ORIGINAL ARTICLE

Challenges in the nurse’s role in rehabilitation contexts

Bjørg Christiansen and Marte Feiring

Aim and objective. To shed light on how nurses perceive particular challenges
that they experience in encounters with patients in rehabilitation wards. What does this paper contribute
Background. Rehabilitation is a tailor-made process that allows someone with to the wider global clinical
impairment to live well. Many rehabilitation institutions embrace strong beliefs in community?
patient participation as well as awareness of and listening to the needs and wishes • Clarifies educative aspects of the
of patients. To our knowledge, few studies have investigated the challenges nurse’s role.
encountered by nurses from patients in rehabilitation contexts and how these • Highlights the authority struc-
tures between nurses and
challenges might influence their roles as nurses.
patients as well as particular
Design and methods. This study has a qualitative design that is based on three challenges.
focus group interviews with nurses working in three rehabilitation wards. A con-
venience sample of 15 nurses, five from each ward, was recruited to participate in
focus group interviews. The participants worked in wards for patients suffering
mainly from stroke and head injuries. The analysis is inspired by hermeneutic
principles to explore the participants’ challenges in their role in rehabilitation
contexts.
Results. Data analyses identified three main themes surrounding the challenges
experienced by nurses: (1) Adjusting patients’ and next of kin’s expectations, (2)
Tailoring support and information, (3) Recognising patients’ knowledge.
Conclusion. Our results from the three rehabilitation wards indicate that nurses
display various educative strategies. There is, however, a need for further empiri-
cal work into how knowledgeable patients and next of kin create new challenges
with implications for the nurse’s role within rehabilitation contexts.
Relevance to clinical practice. The study highlights the educative aspects of the
nurse’s role in relation to patients and next of kin on rehabilitation wards as
significant contributors to recovery processes.

Key words: authority structure, educative strategies, knowledgeable patients,

nurse’s role, nurse–patient interaction, nurse–patient relationships, patient’s role,
rehabilitation

Accepted for publication: 12 November 2016

Authors: Bjørg Christiansen, Dr. Polit., RN, Associate Professor,
Department of Nursing and Health Promotion, Faculty of Health
Sciences, Oslo and Akershus University College of Applied
Sciences, Oslo; Marte Feiring, PhD, Associate Professor, Depart-
ment of Physiotherapy, Faculty of Health Sciences, Oslo and Aker-
shus University College of Applied Sciences, Oslo, Norway
Correspondence: Bjørg Christiansen, Associate Professor, Depart-
ment of Nursing and Health Promotion, Faculty of Health
Sciences, Oslo and Akershus University College of Applied
Sciences, Postbox 4, St. Olavs pl., Oslo N-0130, Norway.
Telephone: +4767236233.
E-mail: bjorg.christiansen@hioa.no

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing, 26, 3239–3247, doi: 10.1111/jocn.13674 3239
B Christiansen and M Feiring
Introduction
Healthcare and rehabilitation services in many European
countries are increasingly influenced by economic
rationalisation and customer orientation (Christensen &
Lægreid 2016). These trends in society strengthen the
democratic expectations of patients towards a more com-
petent, active participation in treatment and care. Patients
in general have become increasingly involved in their
own care (Dent & Pahor 2015). In Norway, this is
reflected in legislation and government reports (Ministry
of Health and Care Services 2009, 2011). The Act on
Patients’ Rights (1999), for example, places a greater
emphasis on patients’ preferences, values and knowledge,
thus empowering patients to make informed choices and
share responsibility in the processes of care and treat-
ment. Thus, traditional authority structures in nurse–
patient relationships are challenged by more ambiguous
role expectations.
Roles express certain social characteristics, framed in
interactions with others in a complementary way (Goffman
1992). The nurse’s role is expressed in encounters with
patients in various situations concerning care-related needs.
A more autonomous and equitable patient’s role has impli-
cations for the nurse’s role, affecting authority structures in
relationships with patients. Scholars argue, however, that
the basis of a trusting relationship is an authority structure
that implies that nurses are more competent than patients
(Calman 2006, Grimen 2009). This indicates the mutuality
between nurse and patient is influenced by the nurse’s
expertise, an area outside the patient’s control. From the
patient’s point of view, the nurse knows what to do and
understands his or her needs. Comforting and imparting
knowledge to patients and relatives constitute various hall-
marks of ‘good work’, all of which are essential in nursing
(Christiansen 2008).
