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Individuals’ with heart failure experiences of collaboration with the health care team : an interpretive… Werry, Terina 2004

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INDIVIDUALS' WITH HEART FAILURE EXPERIENCES OF COLLABORATION WITH THE HEALTH CARE TEAM: AN INTERPRETIVE DESCRIPTION by Terina Werry B.N., Dalhousie University, 1987 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (The School of  Nursing) We accept this thesis as conforming  to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October 2004 © Terina Werry, 2004 T H E U N I V E R S I T Y  OF B R I T I S H C O L U M B I A F A C U L T Y  OF G R A D U A T E S T U D I E S B Library Authorization In presenting this thesis in partial fulfillment  of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference  and study. I further  agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. j e - r i trs a. C^jfx.o^'-f Name of Author (please  print)  —J Date (dd/mm/yyyy) Title of Thesis: l _ . r V ^ ^ J y ' V u ^ i v V W < r t Degree: yVK^ 0 S o y e - A Year: ^ Q Q k ( -Department of ^ ^ The University of British Columbia Vancouver, BC Canada grad.ubc.ca/forms/?formlD=THS page 1 of 1 last  updated:  27-Sep-04 Individuals with Heart Failure Experience of  Collaboration with the Health Care Team: An Interpretive Description I designed this study to explore the experience of  collaboration from  the perspective of  people with heart failure  (HF) attending a heart function  clinic (HFC). There is a paucity of  literature explicating the experience of  collaboration from  the perspective of  the individual with HF, although the literature provides strong support for the benefits  of  collaboration for  people with HF. My intent was to increase the knowledge and understanding of  the experience of  collaboration for  individuals with HF to inform  nursing practice, education, and research. The qualitative research approach, interpretive description, as described by Thorne, Reimer Kirkham, and Macdonald Emes (1997) was utilized as my research method, as it was appropriate to answering my research question, "how do individuals with HF experience collaboration with the health care team in the setting of  an outpatient HFC?" Data were collected utilizing in-depth semi-structured interviews, with a total of  7 participants ranging in age from  52 to 81 years. All of  the participants had been attending a HFC for  at least 2 years, with a mean attendance of  3.4 years. Inductive data analysis was ongoing throughout the data collection process. The findings  informed  and guided the data collection process and allowed the construction of  the interpretive description. The narratives revealed five  dominant themes describing the participants' experiences of  collaboration with the health care team. These were mutual goals, working together, communication with the health care team, being accountable, and sharing power. Antecedents to the experience of  collaboration included non-intimidating communication style and trust in the health care team. Barriers to the experience of collaboration identified  were lack of  time, communication styles that do not support collaboration and inequity of  power sharing. The findings  of  this study may contribute to the theoretical understanding of  the concept of  collaboration, and has provided insight into the experience of  collaboration as experienced by individuals with HF who attend a HFC. Thus this contribution to the existing knowledge about the experience of  collaboration from  the individual with HF may provide additional insight into and expand the understanding of  the experience and thereby enhance the care of  similar individuals. Table of  Contents iv Acknowledgements vii CHAPTER 1: Introduction 1 Background to the Problem 1 Problem Statement 9 Purpose 9 Research Question 10 Definition  of  Terms 10 Assumptions 11 Limitations to the Study 11 Summary 12 CHAPTER 2: Review of  Selected Literature 13 Introduction 13 Individuals Experience of  Heart Failure 13 Collaboration 16 Conceptualization of  Collaboration 16 Collaboration in the Health Care Team-Patient Relationship 22 Outcomes of  Collaboration 23 Summary 25 CHAPTER 3: Method 26 Design 26 Selection of  Participants 29 Criteria for  Selection 30 Selection Procedure 30 Characteristics of  Participants 32 Ethical Considerations 33 Data Collection 34 Data Analysis 36 Rigor 38 Summary 40 CHAPTER 4: Findings 42 Introduction 42 Experience of  Collaboration 44 Mutual Goals 45 Working Together 46 Joint Venture 48 Willing Participation 50 Communication with the Health Care Team 53 Sharing Experiences with the Health Care Team 54 Gaining Knowledge 57 Being Accountable 59 Self  Care Behaviours 60 Taking Responsibility 61 Sharing Power 63 Gaining Control 63 Shared Decision Making 65 Antecedent to Collaboration 67 Non-Intimidating Communication Style 67 Trust in the Health Care Team 71 Barriers to Collaboration 77 Lack of  Time 77 Communication Style that does Not Support Collaboration 80 Inequity of  Power Sharing 83 Summary 87 CHAPTER 5: Discussion of  the Findings 89 Mutual Goals 89 Working Together 94 Communication with the Health Care Team 97 Being Accountable 100 Sharing Power 104 Antecedent to Collaboration 107 Non-Intimidating Communication Style 107 Trust in the Health Care Team 108 Barriers to Collaboration I l l Lack of  Time 112 Communication Style that does Not Support Collaboration 113 Inequity of  Power Sharing 115 Summary 118 CHAPTER 6: Summary, Conclusions and Implications 120 Conclusions from  the Findings 122 Implications for  Practice 123 Implications for  Education 126 Implications for  Research ...128 Conclusion 130 References  131 Appendix A: Participant Information  Letter 137 Appendix B: Participant Consent Form 139 Appendix C: Trigger Questions 141 Acknowledgements I wish to acknowledge my thesis committee, Dr Carol Jillings (supervisor), Dr Angela Henderson, and Ms Annemarie Kaan, for  their help, support and encouragement throughout this process. You have made this an enjoyable and