Original Article

Patients’ Lived Experiences of the Paternalistic Care Behavior: A Qualitative study

Introduction

Nurses play a pivotal role in patient care and compared to other members of the treatment team, spend more time with patients and their families.^1,2 This places nurses in a good position to empower and encourage patients to participate in their own care.³

When nurses leave decision-making to patients, they should help patients participate in their own care via increasing their decision-making power.⁴ Nurses can assist patients to become more involved in care by strengthening patients’ power, knowledge, and self-confidence.^5,6 Self-care management is an example of how patients achieve autonomy and self-care.⁷ Tobiano et al stated that nurses should stop controlling patients and allow them to take part in their own care.³ However, evidence indicates that nurses exhibit paternalistic care behaviors, and hence, the transfer of power from nurses to patients is a challenging process.^8-11

Equal distribution of power allows patients to make decisions about health and disease processes independently and with expert advice. The relationship between the nurse and the patient should not seek to change the values and customs of the patient, but to use the specialist as evidence of the experience of the health and disease process in the patient and family.¹²

In the Cambridge Dictionary, paternalism is defined as a practice that restricts one’s freedom and authority and is justified by promoting well-being and preventing harm to the individual.¹³ In general, when an action (or omission of action) is intentionally performed by someone other than the person and against the individual’s will or without his/her consent and with the explicit purpose of doing good and/or avoiding harm is called paternalistic.¹⁴

Of course, in defense of paternalism, it is argued that not all patients want independence and are dependent and tend to be more dependent.¹⁵ Forcing the patients to be more independent and care for themselves is considered a kind of paternalistic behavior.¹⁶ Studies in recent years have demonstrated that the majority of patients tend to be independent in their own treatment.^17-19 In opposition to the patient’s complete independence, Yavari and Parsapoor state that the patient’s complete independence can conflict with his/her real medical benefit, making appropriate medical decisions, the benefit of others in the community, as well and the responsibility of physicians. Ultimately, the patient’s independence should be to such an extent that s/he does not fall victim to his/her lack of control over the medical condition and the physician’s irresponsibility.²⁰

Considering that in Iran and other parts of the world, not much research has been conducted to study patients’ lived experience of paternalistic care behaviors, conducting a more in-depth study using a phenomenological approach to explain paternalistic care behaviors based on patients’ lived experiences and to clarify ambiguities about this issue, was placed on the researcher’s agenda as a Ph.D. candidate in nursing education, a nurse and a member of the health care team who has always been concerned with protecting the rights of patients in order to respect human dignity in mind.

The nurse-patient relationship is an interesting but little-understood topic in which many concepts play a role. In the history of nursing, due to the prevailing paternalistic model, the patient’s rights were not always observed. It can be argued that both the patient and the nurse/physician have an equal right to freely express their will, desire and decisions about health care.²¹

Past studies have implicitly pointed to the existence of paternalistic behavior in the nursing care system.^22-24 However, no study was found to explain the lived experience of hospitalized people in this field.The present study was designed and performed to explain patients’ lived experiences of paternalistic care behaviors.

Materials and Methods

This qualitative research was conducted with the design of hermeneutic phenomenology consistent with Heidegger’s philosophical view. Hermeneutics is a systematic approach for analyzing a phenomenon that allows the examination of an interpretive perspective to gain a more profound comprehension of lived experiences.²⁵

In this study, purposeful sampling was used, and considering that the study phenomenon i.e. paternalistic care behaviors was based on the patients’ experiences, the participants consisted of individuals with experiences of hospitalization and receiving care in the hospitals of Tehran, Iran.

Purposeful sampling is often the sampling choice used in a qualitative study. A researcher should not only state the population to be sampled but should clearly state certain characteristics of the sampled population.²⁶

During the researcher’s presence in the hospital, the previously admitted patients were contacted. The other participants were patients hospitalized during the researcher’s observation in the hospital and were interviewed after discharge. Subsequent participants were selected by telephone. Patients in this study were in age over 18, hospitalization history, and willingness to participate in the study and talk about their experiences. The objectives of the study were fully explained to the participants and they ensured that participation in the study would be voluntary and that their data would be kept confidential. They can also unilaterally withdraw from the study and informed written consent was obtained from all of them. In the present study, the point of data richness arrived pursuant to conducting 13 interviews with 7 patients. Moreover, they pointed out that data collection should persist until the researcher determines that it is richness. Richness occurs when no new theme is extracted from the participants and the data becomes repetitive.²⁷