In rehabilitation services, the active participation of
patients in their recovery process is highlighted (Ministry
of Health and Care Services 2011). Rehabilitation is,
according to Hammell (2006), a tailor-made process
enabling someone with impairment to live well. Many
rehabilitation institutions embrace strong beliefs in patient
participation, as well as awareness of and listening to the
patient’s needs and wishes. Although a study of rehabilita-
tion services indicates a comprehensive nurse’s role that is
expressed through particular functions (Kirkevold 2010), it
is also found that the role is vague from the perspective of
both nurses and patients (Pellatt 2003, Stoddart 2012,
Dahl et al. 2014).
3240
Aim and objective
This article draws on a selection of data from the study
Knowledge and patient participation in professional work
to shed light on how nurses perceive particular challenges
they experience in encounters with patients in rehabilitation
wards. Our intention is not to describe the total contribu-
tion of nurses to rehabilitation services but to illuminate
how they respond to various aspects of the patient’s role
based on the following research question: How do nurses
perceive their role in relation to rehabilitation patients?
Background
Goffman’s dramaturgical approach applies metaphors
from the theatre in analysing face-to-face interaction in
everyday life. The metaphors role and script are used to
indicate that in all role-play, there exists a mutual under-
standing of the situation. The script represents the taken-
for-granted stock of knowledge in a social world (Goff-
man 1992). Expectations regarding each other’s roles con-
tribute to the way the situation is defined and build up
lines to follow in the interaction (Album 2010). Thus,
patients have particular expectations about how they
should be treated by nurses. According to Goffman, every
person has the ability to act strategically and in strategic
interaction the way one of the participants acts has con-
sequences for the actions of the others (Goffman 1992,
Mik-Meyer & Villadsen 2013). Shattell (2004) applied
Goffman’s approach in a review article analysing nurse–
patient interaction. She emphasised that nurse–patient
relationships were formed over a few encounters and
asked whether nurses recognised the more subtle ways in
which patients communicate their needs. Patients in vul-
nerable health crises depend upon nurses for basic needs,
and the potential for the patient’s loss of face (autonomy,
self-esteem) is high.
Burton (2000) found that the nursing role in stroke reha-
bilitation remains elusive in the literature. Based on a reflec-
tive enquiry among nursing staff (n = 13), three role
categories were identified as follows: caregiver, facilitator
of personal recovery and care manager. Pellatt (2003)
reported in a qualitative study of spinal cord rehabilitation
that although patients valued emotional and physical sup-
port from nurses, they did not regard nursing input to be
part of their rehabilitation services. Nurses saw their role as
multifaceted but identified difficulties in crossing over from
what the author referred to as an ‘acute-care philosophy’ to
a ‘rehabilitation philosophy’. The study concluded that
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 3239–3247
Original article
nurses should develop their professional role in a way that
empowers patients in spinal cord rehabilitation. As noted
by Long et al. (2002), nurses should aim for maximising
client choice within rehabilitation to enhance independent
living in the client’s future environment. In a Spanish study
of two neurological wards, Portillo and Cowley (2011)
found that a poor definition of the nursing role, lack of
time and ineffective communication limited holistic care in
the neurological rehabilitation of patients. Based on a Nor-
wegian qualitative study among professionals working in
institutions rehabilitating patients with head injuries and
multiple sclerosis, Caspari et al. (2013) emphasised the
importance of maintaining and supporting the patient’s
dignity and self-respect.
Kirkevold (2010) proposed a revised, research-based, the-
oretical framework for the role of nurses in stroke recovery
and rehabilitation, from the acute-care period through the
initial and subsequent rehabilitation phases. The conserving
function is directed towards preventing or reducing com-
mon problems following a stroke (e.g. to protect the bodily
and cognitive integrity of the patient). The interpretive
function covers activities that nurses initiate to assist
patients and families in understanding the implications of
stroke for their lives. The consoling function aims at reliev-
ing emotional pain and suffering following a stroke.
Finally, the integrative function addresses helping the
patient transfer new skills and techniques learned in the
exercise rooms to daily situations to achieve practical ends
(e.g. dressing).