worthwhile experience, and I have learned so much. Thank You. I would like to extend my deepest appreciation and gratitude to the participants in this study. Without you this would not have been possible. My learning, in listening to each narrative far  exceeded that is documented in this thesis. I thank you for  opening your lives to me. I wish to thank the staff  and my colleagues at the Heart Function Clinic where this study was conducted. Your support in the recruitment of  participants and the ongoing support you have shown me throughout this process is deeply appreciated Finally my sincere thanks go to my husband, who inspired and supported me throughout this journey. I could not of  completed this without your love and support. CHAPTER ONE Introduction Background to The Problem Heart failure  (HF) is a complex clinical syndrome that is characterized by the inability of  the heart to adequately meet the metabolic needs of  the body. There are numerous causes of  heart failure  including: coronary artery disease, valvular heart disease, hypertension, arrhythmias, myocarditis, metabolic disorders, infective  processes, toxins, and idiopathic etiologies. Regardless of  cause, the underlying pathophysiology of HF "rest on the twin pillars of  ventricular remodeling and neuroendocrine activation". (Baige et al, 1999, p 87). Ventricular remodeling is characterized by pathological changes in ventricular shape, thickness and dimension in response to the inability to maintain adequate stroke volume. The reduction in stroke volume leads to accumulation of  blood in the ventricles and ventricular dilatation. Ventricular shape changes from  cylindrical to spherical as the ventricle dilates and ventricular volume increases. Dilatation of  the myocardium results in reduced contractility and the myocardium hypertrophies in an attempt to compensate. Neuroendocrine activation occurs as a response to decreasing stroke volume and cardiac output. Sympathetic and RAS activation increases heart rate, increases contractility and leads to vasoconstriction in an attempt to maintain adequate blood pressure and cardiac output. While a detailed discussion of  the pathophysiology of heart disease is beyond the scope of  this study it is important to understand that these processes are maladaptive and if  left  unchecked can result in the development of decompensated HF. Decompensated HF occurs when the patient experiences symptoms of  hemodynamic instability, significant  shortness of  breath, peripheral edema, arrhythmias, decreased energy; and cardiogenic shock. Current medical treatment for  HF focuses  on the prevention of  decompensation and decreasing or preventing ventricular remodeling and neuroendocrine activation. Medications such as beta blockers, which block sympathetic stimulation, angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and aldosterone antagonists, all of  which prevent activation of  the RAS, have become standard therapy for  individuals with HF. Current Canadian consensus guidelines for  the management and treatment of  HF as well as a large proportion of  ongoing HF research focuses  on further  explicating these pathophysiological processes in an effort  to develop more effective  treatment modalities. However the health care community is placing increasing emphasis on the experience of the individual living with HF when developing treatment guidelines. The Canadian Cardiovascular Society (CCS) guidelines include recommendations that goals of treatment include improving the "patient's quantity and quality of  life,  to reduce symptoms and hospitalizations, and to coordinate care that is patient centred and evidence based". I feel  that this recommendation highlights the beginning of  an important paradigm shift  in health care towards true patient involvement and collaboration in health care decision-making. Demographics of  Heart Failure Heart failure  is characterized by the Canadian Cardiovascular Society (CCS) as an emerging epidemic. The CCS guidelines for  the management and treatment of  HF (2001) describe HF as the "most rapidly rising cardiovascular condition to affect  the lives of Canadians". Over three hundred and fifty  thousand Canadians are living with HF with a predicted one-year mortality of  between twenty-five  and fourty  percent after  diagnosis. Literature from  the United States mirrors the Canadian experience, with estimates of  four million six hundred thousand people living with HF, and four  hundred thousand new onset cases being diagnosed each year (Dahl & Penque, 2001; McCormick, 1999; Packer & Cohn, 1999, Paul, 2000). Heart failure  affects  approximately one and a half  to two percent of  the population in the United States; with a dramatic increase in prevalence to between six and ten percent after  the age of  sixty-five  (Packer & Cohn, 1999). In Canada, "Heart failure  is currently the commonest hospital discharge diagnosis in patents over the age of  65 years" (Arnold & Miller, 2002). It is estimated that eighty percent of  patients with chronic HF are over the age of  sixty-five.  Arnold and Miller (2002) describe the typical HF patient requiring hospitalization as: over the age of  sixty five,  experiencing advanced symptoms of  HF (NYHA class III-IV), and having one or more comorbid conditions. These comorbid conditions include renal dysfunction,  chronic lung disorders, arthritis, hypertension, diabetes, and cognitive impairment. The cost of  HF to the Canadian health care system is staggering, with estimated spending on in hospital care reaching one billion dollars per year (CCS, 2001). HF is a chronic disease state that is characterized by frequent  episodes of  decompensation requiring hospitalization. The average length of  hospitalization in Canada is eight days and Packer and Cohn (1999) report that one third of  people hospitalized for  HF will be readmitted within ninety days. McCormick (1999) identifies  that between twenty-one and twenty seven percent of  people diagnosed with HF will require multiple admissions yearly. Adding to costs are complex medication