In this study, the unstructured interview method with open-ended, face-to-face, and individual questions and field notes was used to obtain data. The data were collected for 8 months from November 2020 to June 2021. Thirteen interviews were conducted with 7 patients. The mean duration of the interviews was 42 minutes (ranging between 32-61 minutes). All interviews were performed after obtaining consent from the participants in the researcher’s office, except one case, who was interviewed at her home due to physical disability. Each interview started with a general question like: “What is your experience of nursing care?” Then, it continued with questions like “How did you get guidance and obtain the information when your disease was diagnosed and treatment started?”, “What information was provided to you?”, “ What information did you expect that was left unsaid?”, “Which behavior by the nurses bothered you the most?”, “How did you interpret this behavior by the nurses?”, “How did you feel about this behavior?”, “Did you experience any other behavior that made you feel similar?”. The interviews continued with in-depth questions like “May you explain more about this?”, “Do you mean...?”, and “Please give more examples from your experiences in this regard”, etc in order to obtain more comprehensive information about the lived experience of nurses about the phenomenon under study. During the interviews, the participant’s nonverbal feelings and actions were recorded by the researcher. All interviews were digitally recorded with the participant’s permission, transcribed verbatim, and then entered into the MAXQDA software (version 10) for data management.

To avoid bias and ensure it did not directly affect the results of the study, the author initially used reflexivity by recording his experiences and feelings in a notebook. In this study, the seven-step approach of Diekelmann et al was used for data analysis.²⁸ To begin the hermeneutic analysis, based on the first step of Diekelmann’s method, the transcribed texts of interviews were read several times carefully in order to gain a better understanding of them. Thereafter, they were sent to the research team to get their views, as well as to receive guidance and comments on the quality of the interview process, and after receiving the comments, suggestions were applied in subsequent interviews. Secondly, to facilitate a general understanding of the text, an interpretive summary of the text of each interview was written. Next, to facilitate data management and theme extraction, the text of each interview was entered into the MAXQDA software (version 10). Then, the extraction of semantic units (coding) started. In the third stage, the text of the interviews was analyzed. Then, samples of interviews and analyzes were studied by all members of the research team, and corrective comments were applied in the text of the analysis. In the fourth stage, any discrepancies in the analysis and interpretation were resolved by referring to the text. If further elucidation and also resolving ambiguity were required, a re-interview was conducted with the participant. In the fifth stage, by comparing and contrasting the texts, the themes reflecting common meanings were identified and described. In the sixth step, during the evaluation and comparison of themes, structural patterns existing in the text of all interviews connecting the communication themes were identified. In the seventh (final) stage, a draft of themes and template, and an excerpt from the text of the interviews were provided to the research team for comment, and the responses and possible suggestions were applied to the final draft of the findings. The research team consisted of 2 methodologists, the first author (a nursing Ph.D. candidate), and 5 research observers. The researchers’ long history as hospital nurses, as well as research in the field of ethics and protection of patient rights, resulted in better identification of implications in the participants’ responses.

To ensure the trustworthiness of the findings, we used the four criteria of Lincoln and Guba: credibility, dependability, conformability, and transferability.²⁹

To enhance the credibility of the study, one of the cases is a prolonged engagement with the subject under study. The first author was involved in the phenomenon of paternalistic care behaviors for an extensive period during his clinical activity as a hospital nurse. He also conducted the interviews, listened to them several times, typed, and reread repeatedly after completion. Hence, long-term involvement with the phenomenon of paternalistic care behaviors and immersion in the data obtained from the study are helpful in increasing the credibility of the data. “Member check” is also a primary component in enhancing the validity of the qualitative research.^30,31 In the present study, during data collection and analysis, the printed text of the interviews along with its interpretive summary, codes, and themes appeared was presented to the participants for approval. All the seven participants confirmed that the researcher’s interpretations were effectively in line with their experiences of paternalistic care behaviors. Furthermore, in this study, the researcher as a nursing Ph.D. candidate, throughout the study, i.e. the development of methods, procedures, analysis and interpretation of data, and conclusions under the supervision of the research team who were experienced in conducting qualitative and especially interpretative phenomenological analysis.

In this study, in order to increase the dependability of the study, the research process including inviting participants, data collection, and data analysis, were all described transparently in order to enable the same study to be repeated by others. Efforts were also made to carefully record and report the research process and the decisions made during it in order to maintain the confirmability of the research and allow others to follow up on the study if needed. To ensure transferability, the context, as well as the processes of participant selection, data collection, and analysis of data were recorded and made available so that the reader could determine whether the results are transferable to other contexts.