These previous studies indicate that nurses’ roles
within rehabilitation are comprehensive and multifaceted
and that they should be further explored. To our knowl-
edge, few studies have investigated the challenges that
nurses experience concerning patients in rehabilitation
contexts and how these challenges influence their role as
nurses.
Methods
Design
This study has a qualitative design that is based on three
focus group interviews. Focus group interviewing is con-
sidered to be suitable for producing data with regard to
participants’ experiences related to a certain practice,
and it takes advantage of the dynamic conversations
between the participants (Halkier & Gjerpe 2010, Mor-
gan 2012). We follow Holstein and Gubrium (2003),
who claim that knowledge is created in the interviews
rather than transmitted.
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 3239–3247
Challenges in the nurse’s role
Setting and participants
A convenience sample of 15 nurses from three different
institutions was recruited to participate in focus group
interviews based on the following criteria: (1) five to seven
nurses from each institution, (2) a minimum of one year of
experience in a rehabilitation ward, and (3) representing
various nurse-related activities in the ward. Our sampling
strategy involved asking the nurse manager at each rehabili-
tation ward to recruit the participants in line with the
inclusion criteria because she/he could help us to select par-
ticipants based on the purpose of the study. We deemed
that five participants in each group would facilitate group
discussions and the sharing of experiences related to their
practice, thus encompassing the required ‘rich’ data mate-
rial to meet the quality criterion of data saturation (Tracy
2010).
The participants worked in wards for patients suffering
mainly from stroke (Rehab 1 and Rehab 3) and head inju-
ries (Rehab 2). All of the nurses had worked for at least
one year on the rehabilitation wards. Rehab 1 and 2 mainly
received patients after acute treatment of stroke and head
injuries for further rehabilitation phases. Rehab 3 mainly
received stroke patients during the acute-care period.
The focus group interviews were conducted in the wards
and lasted from one hour to an hour and a half. Each focus
group interview was conducted by the first author, who
was assisted by a comoderator from the research group.
We applied a semistructured interview guide developed by
the research group; the aim was to invite the nurses to
reflect upon their challenges and dilemmas regarding their
relationships with patients. They were asked to exemplify
and discuss how they experienced and responded to varia-
tions in the patient’s role, including reflecting on issues such
as the patient’s participation and knowledge usage. The
main moderator (first author) was responsible for the con-
tent-oriented issues to be covered, as well as for supporting
the group interaction. The comoderator assisted with fol-
low-up questions and observed nonverbal communication
(Holstein & Gubrium 2003, Morgan 2012, Brinkmann &
Kvale 2015). All of the interviews were taped and later
transcribed verbatim by an external assistant. The inter-
views were conducted during spring and autumn 2013.
Analysis
The analysis is inspired by hermeneutic principles to
explore the participants’ challenges in their role in rehabili-
tation contexts (Brinkmann & Kvale 2015). Analysing
qualitative interviews is influenced by the pre-understanding
3241
B Christiansen and M Feiring
of the researchers. Thus, combinations of internal and
external perspectives are always useful. According to Rubin
and Rubin (2012), it is a great advantage to have knowl-
edge of the culture being studied (the first author), whereas
the challenge is to create an analytical distance from the
taken-for-granted knowledge (the second author). Varia-
tions in pre-understanding may be helpful in tracing what
is taken for granted, as well as the subtle assumptions and
processes expressed by the participants, and may support
the theoretical interpretations.
Inspired by hermeneutic principles, the data were anal-
ysed with reference to three interpretative contexts (Brink-
mann & Kvale 2015): in the first context of interpretation,
our intention was to understand the meaning confined to
the respondents’ self-understanding. Thus, each of the
authors read the transcripts to gain a sense of the whole.
The entire material was searched for preliminary meaning
units, which were identified by colour coding.
The analytic process proceeded by further attentive read-
ing and discussions between the first and second author.
The second context of interpretation goes beyond the
respondents’ self-understanding and implies a broader, criti-
cal understanding. The preliminary coded meaning units
were sorted and subsequently merged into three main cate-
gories across the interviews. To enhance the rigour of our
analysis, we also discussed our interpretations with other
members in the research group, which uncovered alterna-
tive meanings. The content of each category was re-read
and merged into the following summarised themes reflected
in the results, which were underpinned by verbatim quota-
tions from the transcriptions: adjusting patients’ and next
of kin’s expectations of rehabilitation, tailoring support and
information and recognising patients’ knowledge.