regimes and the need for  frequent outpatient physician follow  up Heart Function Clinics "The provision of  care within a specialty clinic is one approach that has been shown to improve outcomes in chronic illness" (Levine & Hall, 1998, p 258). These clinics are generally staffed  by a multidisciplinary team including physicians, nurses and other health care professionals  with expertise in the management of  HF. Nursing literature provides support for  the clinical and economic benefits  of  utilizing multidisciplinary specialty clinics to manage HF. Several authors provide anecdotal evidence of  benefits  of  outpatient HFCs, including decreases in cost, length of hospitalizations, and readmission rates for  HF (Levine & Hall, 1998; Paul, 1997; Veener & Seelbinder, 1996) While these early results were promising all of  the authors recommend the need for  further  study. Paul (2000) examined the effects  of  a multidisciplinary outpatient HF clinic on hospital readmissions, emergency department visits, length of  stay and cost savings. A statistically significant  reduction was reported in the number of  total hospital readmissions and total number of  hospital days. However, decreases in readmission rate, hospital charges, and emergency department visits for  HF were not found  to be statistically significant.  The authors identified  the small sample size, short follow  up time, and lack of  information  on stage of  the disease process as significant  limitations and recommend further  study. An earlier study by Urden (1998) reported similar findings with decreases in length of  hospital stay, 30-day readmission rates and costs to the hospital. Urden also found  a statistically significant  increase in overall quality of  life, emotional and physical functioning  as measured by the Minnesota living with HF (MLWHF) questionnaire. The updated CCS guidelines for  treatment and management of HF (2003) indicated that evidence is accumulating in favour  of  heart function/failure clinics. This includes evidence of  decreases in hospitalizations and readmissions as well as increases in patient knowledge of  HF. A key component to the success of  specialty clinics is the use of  expert nurses. Paul (1997) describes the value of  expert nurses as "the ability to include the art of nursing in the process by involving the patient and their family  members in their own plan of  care" (p 489). Expert nurses "can assist patients in managing the signs and symptoms of  the disease by educating the patients about diet, exercise, medications and the disease process" (Paul, 2000, p 146). An important aspect of  the HFC nurse's role is that of  providing close clinical follow  up and support with symptom management. This may involve telemanagement, which includes providing patient follow  up via telephone or email, or the use of  nurse only clinics. Telemanagement may include monitoring volume status, adjusting medications with the assistance of  physicians or use of  protocols, reinforcing  education or answering questions and providing support for  individuals enrolled in the clinic. The CCS guidelines have identified  that telemanagement by experienced nurses is "often  the key intervention that may prevent recurrent hospitalization" (CCS Guidelines, 2003). As previously discussed, the efficacy  of  speciality clinics in the treatment of chronic illness is well supported in the literature. Levine and Hall (1998) identify  four characteristics that HFCs should incorporate to ensure successful  chronic illness management. The features  that characterize successful  chronic illness care are: 1. Provision of  care in accordance with a specific  plan, 2. Ability to meet the needs of complex patients that require time and intensive follow  up, 3. Attention to self-management needs, 4. Access to necessary expertise. I feel  that these characteristics are only attainable through multidisciplinary collaboration, a belief  that is strongly supported in the literature (Levine & Hall, 1998; Paul, 2000; Urden, 1998; Veener & Seelbinder, 1996). Patients Experience of  Collaboration The use of  a collaborative team approach between physicians, nurses and other members of  the health care team is supported throughout the literature. Morse and Brown (1999) discuss the acute care nurse practitioner's role as being designed on a "collaborative model that include patients, families,  significant  others, nurses, physicians, and other health care providers" (p.32). One important result of  interdisciplinary collaboration is the potential to positively affect  patient outcomes (Henneman, Lee & Cohen, 1995; Miller, 2001; Van Ess Coeling & Cukr, 2000). Henneman et al (1995) identify  that a lack of  collaboration may "play a central role in the fragmentation  of  care, patient dissatisfaction,  and poor outcomes" (p 108). One study demonstrated that intensive care units with poor collaborative communications report as much as a "1.8 fold increase in risk adjusted mortality, and significant  increases in length of  stay" (Miller, 2001). Another study reports a significant  increase in the perception of  quality of  care and patient outcomes in the presence of  collaborative communication (Van Ess Coeling & Cukr, 2000). There are few  studies addressing the effect  collaboration has on outcomes for individuals with HF. Paul (2000) and Urden (1998) examined the effects  of  a multidisciplinary outpatient HFC on hospital readmissions, emergency department visits, length of  stay and cost savings. While not explicitly identifying  the effects  of collaboration, both authors describe interdisciplinary collaboration as supporting positive patient outcomes. Paul (2000) reported a statistically significant  reduction in the number of  total hospital readmissions and total number of  hospital days after  initiating treatment in a clinic. Urden (1998) reported similar findings  with decreases in length of  hospital stay, 30 day readmission rates and costs to the hospital. Urden (1998), utilizing the MLWHF questionnaire, reported statistically significant  increases in overall quality of life,  emotional and physical functioning. While the benefits  of  collaboration are well supported in the literature, there remains a paucity of  information  regarding collaboration between the health care team and individuals with HF. Whitehead (2001) identifies  that "One example of  teamwork that is surprisingly neglected in the literature is the partnership between the client and the nurse" (p 34). Many authors appear to support development of  collaborative relationships with individuals with HF. Unfortunately  the support is generally implied rather than being explicitly identified.  