Participants were informed about the aims and method of the study and ensured that their identities would be kept confidential. Their participation was voluntary, and they signed a written consent and had the right to withdraw from the study at any stage. The researcher also had no therapeutic or caring relationship with the participants.

Results

The mean (SD) of the participants’ age was 32.85 (8.69) years. Five participants were female and two were male, and their mean (SD) of hospitalization length was 5.57 (3.33) days. Patients were admitted to the intensive care unit, cardiac care unit, surgical, internal medicine, and obstetrics and gynecology wards (Table 1).

Data analyses revealed, four themes, thirteen sub-themes, and one structural pattern formed the structure of patients’ lived experiences of paternalistic care behaviors (Table 2).

Constitutive Pattern: Duality of Supporting and Suppressing of Independence

As is evident in themes and sub-themes, patients are in a duality over paternalistic care behaviors. On the one hand, due to the need for attention and fear of loneliness, they consider this behavior a kind of support, and on the other hand, the patient finds him/herself in a situation where his/her independence is ignored, which may cause many problems for him/her.

Theme 1: Support at Helplessness

One of the main themes mentioned in most interviews was support at helplessness. Following hospitalization, patients found themselves in a weak position that needed nurses to meet their needs. Hence, they even considered paternalistic care behaviors as a form of support. This theme includes three sub-themes: Supportive care behavior, good sense of being noticed and accepted, and Substitute for family support.

Supportive Care Behavior

From the lived experiences of participants, it was inferred that they did not always have a negative attitude towards paternalistic behavior. It seems that if the paternalistic behavior is in line with the patient’s wishes, the patient does it willingly and considers it as supportive behavior. In this regard, one of the participants stated that:

“The nurse told us we could not have visitors or a companion due to the COVID-19 pandemic. Well, it was hard, but I was satisfied with their decision since it reduced the possibility of getting infected with COVID-19.” (P4)

Another participant said: “When changing my wound dressing, the wound was open and bleeding. I couldn’t see it and asked them what happened. They replied: Nothing. I knew what was going on, but this showed that they were thinking about me and didn’t want me to worry. Maybe they were afraid to say that moment and maybe if there was another patient s/he would complain why you did not say but I think they did a good job because I could have felt worse knowing that.” (P5)

Good Sense of Being Noticed and Accepted

The participants’ lived experiences revealed that they need attention, affection, and receiving a sense of importance from nurses at the time of hospitalization, even if this attention and affection is accompanied by a paternalistic behavior, they consider it a positive feature that exists in the minority of nurses. In one of the interviews, it was stated that:

“I was working with my tablet on the bed when a nurse came in and sat on the bed next to me and asked me how I was. She even asked me in a very friendly way that what city I’m from; what university I studied at; what my field of study was; etc, like a conversation between two friends! Even though she came in the middle of my work, I didn’t mind and I got a good sense of her behavior.” (P2)

Substitute for Family Support

Data analysis demonstrated that patients expect support from the nurse after hospitalization in the same way that the family provides support. So, they are more afraid of inattention and loneliness than of paternalistic behavior. In this regard, one of the participants stated that:

“During hospitalization, I couldn’t eat at all. Most of the time, no one asked why I didn’t touch my food, but one of the nurses asked, ‘Is there something wrong? Why aren’t you eating? The less you eat, the less energy you’ll have and the slower your recovery.’ I needed to hear exactly those words in order to motivate me to eat. I felt there was someone other than my family who was worried about me.” (P2)

Theme 2: Inflexibility

The shared experience of participants showed that inflexibility is a manifestation of paternalistic care behavior. This theme consists of 3 sub-themes: “lack of creativity”, “routine actions being considered as the best action”, and “inattention to the uniqueness of each patient”.