At the third level, the interpretation extends a critical,
common-sense understanding using a theoretical framework
and previous research, which is reflected in the discussion.
In accordance with Brinkmann and Kvale (2015), we
understand validity as being linked to the entire research
process, including the selection of participants, how the
Table 1 Characteristics of the participants in the three focus group interviews
Rehab 1: Mainly stroke patients Rehab 2: Mainly patients suffering from
The five nurses (all female) knew one another but head injuries
worked in two different rehabilitation wards. The five nurses (all female) knew one another but
One held a Master’s degree in rehabilitation. worked on different teams. Two of the nurses
Their work experience at the hospital ranged specialised in psychiatric nursing. Their work
from 7–19 years experience at the hospital ranged
from 1–23 years
3242
interviews are conducted and the transparency of further
analyses.
Ethical issues
The study was approved by NSD (Norwegian Data Protec-
tion Official for Research, project number 30824) and the
local hospitals where the study took place. The participants
from each ward provided written consent before the inter-
views began. They were also verbally informed by the
researchers that participation was voluntary and that they
had the right to withdraw at any time. The data materials
were stored safely, and this article contains no identifiable,
person-specific information.
Results
In total, three focus groups, involving 15 nurses from three
wards, were conducted. Table 1 provides the demographic
characteristics of focus group participants. The participants
were mainly female, between the ages of 24 and 55 years.
Data analysis revealed three themes:
Adjusting patients’ and next of kin’s expectations
During the rehabilitation process, patients are often trans-
ferred from an acute medical-oriented hospital department
to a more everyday-life-oriented rehabilitation department
(Rehab 1). In the latter situation, patients usually dress in
their own clothes, which are often sportswear, and are
expected to be active in personal daily activities as well as
in individual training.
When a nurse asked a patient to dress in his ordinary
clothes, the patient (according to the nurse) acted surprised:
Patient: ‘Oh, can I wear those clothes?’
Nurse: ‘Yes, of course you can’.
Patient: ‘Oh, so I’m not just going to lie in bed?’ (Rehab 1)
Rehab 3: Mainly stroke patients
The five nurses (one male) knew
one another. They worked in
the same ward but had varied
functions and responsibilities
(e.g. acute-care, transitions from
the hospital to home or
municipal care). Their work
experience at the hospital
ranged from 1
5–9 years
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 3239–3247
Original article
According to the nurses, patients may have a different
understanding of what rehabilitation entails, and their beliefs
may be more in line with expectation of service: ‘That the
health care system is all about the patient being the recipient
of care, while we have to say, no, you must make an effort
yourself’. In one example, a patient wanted help from a nurse
to dress to save her energy for later training and exercises.
‘So, she did not understand that dressing is the point of that
exercise, not the other way around’. (Rehab 1).
The nurses from Rehab 3 perceived it as challenging
when some patients and next of kin had unrealistic expecta-
tions concerning medical treatment in the acute stage with
consequences for further rehabilitation. One example was
related to medical treatment after an acute stroke, which
influences the extent of brain damage and the patient’s
prognosis. The treatment must start within four and a half
hours to dissolve the blood clots that are blocking blood
flow to the brain. Some of the nurses experienced that
patients and their kin had read about this and became
angry if this type of treatment was not offered: ‘(. . .) with-
out knowing that there are other factors at play that they
might not be aware of’. (Rehab 3)
The implementation of co-ordination reform in the health
services, aimed at better interaction between local and spe-
cialist services in Norway, seems to advance expectations of
a ‘seamless’ transition between specialised rehabilitation ser-
vices and the local healthcare system for patients and next of
kin. The nurses found that they were in a difficult position
when they encountered next of kin who were not satisfied
with the way the municipalities followed up with patients at
the local level after their discharge from hospitals:
Previously, they were discharged and then had to wait three weeks
before being admitted. Today, their next of kin know that they can be
discharged tomorrow. We cannot promise that the municipality has
anything available, because it is the municipality’s decision to make. So
then, we are squeezed between the municipality and the kin. (Rehab 3)
In cases such as this, the nurses encountered frustrated and
angry next of kin, which is exemplified by a statement from a
patient’s wife: ‘If he is discharged tomorrow, then I’ll lock
the door. I shan’t be home, and he won’t come in’. (Rehab 3)
These examples of encounters with patients and next of
kin encouraged the nurses to display a number of profes-
sional strategies, such as informing and reassuring, to mod-
ify expectations of rehabilitation.