Levine and Hall (1998) describe the need for  an individualized plan of  care and the importance of  attention to self-management  needs. Paul (2000) describes the benefits  of  comprehensive education and close follow  up including use of telephone management. Veener and Seelbinder (1996) also identify  the benefit  of education and discuss the positive outcomes that are associated with the patient having a more internal locus of  control. While each of  these authors seem to be describing aspects of  what is commonly considered collaboration between nurse and client, it is not clear that this is in fact  what they are describing. This ambiguity may reflect  the challenges many health professionals  have with what it means to collaborate with patients. The greatest challenge is the need to redefine  the patient as a member of  health care team rather than a passive bystander. This supports the need for  a paradigm shift  from  the traditional paternalistic medical model that may not be comfortable  or even possible for all health care professionals.  Sharkey (2002) describes how it remains common practice for  professionals  to define  what "collaboration means, what is required for  patient involvement, and how engagement should take place, with little if  any reference  to the patients themselves" (p 49). Some authors are more explicit in their support of  client- health professional collaboration. Hutchings (1999) discusses the client as an expert, active agent and decision-maker. She goes on to describe clients with chronic illnesses as being uniquely able to identify  how illness impacts their life  experience, and how health professionals should accept and utilise their expert knowledge. Whitehead (1999) states that to respect the autonomy of  the client, health professionals  must "relinquish their reductionist power base and actively acknowledge the client as a member of  the collaborative team" (p 37). While there is support in the literature for  collaboration between patient and health professional,  there is little information  on how collaboration is experienced by the patient. Sharkey (2002) utilises a hermeneutic-phenomenological approach to illuminate the experiences of  a patient with severe and enduring mental illness. Barr and Threlkfeld, (2000) describe application of  Jensen's patient practitioner collaborative model with a person with a physical disability. Hutchings (1999) presents a case study describing collaboration with an individual with multiple sclerosis when designing an education session for  nursing staff.  Finally, Clarke and Mass (1998) identify  the experiences of clients attending a nursing centre. The experience of  collaboration for  individuals with HF has not been explored, and while there may be similarities with what has been reported it should not be assumed that the experience is identical for  this unique population. Given the absence of  research exploring the experience of  collaboration in individuals with HF, and the importance of  collaboration to client outcomes, I suggest that there is insufficient  knowledge to enable understanding of  these individuals' experiences. This may lead to significant  gaps in provision of  care, and decrease the efficacy  of  nursing and medical interventions. Problem Statement Individuals with HF who participate in outpatient HFCs are asked to modify  their lifestyle  significantly  and to follow  complex medication regimes. Adherence to medication regimes, lifestyle  modification  and other self-management  techniques decreases both the experience of  symptoms of  HF and the number of  hospitalizations. The literature supports development of  collaborative relationships between the health care team and individuals with HF as a means to increase compliance and decrease negative side effects.  However no literature explores these relationships from  the perspective of  the individual with HF. There is no literature exploring how individuals with HF interacting with the health care system experience or identify  collaboration, or even if  it is desired or sought out. Purpose The purpose of  this study was to explore the experiences of  collaboration between individuals with HF and the health care team in the setting of  an outpatient HFC from  the patient's perspective. Expected outcomes included developing an understanding of  how collaboration is experienced and what meanings are given to the experience. Areas of exploration included identification  of  processes and outcomes of  collaboration, and identification  of  antecedents and barriers to collaboration. Findings derived from  this inquiry are expected to increase the knowledge and understanding of  the individual with HF's experience of  collaboration. This is anticipated to provide guidance for  the health care team and enhance care for  similar individuals. Research Question The question guiding this research study was: "how do individuals with HF experience collaboration with the health care team in the setting of  an outpatient HFC?" Definition  of  Terms For the purposes of  this study major terms were defined  as follows: Heart Failure: a pathophysiological state in which the heart is unable to pump blood throughout the circulatory system to meet the peripheral demands of  the metabolising tissues. It is often  caused by a defect  in myocardial contraction and relaxation, and accompanied by elevated cardiac filling  pressures. It may also occur when the normal heart is suddenly presented with excessive demands or severe impairment of its filling.  (CCS Guidelines, 2001) Collaboration: an interactive process where there is a need and willingness to work towards a shared goal that would be difficult  to achieve individually. There is a perception by the participating parties that benefits  of  the activity outweigh the risks and the interaction is equitable. A team approach is developed by sharing responsibilities and decision-making and by use of  effective  communication and conflict  resolution skills. It requires high levels of  cooperation and assertiveness to be present in all involved. There is convergence of  beliefs  and values and an exchange or degree of  sharing of  power. Those involved evaluate outcomes; however others not involved in the collaboration may be affected  and can evaluate outcomes differently. Assumptions 1. Individuals experiencing HF and health care professionals  working in a HFC can and should experience collaborative relationships. 2. Relationships between clients and health care professionals  in a HFC setting tend to be long term in nature and may differ  from  relationships developed during hospitalization for  acute illness. 3. Individuals with HF are willing to describe their experiences to researchers. Limitations of  the Study The findings  of  the study were limited by selection criteria that preclude the utilization of  non-English speaking individuals. Participants must be English speaking, so the findings  may not represent the experiences of  non-English speaking individuals. Participants were all living in the same urban area, and may not represent the experiences of  individuals living in rural or remote communities. The participants were volunteers and there is a threat that I might not have talked to persons with unique experiences that had chosen to not participate in the study due to a variety of  reasons. There is also a threat that given the nature of  the research, participants may have shared experiences that present the HFC in the best light, or answered questions in a way they think I want them to. Individuals who attend HFCs must be physically able to get to the clinic so individuals who lack the mobility required to attend to the HFC were not represented. Individuals attending HFCs are probably more likely seek medical attention for  their illness. There are many chronic HF patients who do not participate in HFCs, and these voices were not heard. I risked missing the experience of  individuals who may be marginalized due to socioeconomic status and lifestyle,  and do not choose to seek medical attention. Summary In chapter one I introduced the background and rationale for  choosing this study topic. I offered  a brief  review of  literature discussing the pathophysiology and demographics of  HF. I then discussed HFCs, and the patients' experience of collaboration. Finally I presented the purpose of  the research, the research question, definitions  of  terms used in the study, assumptions of  the study, and limitations to the study CHAPTER TWO Review of  Selected Literature I begin by briefly  exploring the current literature describing the individuals' experiences of  HF. I first  explore literature describing the physical and emotional responses to HF. I then examine the literature about becoming a HF patient, and the effects  of  gender on the experience of  living with HF. I then focus  on the concept of  collaboration. It is important to place the individual experience of  collaboration within the broader context of  the process of  collaboration. I have structured this section of  the literature review to first  provide a general overview of the concept and uses of  collaboration. The literature is critically reviewed for  the presence of  definitions,  conceptualizations, models, and theories describing collaboration and the collaborative process. These divergent views are then synthesized and common themes are identified.  I then review the current research on collaboration found  in the literature. This includes a discussion of  the individual's experiences of  collaboration. Finally, I examine the literature related to the impact collaboration has on patient outcomes of  collaboration. Individuals' Experience of  Heart Failure Literature exploring the experience of  the individual with HF commonly focuses on the physical manifestations  of  the disease. Common descriptions include feelings  of fatigue,  shortness of  breath, increasing physical limitations, and generalized debility (Martensson, Karlsson, & Fridlund, 1997; Rhodes & Bowles, 2002; Winters, 1999) However HF " affects  more than the physical aspects of  the lives of  those with the syndrome. In fact  HF has been shown to affect  virtually every aspect of  life"  (Winters 1999, p 442). Common emotional responses found  throughout the literature include uncertainty, anger, fear  worry, pulling back from  life,  and in some cases acceptance and a sense of  hope (Stull, Starling, Haas & Young, 1999; Martensson, Karlsson, & Fridlund, 1997; Rhodes & Bowles, 2002; Winters, 1999). These experiences may vary based on gender, age, New York Heart Association (NYHA) classification,  and length of diagnosis. The NYHA classifications  allow quantification  of  functional  capacity. NYHA class I indicates no symptoms with normal activity while NYHA class IV indicates symptoms at rest. Stull et al (1999) utilized a grounded theory approach to describe the experience of  becoming a HF patient. Twenty-one participants, of  varying age and gender, in NYHA class II to IV HF were interviewed. The overriding or higher order theme identified  was a search for  meaning and identity on the part of  the patient. Five distinct phases of  the process emerged from  the data. These were "a crisis event, the diagnosis, the patient's and family's  response to the diagnosis, their acceptance and adjustment to life  with their condition and the decision to get on with life"  (Stull, et al 1999, p 287). The first  three phases were associated with much uncertainty and