Lack of Creativity

Data from patients’ lived experiences shows that lack of creativity in nursing practices leads to nursing care without considering patients’ opinions or their desired care. Regarding this topic, one of the participants stated that:

“The room I was in had a window facing the yard. I was told not to move at all, but once I was so down I just wanted to go to the window and look outside. I asked the companion of the patient in the next bed to help me. She went outside to get the nurse so they could both help me, but suddenly the nurse walked in screaming and shouting: “Didn’t I tell you not to move?” She paid no attention to how I felt and how much I needed that and even did not say, for example, you can go there tomorrow, ‌or we will take the bed by the window. I just didn’t feel like arguing with her, but I was really upset.” (P1)

Routine Actions Being Considered as the Best Action

One of the causes of paternalistic care behaviors by nurses is that they think routine actions are the best actions. One of the participants said on this topic:

“After the doctor would come in and open the dressing, I always wanted the dressing to be changed immediately, but usually it wasn’t done in the morning, it was around 2-3 pm. “When I told them why they don’t change my dressing right away, they said that there is a special nurse who will come at that time according to the schedule.” (P4)

Inattention to the Uniqueness of Each Patient

A review of the data demonstrated that another factor that leads to the emergence of paternalistic care behaviors is inattention to the uniqueness of the patient. Patients believed that because of the large number of patients, nurses saw them as their illness or their bed or room number and did not pay attention to patient differences. Specifically, one of the participants remarked:

“Rather than saying it was a top-down view, it’s fairer to say that their behavior toward patients was programmed. Well, different patients come and go, the nurses do a series of things for them, and they seem to get better. I feel that the nurses see the patients in the form of their illness, that is, they do not care about them individually.” (P3)

Theme 3: Vague Awareness

Paternalistic care behaviors in various forms create conditions for patients not to be fully informed and to be aware of what the treatment team wants. This theme includes three sub-themes: “Providing routine training”, “Providing vague information to maintain the patient’s spirit” and “The obligatory of the physician’s orders”.

Providing Routine Training

Many nurses consider routine training to be sufficient and give out standard training regardless of the different needs of each patient. Training the patient regardless of his/her questions and needs causes the patient to remain in a vague state of what s/he wanted to know. In one of the interviews about providing routine training, it was stated that:

“I used to notice how they explained to everyone about chest tubes, as if it was part of their rules to inform everyone about it because all the patients there had chest tubes. Or, for example, they told everyone about the possibility of bleeding from cervical vein but things that were specific to me and I had questions about, didn’t matter to them at all.” (P6)

Providing Vague Information to Maintain the Patient’s Spirit

Another paternalistic care behavior noticed by participants was not keeping patients fully informed about their status in order to maintain their spirit. Regardless of the fact that it was the right of the patient to know where s/he stood medically, wherever they thought it might upset the patient, the nurses avoided providing the right or full information. One of the participants stated:

“Before the surgery, the nurses told me that I was going to have an outpatient surgery, but I found out after the surgery that I was in the operating room for about two hours, which created a great deal of worry and stress for me because I really didn’t expect my surgery to be accompanied by anesthesia. I had once undergone outpatient surgery, and I think it was the major thing that I should have been properly informed and trained on, but they told me: ‘because we wanted to keep you in good spirits, we did not tell you how long it was going to take’.” (P5)

Obligatory of the Physician’s Orders

Participants noted that many nurses did not see the need to explain and teach us about the physician’s instructions and simply considered them obligatory, and this is a clear manifestation of paternalistic care behavior. An interviewee mentioned that:

“After the delivery, the nurses came and pressed hard on my abdomen and caused a lot of pain. I told them to stop and that it was intolerable, but the nurse simply responded that this was an order from the doctor and we have to do it. No explanation as to why. And it didn’t stop after I asked them. They just insisted it was the doctor’s orders and it had to be done.” (P7)

Theme 4: Despair Due to Lack of Autonomy

When paternalistic care behavior conveys a sense of lack of autonomy to the patient, the person experiences a sense of despair and helplessness. This theme includes 4 sub-themes: “Despair due to the feel of being neglected”, “Feeling unable to make decisions”, “Fear of self-harm”, and “Opposition to the patient’s requests”.

Despair Due to the Feel of Being Neglected

An analysis of the lived experiences of patients about paternalistic care behaviors showed that not paying attention to the patient’s independence in decision-making and his/her needs can cause a sense of despair in them. In this regard, one of the participants stated that:

“I felt ignored by the nurses when I felt my voice wasn’t being heard or that they didn’t care about my opinions. I felt trapped in the room and I felt I was suffocating. I wished I had never come to this hospital nor been hospitalized. I just wanted to be discharged sooner so I wished I had never come here.” (P3)

Feeling Unable to Make Decisions

Data analysis revealed that when the nurses, without sufficient training and explanation to convince the patient, oppose his/her request, they induce him/her that s/he does not have the power and ability to make decisions for him/herself. In this regard, it was stated in an interview that:

“When I insisted that I want to stay in the ICU and I’m not feeling well, the nurses said we have no empty bed in the ICU and you have to be transferred to the general ward. Well, this means that I cannot make a decision for myself, and they’re the ones who’ll decide what’s to be done for me and what’s not to be done. This is not right.” (P6)

Fear of Self-harm

Patients’ lived experiences showed that with the repetition of paternalistic care behaviors, the patient gradually feels that it may worsen the condition and harm him/herself by expressing his/her opinions, and therefore prefers not to express his/her opinions and leave the decision to the medical staff. For example, in an interview, this issue was clearly mentioned:

“When I told the nurse that I’m really in pain and need to be injected with additional morphine, he would tell me that excessive drug has side effects and I just have to tolerate the pain. I was really scared if I insisted and they inject me more morphine, my condition could deteriorate, so I just tried to bear it, but I was in excruciating pain.” (P4)

Opposition to the Patient’s Requests

One of the most obvious manifestations of paternalistic care behaviors is opposition to what the patient wants. Data analysis showed that nurses opposed many of the patients’ requests in different situations and for various reasons. Concerning this matter, one of the participants stated that:

“When the IV would run out, I would tell the nurses to disconnect it but they would make all kinds of excuses not to do it. They would say it’s not a problem or in a few minutes we’ll connect the next IV and it may be bothersome for you to disconnect/reconnect while it was important for me to be separated from the IV, even for a few minutes to be able to do other things.” (P5)

Discussion

This study analyzed the patients’ lived experiences of paternalistic care behaviors. After the interviews and data analysis, four themes emerged. The findings revealed that patients found themselves in duality when confronted with paternalistic care behaviors. The views of patients who viewed paternalistic behavior as supportive can be seen in line with those of Lougheed or Ambuehl et al. These researchers have an optimistic approach to paternalism and believe that it is desirable if the behavior is respectful and fair.^32,33 On the one hand, the patient needs attention as a substitute for family support and considers paternalistic care behaviors as supportive care behaviors, and on the other hand, inflexibility, vague awareness, and lack of autonomy as the consequences of experiencing paternalistic care behaviors suppress their sense of independence. There are different interpretations of the concept of independence.^34-36 While in most countries, there is a satisfactory understanding of patient independence, in certain societies such as some Latin American countries.³⁷ and some Asian nations, patients and their families consider paternalism a blessing.^37,38 Murgic et al express in their study that, despite all the issues that paternalism entails, if it leads to the well-being and health of the patient, it has nothing to do with independence, and hence they believe that paternalism should not be rejected altogether and should be modernized and adapted to new attitudes.³⁹ By providing knowledge and participation of patients in self-care, nurses can create responsibility for health in patients, and by recognizing the principles of independence and usefulness, it can be ensured that full observance of patient independence is not contrary to the duty of nurses, i.e. care.²¹

The first theme that emerged in this study was Support at helplessness. It seems that if paternalistic behavior is in line with the patient’s wishes, the patient can be satisfied with it and consider it as supportive behavior, but for instance, when the nurse does not inject a painkiller when the patient in order to prevent drug side effects, the patient expresses dissatisfaction with this paternalistic behavior because it is not in line with what s/he wants. The study by Fernández et al stipulates that although the promotion of autonomy is intrinsically right, it may be adjusted to the individual baseline characteristics, taking into consideration that a very high level of autonomy demand could overcome the individual baseline, producing anxiety, and suffering.⁹ Patients consider the nurses’ explanations without asking them a question as a sign of their attention and affection, and this is a kind of paternalistic behavior in line with the patient’s needs. In this regard, Lepping et al pointed out that autonomy is only one of several important moral values that exist in the patient-medical staff relationship, and other values such as “beneficence & justice” should also be considered in the relationship.⁴⁰ In their conversations, patients pointed out that they expect attention, affection, and a sense of being important from nurses as what the family provides, and see this as a positive trait that exists in the minority of nurses. The fact that patients need the nurse to pay attention to them and consider them important shows that in some cases, patients are more afraid of not paying attention to themselves and feeling lonely than they are of paternalistic behavior. What matters, then, is how to do the best to increase the patient’s independence so that other moral values are not lost.⁴¹