Tailoring support and information
A common experience among nurses was that patients may
not realise the practical consequences that their medical
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 3239–3247
Challenges in the nurse’s role
condition may have on their daily life during the first weeks
after a stroke. Stroke symptoms often include cognitive
impairment, which may manifest in a reduced ability to
recognise the impairment. ‘(. . .) towards the end of the stay,
however, they begin to understand what challenges it has
resulted in’. Even after several weeks, some stroke patients
had problems with formulating goals because of cognitive
confusion: ‘It was chaos. A very bright person (. . .) but
nothing worked’. (Rehab 1).
After a stroke, patients often showed a ‘lack of insight
into medical conditions’. When the patient’s main goal is to
go home, the situation may be challenging to handle. A
nurse explained that one strategy is to let the patient dis-
cover his/her need for help. ‘There are positive sides to let-
ting them be on their own, but when we see that they cross
the road without looking properly to left or right, they are
not ready to go home’. (Rehab 2)
The nurses agreed that they had to give a sort of adapted
information to patients after brain injury. The information
had to be realistic while simultaneously taking into account
the patient’s hope for progress and the fact that the rehabil-
itation process can be lengthy:
Most patients say they want to be as they were before, but then we
say to them, “Yes, but that arm is very weak now” or “now we
are going to do exercises on it.” (Rehab 1)
Although they supported the patient’s preferences and
values, they also had to prevent patients’ risky behaviours,
which may result in the patients hurting themselves or
others. Skills and experience were required to see that a
patient’s actions resulted from post-traumatic confusion.
‘They did things that were inappropriate’. One example
was when a patient self-discharged without notice. ‘We
have lost some of them. They leave the ward because we
haven’t caught them’. It could sometimes be challenging to
judge whether patient behaviour was based on confusion
and impaired judgment or improvement. A phase of confu-
sion, disorientation and inconsistent behaviour often fol-
lows a traumatic brain injury. To want to read a book
could easily be interpreted as a sign of progress. This was,
however, not always the case:
And then I tell my colleague, “He says he has ordered some
books.”
“But it’s not right,” she says. “He is in that phase.” (Rehab 2)
The nurses wanted to help these patients to maintain the
coherence of everyday life and relationship to others. Next
of kin were an important source of knowledge to accom-
plish this challenge: to tailor support and information the
3243
B Christiansen and M Feiring

nurses needed to deepen their insight into the needs and to the patient, the PICC line was gone. The patient said, “I took it
values of patients. ‘The patients cannot always impart it out yesterday. I found out how to do it on YouTube.” (Rehab 2)
themselves’.
In another case, a patient had discovered an instruction
According to the nurses, not all patients are familiar with
video on YouTube about how to get back into the wheel-
the terminology of goals or goal formulation. In addition to
chair after falling out. ‘He had watched it many times, and
challenges related to the formulation of goals, the nurses
he just dropped himself to the floor and got back up effort-
identified a generation gap. ‘A lot of the older patients have
lessly’. (Rehab 2) Although these encounters with knowl-
trouble understanding what we mean when we talk about
edgeable patients caught the nurses off guard, they also
setting goals and those kinds of things’. To overcome this,
approved of the patients’ knowledge-based initiatives.