dramatic changes in patient identity, role performance,  and due to the novelty of  the diagnosis, experiences of  fear  and worry (Stull et al, 1999). Winters (1999) found  that periods of  uncertainty were greatest during the time of  initial diagnosis, when the condition or treatments were changing and when a sense of  control over ones life  was lost. The initial period of  diagnosis and treatment is one of  constant change and adjustment and I have frequently  seen, as a nurse in a heart function  clinic (HFC), individuals experiencing loss of  control, and high levels of uncertainty and anxiety. The final  phases described by Stull et al (1999) represent the regaining of  control over ones life  and finding  meaning and a new identity. This model provides new insight into the experience of  becoming a HF patient; unfortunately  HF is characterized by periods of  rapid decompensation and constant change in status throughout all stages of  the disease process. There is no discussion of  the possible effects a new crisis event might have on finding  meaning and a new identity, and I have concerns about the apparent linearity of  the model. Rhodes and Bowles (2002) examined, using a phenomenological methodology, the experiences of  HF in six women aged 60 to 90 in NYHA class II failure.  Four themes impacting on the lives of  older women with HF were identified.  The themes were: "acknowledging losses in their lives, accepting the losses, changing their lives and deepening relationships" (Rhodes & Bowles, 1999, p 444). Martensson, Karlsson and Fridlund (1997) utilised a phemomenographic approach to examine conception of  their life  situations of  12 males aged 48 - 80 in NYHA class II to IV HF. Six categories emerged: " feeling  a belief  in the future,  gaining awareness, feeling  support from  the environment, feeling  limitation, feeling  a lack of  energy, and feeling  resignation" (Martensson et al, 1997, p 582). Although looking at different  genders and NYHA classes several similarities were noted. Both studies reported participants experienced changes in physical functioning,  feelings  of  loss both physically and emotionally and the need to make adjustments in their daily lives. Other commonalities included an acceptance of their condition and feelings  of  hope for  the future.  One striking difference  was that females  reported a deepening of  relationships with others while males did not. These findings  lend support to my belief  that men and women may experience HF differently, and suggest directions for  further  research. Collaboration Conceptualization of  Collaboration Collaboration first  appeared in English literature in 1871, and is defined  as: "to work jointly with others or together especially in an intellectual endeavour; to cooperate with or willingly assist an enemy of  one's country and especially an occupying force;  to cooperate with an agency or instrumentality with which one is not immediately connected" (Meriam-Webster online dictionary). This definition  gives some guidance as to what is meant by collaboration, but lacks such critical information  as antecedents to collaboration, characteristics of  collaboration and outcomes of  collaboration. It also provides no insight into how collaboration is experienced by individuals. I reviewed nursing and allied health literature for  definitions  and conceptualizations of  collaboration, theoretical models of  collaboration, and finally  experiences with collaboration. Nursing and allied health literature contains numerous articles examining collaboration including editorials, case studies, concept analyses, and descriptions of collaborative models. In addition there are a limited number of  qualitative and quantitative studies that explore aspects of  collaboration. Despite the abundance of literature, collaboration remains " a complex phenomenon whose definition  has remained vague or highly variable" (Henneman et al 1995, p 103). Several related concepts appear to be used as synonyms in the literature. These include: reciprocity, partnership, cooperation, compromise, negotiation, and empowerment. The interchangeable use of these similar but not identical concepts further  confuses  the meaning of  collaboration. "Despite its elusiveness, its essence continues to be sought after  as a means of  improving working relationships and patient outcomes" (Henneman et al, 1995, p 103). One of  the more influential  works of  the past decade appears to be Henneman et al (1995) concept analysis of  collaboration. Defining  attributes, antecedents, consequences and empirical referents  of  collaboration are presented using model, contrary and borderline cases in the context of  the nurse-physician relationship. They conceptualize collaboration as being one extreme of  interpersonal conflict  styles that involve varying levels of  assertiveness and cooperation. Collaboration occurs in the presence of  high levels of  cooperation and assertiveness, while avoidance occurs with low levels of  cooperation and assertiveness. Competition occurs with high levels of assertiveness and low levels of  cooperation, accommodation occurs with low levels of assertiveness and high levels of  cooperation and compromise as falling  between extremes of  collaboration and avoidance. Gardener and Cary (1999) described collaboration in a very similar manner. They described differences  of  interpersonal conflict  styles based on degree of  concern with self  and degree of  concern with others. It is my opinion that concern with self  is roughly analogous to levels of  assertiveness, and concern with others is analogous to levels of  cooperation. Collaboration can then be conceptualized in the context of  the nurse-physician relationship as occurring when high levels of  concern with self  and high levels of  concern with others are present. Unfortunately  the authors do not identify  if  this conceptualization should be applied in any other context than in nurse-physician collaboration, which may somewhat limit utility when describing collaboration with patients. Nine