Another theme that has emerged in examining the lived experiences of patients when it comes to paternalistic care behaviors is inflexibility. Paternalism in medicine is known as a kind of authoritarianism, in which one person exercises power over another by making decisions based on self-belief of superior knowledge, thus applying a kind of patriarchy, namely: I am the one who knows, hence, I decide what is right for you.^21,42 Participatory decision-making is the opposite of paternalistic behavior.⁴³ In order to increase the quality of care and avoid paternalistic behaviors, nurses should find a suitable way to communicate with the patient and identify their needs for care. In general, talking and communicating in all forms in counseling and conversation can be a good way to replace access to excellent nursing care. Sanchez stated that patients’ right to participate in informed health-related decisions should always be promoted and protected.²¹

Vague awareness is another theme that has emerged from the lived experiences of patients. Webster defines “obscurantism” as the practice of keeping knowledge or understanding about something from people.⁴⁴ Nurses play a key role in the hospitalization experiences of patients, including involving patients in their own self-care during hospitalization, and more than any other health care provider, nurses are mostly in contact with patients in hospital care settings.² Strategies that promote and perpetuate the efforts of nurses to increase patient participation in self-care, play an essential role in improving patients’ experiences during hospitalization and should be considered.⁴⁵ It should be noted that patients have the right to be fully aware of any action related to their health, except those that are prohibited by law, and also to be able to express all of their health concerns.²¹ Sometimes, nurses place patients in a vague state of awareness about their own conditions for various reasons, such as considering routine actions as the best actions, preventing the patient from being annoyed, or following the physician’s instructions. Obscurantism and lack of training the patient are in conflict with the patient’s self-care and satisfaction.⁴⁶ Moreover, the Stanford Encyclopedia Philosophy, describes medical paternalism as preventing the medical team from providing information about the patient’s condition.⁴⁷

Another theme that emerges from the lived experiences of patients is despair due to lack of autonomy. When the patient sees that s/he has lost his/her independence, s/he experiences despair and a feeling of weakness in making decisions for him/herself. When the power of nurses is delegated to patients, nurses need to empower patients to help them participate in their own care.⁴ Managing self-care is an example of how patients achieve autonomy and self-responsibility in care.⁷ Nurses can help patients by empowering their strengths, knowledge, and self-confidence thereby encouraging their increased participation in their own care.⁵ The study by Tobiano et al proposed that nurses should relinquish control of patients and delegate responsibility for caring to patients.³ However, according to the evidence, paternalistic care behaviors are still observed in nurses; hence, the transfer of power from nurses to patients is a difficult process.¹¹

Given the challenges in the field of paternalistic care behaviors, we can see the creation of new ethical values ​​in care behaviors in the clinical environment by thinking deeply about the meanings extracted from the present study and turning them into practical values. Nurses should know that the support of patients and their participation in their own care are two essential principles. The concepts extracted from the patients’ experiences should be explained in the form of in-service training workshops for nurses and in the form of training programs for nursing students. Localizing ethical values and applying them to patient care will improve the quality of care.

The most important challenge confronted during conducting the present study was the limitations caused by the COVID-19 pandemic. Since according to the decision by the research team, all interviews were performed face-to-face, the researcher and the participant used masks, protective shields, and disinfectants. Indeed, due to the lack of study on this concept and nursing care, understanding the main intention of nurses to perform the behavior and whether it is paternalistic or non-paternalistic is debatable. It is therefore recommendation that, Subsequent studies can be conducted as a focus group among nurses to provide feedback and examples of paternalistic care behavior. It is also suggested that a phenomenological study be conducted on nurses’ experience of paternalistic behaviors in the health care setting.

Conclusion

The findings of this study reflect the patients’ in-depth experiences of paternalistic care behaviors. The meanings discovered such as support at helplessness, inflexibility, vague awareness, and lack of autonomy demonstrated that patients face a duality regarding paternalistic care behaviors. On the one hand, they are satisfied with the support provided, and on the other hand, their deprivation of independence makes them desperate and unable to make decisions. Therefore, performing supportive care behavior with emphasis on patient participation should be considered as an essential ethical principle in patient care.

Acknowledgements

This article is part of a PhD dissertation in nursing approved by Iran University of Medical Sciences. The authors would like to profusely thank all individuals who supported and helped them in conducting this study.

Authors’ Contributions

NP, MSH, LB: Conceptualization; NP, LB: Data collection; NP, MSH, LB: Data analysis and interpretation; NP, MSH, LB: Draft preparation; NP, MSH, LB: Review of article and find approval; LB: Supervision; NP, LB: Project administration. All authors have read and agreed to the published version of the manuscript.

Conflict of Interests

The authors declare that they have no competing interests.

Data Accessibility

The data that support the findings of this study are available from the corresponding author, [N.P], upon reasonable request.