the nurses used different or more specific words to help the
patient understand. The younger generation of patients
seemed to be more familiar with the goal terminology. ‘So
Discussion
you have to adjust the message depending on who you’re
talking to’. (Rehab 2) The results illustrate how the diverse ways of being a
To deepen the nurses’ insight into the needs and val- patient affect the nurse’s role. In two of the above exam-
ues of patients, next of kin were an important source of knowl- ples, the patients saw themselves as passive recipients of
edge. ‘The patients cannot always impart it themselves’. care when encountering nurses, although they were in a
This indicates that patients’ participation in formulating rehabilitation ward. Goffman claimed that a ceremony
goals for their own treatment seems to be challenging, called depersonalisation manifests in the process of becom-
which is not limited to when they are suffering from cogni- ing a patient, which is symbolised by hospital clothing and
tive impairment. Various forms of support and information an identity band around the arm (Goffman 1974). In the
from nurses are required in the process of goal setting and traditional sick role, the patient is often characterised as a
recovery. passive recipient of care, leaving responsibility and deci-
sions to knowledgeable professionals (Calman 2006, Gri-
men 2009). Patients know that they are expected to follow
Recognising patients’ knowledge a nursing agenda (Shattell 2004). Nurses are associated
with care, and helping patients with their daily activities is
The nurses in our study stated that more patients knew their
a primary responsibility in basic nursing care (Hendersen
rights and had obtained information on their medical condi-
1997). Although patients on rehabilitation wards partici-
tion. ‘We are starting to see that more people coming in have
pate in individually tailored training programmes, the
read a lot on the Internet’. Although this could nourish feel-
results illustrate that mundane nursing situations, such as
ings of insufficiency in the nurses, it also incited the nurses to
the morning toilet, are not necessarily associated with train-
seek knowledge. ‘I have to read a little (. . .)’. At the same
ing. Studies have indicated that nurses may have difficulty
time, it was perceived as a challenge because patients col-
describing their role and responsibility in interdisciplinary
lected information or knowledge that may be incorrect.
rehabilitation (Burton 2000, Dahl et al. 2014) and that
‘There is a lot of misinformation out there, so that is a chal-
patients do not regard nursing input to be part of rehabili-
lenge’. The nurses also acknowledged that patients had the
tation (Pellatt 2003).
ability to acquire knowledge about their own condition. ‘We
Nevertheless, our results show that nurses redefine the
have had some groups where some of the patients knew more
morning toilet from service to goal-oriented training while
than I did’. The nurses deemed it important to discuss and
interacting with patients by clarifying lines to follow to
grade knowledge sources together with patients and kin.
become an active, exercising patient. Thus, conflicting role
‘Then I showed an interest in what they had found, which
expectations urge the nurse to take on an instructive atti-
resulted in a critical evaluation of the knowledge’. (Rehab 1).
tude towards the patient, providing information on what
In one ward, patients had found instructions and medical
rehabilitation entails and helping the patient to see the cur-
procedures on YouTube. One example concerned a patient
rent situation in the light of the rehabilitation process. Kir-
who removed a PICC line [peripherally inserted central
kevold (2010) suggested that nurses have an integrative
catheter], which was placed inside a blood vessel and
function to help patients to transfer new skills and tech-
advanced towards the heart to administer medicines:
niques learned in training programmes to daily situations,
It is not something we do a lot, so we wanted a description from a such as the morning toilet. Our results indicate that in these
specialist hospital on how to do it. When we received it and went cases, the nurse–patient relationship may be characterised

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3244 Journal of Clinical Nursing, 26, 3239–3247
Original article
as asymmetrical, and the nurse’s role as educative, because
in different ways the patients have traditional expectations
concerning rehabilitation processes and the role of the
nurse.
The results illustrate that patient involvement in goal for-
mulation and decision-making is perceived as challenging
by nurses, especially when the patient is suffering from cog-
nitive impairment. Goal setting is seen as advantageous in
rehabilitation processes (Siegert & Taylor 2004, Hammell
2006, Ministry of Health and Care Services 2011). For
some patients, participating in goal setting may be particu-
larly challenging, especially when they are stricken by cog-
nitive impairment. According to Romsland (2011),
cognitive deficits may manifest in different ways, such as
confusion, memory problems, decreased mental ability,
impulsiveness and impaired judgement. To facilitate the
patients’ active role in rehabilitation processes, the nurses
de-emphasised inherent power inequalities in the relation-
ship by allowing the patients to find their own way while
watching at a distance. They also explored individual needs
by seeking knowledge from next of kin. Playing a vital role
in the rehabilitation of stroke patients seems to evoke a
sense of personal responsibility among nurses (Christiansen
2008). They supported patients in activities that have simi-
larities with the interpretive functions of nurses, as
proposed by Kirkevold (2010).