defining  attributes of  collaboration are identified  as: joint venture, cooperative endeavour, willing participation, shared planning/decision-making, team approach, contribution of  expertise, shared responsibility, non-hierarchical relationships, and power sharing (Henneman et al, 1995; Clarke & Mass, 1998). Antecedents to collaboration are identified  as: individual readiness, understanding of  role, confidence  in ability, recognition of  boundaries, effective  group dynamics, team environment, and congruent organizational values. Similar to the antecedents, are the core competencies needed for  collaboration described by Gardener and Cary (1999) which consist of:  critical (system) thinking, clinical competence, strong interpersonal communication skills, knowledge of  roles, conflict  resolution skills, and group process knowledge. Consequences of  collaboration identified  by Gardener and Cary (1999) include: supportive environment, confidence/self  esteem, win-win, esprit de corps, interprofessional  cohesiveness, improved productivity, increased satisfaction,  and improved patient outcome. Gardener and Cary focused  on nurse physician collaboration, and while appearing complete is somewhat limited when used to describe nurse-patient relationships. Collaboration requires time to develop and several authors have conceptualized the collaborative process as passing through a series of  stages or phases. Gardener and Cary (1999) described the seven stages of  collaboration as: awareness, tentative exploration and acknowledgement, trust building, collegiality, consensus, commitment, and collaboration. The stages of  collaboration can be more accurately described as identifying  antecedents to collaboration and provide very limited information  on the defining  attributes of  collaboration. An additional limitation as previously mentioned is the focus  on nurse-physician collaboration. Barr and Threlkeld (2000) utilized a patient-practitioner collaborative model that also describes stages or phases of  the collaborative relationship. The four  phases are: establishing a therapeutic relationship, diagnosing through mutual inquiry, finding  common ground through negotiation, and intervening and following  up. Paavilainen and Astedt-Kurki (1997) conceptualized client nurse collaboration as occurring in 5 stages. The stages are trust, a friendly  and confidential relationship, common actions, experience of  togetherness, and achieving the common goal of  client well being and the ability to cope. Of  concern is the presentation of  the collaborative process as being linear in nature. I believe collaboration is a dynamic process, which is experienced uniquely by each individual. These models, while providing structure and insight to the experience, do not adequately capture the unique and complex nature of  collaboration. Nursing literature is replete with case studies describing collaborative processes. Akhavain, Amaral, Murphy, and Uehlinger (1999) used Bowen's family  systems theory to examine collaboration in an interdisciplinary psychiatric treatment team. Collaboration is defined  as "working in a system while giving of  oneself  without giving up oneself.  It is the ability to combine assertiveness and cooperativeness and remain true to individual principles while working toward a common goal"(p. 4). Oda, O'Grady and Strauss (1994) described the collaborative process between public health nurses and researchers in an investigator initiated study. They found  three concepts that are important in collaboration. These are the concepts of  negotiation, mutuality and respect. While uncommon, several research studies have examined collaboration, although few  from  the perspective of  the patient. Paavilainen and Astedt-Kurki (1997) conducted a phenomenological examination of  public health nurses' perceptions of  the content and preconditions of  collaboration between the nurse and the client. They concluded that collaboration between client and nurse begins with trust and proceeds towards a common goal. They also identified  the following  as preconditions of  collaboration: trust, friendly and confidential  relationship, common actions, experience of  togetherness, and the clients ability to cope. Gedney- Baggs and Schmitt (1996) performed  a grounded theory study examining the perceptions of  nurses and residents on the process of  collaboration in a Medical Intensive Care Unit (MICU). They found  that important antecedents to collaboration include being available and being receptive. They also describe the core components of  collaboration as working together, a sense of  team, patient focus  and sharing. Outcomes of  collaboration were found  to be: improved patient care, feeling better in the job, learning, and controlling costs. Unfortunately  there were no qualitative studies examining the experience of  collaboration from  the perspective of  the individual with HF. This paucity of  information  supports the need for  research into this aspect of  the experience of  collaboration. Van Ess Coeling and Cukr (2000) provide one of  the rare quantitative looks at collaboration. The study utilized a post-test design with nonequivalent groups to assess the perception of  collaboration between physicians and nurses as affected  by the use of dominant, contentious, or attentive communication styles. I have questions about the reliability and validity of  the instrument as it is newly developed; however the researchers do acknowledge this limitation. Implications for  practice and direction for future  research are addressed, but again may be of  limited use when trying to illuminate the experience from  the perspective of  an individual with HF. The study found  that use of attentive communication styles facilitated  collaboration. I shall now present what I believe are common themes found  throughout the collaboration literature. The first  theme I have identified  is that collaboration is a complex process that involves the interaction of  at least two people. Certain interpersonal skills are needed to make the collaboration successful.  