Nurse-patient mutuality in chronic illnesses: creating a conceptual framework, developing an instrument, and describing mutuality in nurse and patients

Introduction. Chronic diseases are long-lasting and generally slow-progressing and causing early death, they are responsible for 74% of all deaths worldwide. The relationship and the communication between healthcare professionals and chronic conditions patients plays a pivotal role in the management of the chronic illness. Mutuality is a form of social cooperation based on mutual protection and assistance, is a reciprocal relationship between two or more people, groups, or institutions. Mutuality in the nurse-patient relationship was defined as high levels of empathy, collaboration, equality, and interdependence, and includes trust, listening without judgment, empathy. Mutuality between nurses and patients can benefit nurses, patients, and organizations. Although nurse-patient mutuality may influence patients’ and nurses’ outcomes, (1) no conceptual, theoretical framework or theories are available; (2) no measures are available to measure this concept; (3) no prior studies has described mutuality in nursepatient dyads. Aims. This doctoral program had three aims: (1) to create a conceptual framework of nurse-patient mutuality in chronic conditions; (2) to develop and psychometrically test an instrument to measure the concept of nurse-patient mutuality in chronic conditions; (3) to describe the nurse-patient mutuality in chronic conditions. Methods. To respond to the first aim, a qualitative study with a Grounded Theory qualitative design, following the constructivist approach of Charmaz, was conducted. Interviews, comparative, and simultaneous data analyses were performed. To respond to the second aim a multiphase methodological study was conducted. Firstly, a qualitative investigation and the inductively generation of the items of two instruments, one for nurses and one for patients, was performed; secondly on a sample of patients and nurses, collected through a cross-sectional study, the assessment of the content and the face validity, the construct validity and reliability was performed. To respond to the third, aim a multi-center national crosssectional study was conducted and descriptive statistics and associations measures were performed, to explain the characterization of mutuality in this dyad. For each study, the sample included nurses and patients with chronic conditions. Results. A conceptual framework was developed, including the mutuality process, influencing factors, and outcomes. The mutuality process was characterised by three dimensions both for nurses and patients: developing and going beyond, being a point of reference, and deciding and sharing care. The Nurse–Patient Mutuality in Chronic Illness (NPM-CI) scale in two versions, one for nurses and one for patients, was developed. Both scales included 20 items in their final versions. Content validity index ranged between 0.78 and 1, Exploratory Factor Analysis identified three latent factors for both scales. Internal consistency, with Cronbach’s alphas ranged between 0.80 and 0.90. Intraclass Correlation Coefficient, for Test-Retest stability, was 0.96 (nurse scale) and 0.97 (patient scale). Predictive validity between the mutuality scales and care satisfaction, with a Pearson correlation resulted 0.43 (nurse scale) and 0.55 (patient scale). In the cross-sectional study patients had an average total score of 84.20 and nurses 79.12 (p < 0.001) Patients demonstrate high mutuality towards nurses and the ability to express and share their emotions. Nurses had lower scores especially in the items related to the sharing of emotions, objectives, and planning. The egalitarian relationship score was low both in patients and nurses. Conclusions. This doctoral program led to the creation of a new conceptual framework on mutuality in nurse-patient dyads in chronic illness, with its pivotal role to lead the practice and future research. Based on the conceptual framework, the development, and its subsequent psychometric validation of the Nurse-Patient Mutuality in Chronic Illness (NPM-CI) scale was possible. Using the NPM-CI scale, we have shown how mutuality is represented between nurses and patients with chronic conditions, to plan specific interventions in the clinical practice on specific groups of patients at risk of low levels of mutuality. Furthermore, having an instrument based on a conceptual framework is fundamental to measure the concept and allows to associate it with the hypothesized outcomes and influencing factors.