The results also exemplify encounters with active patients
and next of kin who want to define the situation, including
their need for medical treatment and municipal services
after discharge from the hospital. This may indicate a ‘cus-
tomer mentality’ among patients and next of kin, which is
not necessarily in line with professional knowledge and
realities in health services. On the other hand, health care
in many countries seems to be increasingly influenced by
economic rationalisation, which promotes customer orienta-
tion and health services as commodities. The patient as cus-
tomer is a metaphor that indicates that power is shifted in
favour of patients, towards greater choice and influence in
matters that concern them (Lian 2008). The customer meta-
phor is reflected in the behaviour of some patients and next
of kin in a way that also seems to cause some tension in
relationships with nurses. Although the roles are designed
to be complementary (Goffman 1992), our results indicate
that nurses do not seem to conform to customer-oriented
role expectations from the patient because it undermines a
professional way of thinking in rehabilitation.
Another challenge concerning the authority structure
between nurses and patients was highlighted when knowl-
edgeable patients undertook responsibility for medical pro-
cedures after having informed themselves via YouTube. The
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 3239–3247
Challenges in the nurse’s role
knowledgeable patient is defined in the literature as an indi-
vidual who ‘interacts with health professionals (such as
nurses) by asking questions about the evidence for treat-
ment, seeking support, exchanging views and contributing
experience and new ideas on how to improve the health
system’ (Hill 2011). In line with Hill (2011) and Stokken
(2008), one of the above examples also illustrates an
inverted relationship, where the patients knew more about
medical themes than the nurses. Giddens (2013) argued that
confidence in ‘expert systems’ is less prominent in late mod-
ern society. We trust neither science or doctors’ diagnoses
in the same way as before. Although today’s patients are
more diverse and autonomous, health professionals, accord-
ing to Stokken (2008), have a clear advantage over the
patient because the latter is in need. Nevertheless, the Inter-
net is increasingly used by patients and their families to col-
lect health-related information (Weber et al. 2008,
Wangberg et al. 2009, Bekker & Jensen 2010). According
to the nurses in our study, seeking knowledge on the Inter-
net requires the capacity for critical judgement, which they
saw as their own important contribution. As this study sug-
gests, knowledgeable patients and next of kin challenge the
nurse as an ‘expert’ while simultaneously providing an
incentive for nurses to critically assess their own knowl-
edge, including science-based information.
Methodological considerations
Concerns on validity were attended to by conducting focus
group interviews at three different rehabilitation wards,
although these settings in no way represent the full spec-
trum of nursing practice in rehabilitation contexts. Empha-
sis was placed on allowing the participants to talk freely in
concrete form on the themes in focus. It may, however, be
considered a methodological limitation that we possess data
regarding only how nurses report the ways in which they
talk and work with patients, and further research is needed
involving observational methods, as well as interviews with
patients. The validity of this work was strengthened during
the analysis because we were two researchers with varia-
tions in pre-understanding. According to Brinkmann and
Kvale (2015), different interpreters are sources of fruitful-
ness and virtues of interview research.
Conclusion
Our results from three rehabilitation wards indicate that
nurses display various educative strategies: First, they adjust
patients’ and next of kin’s expectations concerning what
rehabilitation entails, which resembles an integrative
3245
B Christiansen and M Feiring

function (Kirkevold 2010). Second, they support and
inform patients in understanding their condition, as well as
their ability to set goals, activities that have similarities
with the nurses’ interpretive function coined by Kirkevold
(2010). Third, encounters with knowledgeable patients
incited them to develop their capacity for critical assess-
ment of knowledge together with patients and next of kin.
Our results also address situations where patients, informed
by the Internet, performed procedures that may cause
potential self-harm. This indicates a need for further empir-
ical work into how such initiatives from knowledgeable
patients and next of kin create new challenges with implica-
tions for the nurse’s role within rehabilitation contexts.
Relevance to clinical practice
The study highlights the educative aspects of the nurse’s
role in relation to patients and next of kin on rehabilitation
wards as significant contributors to recovery processes.
Particular challenges should be addressed concerning
knowledgeable patients who monitor themselves through
complex procedures as these situations indicate tension
between supporting the patient as a competent, active par-
ticipant in treatment and care and simultaneously prevent-
ing risky behaviour that may hurt the patient.
Acknowledgements
The authors would like to express their gratitude to the
Phlegethon Research group, www.phlegethon.net/theories-
and-methods/
The submitted manuscript – or very similar work – has
not been previously published, or orally presented, or is
under consideration elsewhere. We declare there are no
financial or other relationships that could lead to a conflict
of interest.
Contributions
Study design: BC, MF;
Data collection and analysis: BC, MF;
Manuscript preparation: BC, MF.

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