Ethical Issues

This study was approved by the Research Ethics Committee of Iran University of Medical Sciences on February 22, 2019 (ID: ir.iums.rec.1398.1249). Participants were informed about the aims and method of the study and ensured that their identities would be kept confidential. Their participation was voluntary, and they signed a written consent and had the right to withdraw from the study at any stage. The researcher also had no therapeutic or caring relationship with the participants.

Funding

The research leading to these results has received funding Iran University of Medical Sciences under the Grant agreement number. ”98-4-3-16958”

Research Highlights

References

1. Nurses’ emotions on care relationship: a qualitative study. J Nurs Manag 2020; 28(8):2247-56. doi: 10.1111/jonm.12934 [Crossref]
2. How much time do nurses have for patients? a longitudinal study quantifying hospital nurses’ patterns of task time distribution and interactions with health professionals. BMC Health Serv Res 2011; 11:319. doi: 10.1186/1472-6963-11-319 [Crossref]
3. Nurses’ views of patient participation in nursing care. J Adv Nurs 2015; 71(12):2741-52. doi: 10.1111/jan.12740 [Crossref]
4. Nurse strategies for optimising patient participation in nursing care. Scand J Caring Sci 2009; 23(3):490-7. doi: 10.1111/j.1471-6712.2008.00649.x [Crossref]
5. Action brief: patient engagement and activation: a health reform imperative and improvement opportunity for nursing. Nurs Outlook 2013; 61(1):51-4. doi: 10.1016/j.outlook.2012.11.003 [Crossref]
6. Effect of participatory care on the satisfaction of parents of children admitted to the children’s wards: clinical trial study. Natl J Physiol Pharm Pharmacol 2018; 8(5):664-70. doi: 10.5455/njppp.2018.8.1247303012018 [Crossref]
7. The development and initial validation of a clinical tool for patients’ preferences on patient participation--the 4Ps. Health Expect 2015; 18(6):2522-35. doi: 10.1111/hex.12221 [Crossref]
8. Remote area nursing: best practice or paternalism in action? The importance of consumer perspectives on primary health care nursing practice in remote communities. Aust J Prim Health 2021; 27(1):62-6. doi: 10.1071/py20089 [Crossref]
9. Paternalism vs. are they alternative types of formal care? Front Psychol 2019; 10:are they alternative types of formal care? Front Psychol 2019; 10. doi: 10.3389/fpsyg.2019.01460 [Crossref]
10. A training intervention to reduce paternalistic care and promote autonomy: a preliminary study. Clin Interv Aging 2019; 14:1515-25. doi: 10.2147/cia.s213644 [Crossref]
11. Nurses’ perceptions of patient participation in hemodialysis treatment. Nurs Ethics 2012; 19(3):419-30. doi: 10.1177/0969733011429015 [Crossref]
12. Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. Int J Environ Res Public Health 2020; 17(3):835. doi: 10.3390/ijerph17030835 [Crossref]
13. Audi R. The Cambridge Dictionary of Philosophy. 2nd ed. Great Britain: Cambridge University Press; 1999.
14. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. Great Britain: Oxford University Press; 2001.
15. Support for advocacy. Nurs Times 1995; 91(4):28-9.
16. An exploration of the relationship between patient autonomy and patient advocacy: implications for nursing practice. Nurs Ethics 2002; 9(5):472-82. doi: 10.1191/0969733002ne537oa [Crossref]
17. Shared decision making and autonomy among US participants with multiple sclerosis in the NARCOMS registry. Int J MS Care 2017; 19(6):303-12. doi: 10.7224/1537-2073.2016-091 [Crossref]
18. Shared decision making and self-management in multiple sclerosis--a consequence of evidence. J Neurol 2007; 254 Suppl 2:Ii116-21. doi: 10.1007/s00415-007-2028-z [Crossref]
19. Shared decision making: a model for clinical practice. J Gen Intern Med 2012; 27(10):1361-7. doi: 10.1007/s11606-012-2077-6 [Crossref]
20. Yavari N, Parsapoor A. The domain of autonomy, limitations and solutions. Iranian Journal of Medical Ethics and History of Medicine 2017; 10(1): 182-97. [Persian].
