar o cliente para enfrentar o tratamento difícil de uma doença grave, a partir de suas necessidades, estabelecendo uma relação íntima, transparente e forte, ocorrendo de forma espontânea e natural. Para estabelecer esta relação os enfermeiros utilizam estratégias como: a empatia, a brincadeira, o carinho, a confiança e a disponibilidade para promover o cuidado de enfermagem. As relações interpessoais se mostraram inerentes à ação de cuidar desse enfermeiro, ator social da equipe de saúde, o qual possui a disponibilidade para interagir com o cliente, transcendendo o aspecto tecnicista, fazendo parte de sua identidade profissional o constituinte relacional. / During my professional trajectory experiencing the take care of the clients with onco-hematological disease, I perceived the fight of these human beings for the life and how the nurse-client relationship was vital for the care realization. The nurse interacts much of the time with this clientele which comes a way of re-hospitalizations and long ways of treatment. In this sense, understanding that the interpersonal relation be an important condition so that the nurse understand the other in its totality and take a singular care I delineated as study object the nurse s interpersonal relations in the action of take care of the client hospitalized for onco-hematological treatment. For such, the objective was to understand the meaning of the interpersonal relationship in the action of take care of the nurse with the hospitalized client for onco-hematological treatment. It treats of study of qualitative nature, which theoretical reference based on the conceptions of the sociological phenomenology of Alfred Schütz. The Scenario of the study realization was the nursery of Hematology of a Federal University Hospital of the Rio de Janeiro state and the subjects were all the six (06), nurses placed in this unit. Before the field step and in compliance with the ethical principles of the 196/96 Resolution of the CNS that treats of the research with human beings, the project was submitted to the Ethical Committee of this institution scenario of this study, being approved with the Opinion n. 092/11. The speeches capture occurred by means of interview with the utilization of the following guiding questions: Talk to me about the actions that you develop with the hospitalized client for onco-hematological treatment. What means the interpersonal relationships in the action of take care of the hospitalized client for onco-hematological treatment? What do you do so that this relationship occurs? The comprehensive analysis of the speeches made possible the categories apprehension: To take care through technical and scientific procedures guiding to the confronting of the disease and Attend the patient in the perspective of its needs establishing the interpersonal relationship between nurse and the client. The nurse describes the actions developed with the client in onco-hematological treatment as a technical making, rich in procedures that have in view to support the client to confront the hard treatment of a serious disease, from its needs, establishing a close, transparent and strong relationship occurring in a spontaneous and natural way. To establish this relationship the nurses use strategies like: the empathy, the joke, the confidence, the availability to promote the care of nursing. The interpersonal relationships showed inherent to the action of take care of this nurse, social actor of the health team, which has the possibility to interact with the client, transcending the technicality aspect, being part of its professional identity the relational constituent.