21. Paternalism vs patient empowerment: nursing challenges from Spain and Greece. Int J Caring Sci 2020; 13(3):2288-93.
22. Dominance of paternalism in family-centered care in the pediatric intensive care unit (PICU): an ethnographic study. Issues Compr Pediatr Nurs 2015; 38(2):118-35. doi: 10.3109/01460862.2015.1035464 [Crossref]
23. How is family involved in clinical care and decision-making in intensive care units? A qualitative study. Contemp Nurse 2020; 56(3):215-29. doi: 10.1080/10376178.2020.1801350 [Crossref]
24. Balancing overuse and underuse in the Iranian healthcare system: a force field theory analysis. Ethiop J Health Sci 2019; 29(2):231-8. doi: 10.4314/ejhs.v29i2.10 [Crossref]
25. Van Manen M. Researching lived experience: human science for an action sensitive pedagogy. 2nd ed. Great Britain: Routledge; 2018.
26. Using emphasis-purposeful sampling-phenomenon of interest–context (EPPiC) framework to reflect on two qualitative research designs and questions: a reflective process. Qual Rep 2019; 24(10):2524-35. doi: 10.46743/2160-3715/2019.4082 [Crossref]
27. Experimental phenomenology: what it is and what it is not. Synthese 2021; 198(9):2191-212. doi: 10.1007/s11229-019-02209-6 [Crossref]
28. Diekelmann NL, Allen D, Tanner CA. The NLN criteria for appraisal of baccalaureate programs: a critical hermeneutic analysis. USA: National League for Nursing Press; 1989.
29. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Directions for Program Evaluation 1986; 1986(30):73-84. doi: 10.1002/ev.1427 [Crossref]
30. Reconceptualizing the member check interview. Int J Qual Methods 2013; 12(1):168-79. doi: 10.1177/160940691301200105 [Crossref]
31. Teacher beliefs about instructional choice: a phenomenological study. J Educ Psychol 2000; 92(4):634-45. doi: 10.1037/0022-0663.92.4.634 [Crossref]
32. Epistemic paternalism, open group inquiry, and religious knowledge. Res Philosophica 2021; 98(2):261-81. doi: 10.11612/resphil.2041 [Crossref]
33. What motivates paternalism? An experimental study. Am Econ Rev 2021; 111(3):787-830. doi: 10.1257/aer.20191039 [Crossref]
34. Registered nurses’ perceptions and experiences of autonomy: a descriptive phenomenological study. BMC Nurs 2019; 18:51. doi: 10.1186/s12912-019-0378-3 [Crossref]
35. Free choice and patient best interests. Health Care Anal 2016; 24(4):374-92. doi: 10.1007/s10728-014-0281-8 [Crossref]
36. Autonomy and selfishness. Lancet 2008; 372(9645):1214-5. doi: 10.1016/s0140-6736(08)61507-x [Crossref]
37. Autonomy versus paternalism in Latin America. Oncology (Williston Park) 2012; 26(1):46-7.
38. Who makes the decision? Patient’s autonomy vs paternalism in a Confucian society. Croat Med J 2003; 44(5):558-61.
39. Paternalism and autonomy: views of patients and providers in a transitional (post-communist) country. BMC Med Ethics 2015; 16(1):65. doi: 10.1186/s12910-015-0059-z [Crossref]
40. Paternalism v. autonomy - are we barking up the wrong tree? Br J Psychiatry 2016; 209(2):95-6. doi: 10.1192/bjp.bp.116.181032 [Crossref]
41. Crichton PPaternalism vautonomy. Br J Psychiatry 2017; 210(1):83. doi: 10.1192/bjp.210.1.83a [Crossref]
42. Are opinions based on science: modelling social response to scientific facts. PLoS One 2012; 7(8):e42122. doi: 10.1371/journal.pone.0042122 [Crossref]
43. Shared decision making, paternalism and patient choice. Health Care Anal 2010; 18(1):60-84. doi: 10.1007/s10728-008-0108-6 [Crossref]
44. Webster M. Merriam Webster Online [Internet]. USA; 2014. Available from: https://www.merriam-webster.com/dictionary/obscurantism. Accessed February 10, 2022.
45. Improving the patient experience: real-world strategies for engaging nurses. J Nurs Adm 2014; 44(3):142-51. doi: 10.1097/nna.0000000000000042 [Crossref]
46. Engaging patients in their care versus obscurantism. Nurs Forum 2015; 50(3):196-200. doi: 10.1111/nuf.12105 [Crossref]
47. Dworkin G. Stanford University. Stanford Encyclopedia of Philosophy [Internet]. USA; 2020. Available from: https://plato.stanford.edu/contact.html. Accessed February 10, 2022.