These include communication, conflict  resolution, and group process skills. A second common theme is the process of  collaboration is outcome driven. There must be a need as well as a willingness to collaborate, and a shared vision of  the outcome of  collaboration. A third common theme is that there are risks and benefits  to collaboration. The decision to collaborate is almost always based on an analysis of  the benefits  versus the risks. Collaboration will not occur if  one party determines the risks outweigh the potential benefits.  In general, collaboration will only occur if  all parties involved perceive the expected outcome of  collaboration to be positive. Often  the people who are involved in the collaboration are not negatively affected  and do not view the collaboration as negative; however others involved indirectly can feel  betrayed or harmed by the collaboration A fourth  common theme is that collaboration is affected  by individual or group beliefs  and values, and the beliefs  and values of  each person involved in a collaborative endeavor must be congruent. This is not to say that individuals must share the same beliefs  or values; however the beliefs  and values must not be completely opposing. A final  common theme I have identified  is that Sharing or gaining of  power is an outcome of  collaboration. The willingness to collaborate is often  initiated by the desire for  power exchange, and can be inhibited by too large a differential.  The sharing of power is not necessarily equal, but there must be feelings  of  fairness  or equity to enable the collaborative relationship. Collaboration in the Health Care Team- Patient Relationship While there is a wealth of  literature examining the concept of  collaboration there is a paucity of  information  addressing collaboration in the nurse client relationship. Clarke and Mass (1998) did explore the nurse client relationship and collaboration utilizing Henneman, Lee and Cohen's (1995) conceptualization. They identified  the following  as key client antecedents: willingness to enter into a relationship with nurses, and trust in the nurses' abilities. Other antecedents include confidence  in ones abilities to make appropriate decisions and willingness to accept responsibility for  their role in care. The clients identified  collaboration as "being respected as an individual, having time to be understood, getting useful  information,  and being asked about what help was required" (Clarke & Mass, 1998, p 223). They also identified  outcomes of  collaboration as becoming more knowledgeable, improvements in physical and mental condition, feeling better when communicating with nurses, and increased confidence  when taking actions on their own. This discussion is presented as an evaluation of  how collaboration was actualized or suppressed, and how collaboration impacted empowerment for  nurses, clients and the community. However, there is no discussion of  research questions, methodology used to guide the inquiry, or data analysis techniques. I feel  the most significant  limitation to this discussion was the lack of  data presented to support their claims. Clark and Mass indicate that evaluation reports containing excerpts of  raw qualitative data were used in the analysis; however, none of  this data is presented. This discussion provides some insight into the experience of  collaboration from  the perspective of  a patient but is of  limited utility due to these significant  limitations. This provides further  support that further  research is needed into the experience of collaboration form  the client's perspective. Other authors also describe positive client outcomes arising from  collaboration. Hutchings (1999) describes the collaboration of  a nurse educator and a client with multiple sclerosis who partnered to design and implement an inservice program, as having a dramatic effect  on both staff  and client. She reports a shift  towards a more egalitarian relationship with the client being viewed as the expert. Barr and Threlkeld describe the outcomes of  collaboration with a client requiring physiotherapy for  chronic back pain as decrease in pain and a sense of  increased independence. Unfortunately  not all attempts at collaboration are perceived as positive by clients. In a hermeneutic-phenomenological examination of  the experience of  collaboration with a patient with a diagnosis of  severe and enduring mental illness, Sharkey (2002) reports little evidence of  collaboration. She goes on to state "it is more honest to acknowledge that either collaboration does not happen when they are acutely ill or aspects of  it occur on our terms" (Sharkey, 2002, p 54). The experiences reported and described are those of fear,  mistrust, loneliness, loss of  control, and not feeling  as part of  the decision making process. This is a stark reminder that even if  health professionals  believe they are collaborating, the experience for  the individual may be dramatically different. Outcomes of  Collaboration As reported earlier there is some evidence supporting the benefit  of  collaboration on patient outcomes. Physician nurse collaboration in intensive care units (ICUs) and effects  on outcomes is relatively well represented in the literature. Miller (2001) reported, "collaborative interaction between nurses and physicians is significantly  related to mortality rates and length of  stay on ICUs" (p 350), with a 1.8 fold  increase in risk-adjusted mortality in ICUs with poor leadership and poor collaborative communication. Miller (2001) goes on to report that other studies have found  a fourty-one  percent lower death rate than expected in units with high levels of  interdisciplinary collaboration. Perhaps more chilling are reports of  a fifty-eight  percent higher death rate in units with the worse interdisciplinary collaboration. Pisek (1997) studied effects  of  cardiovascular surgeons who formed multiorganizational quality improvement collaboratives on in-hospital mortality rates. Twenty-three cardiothoracic surgeons were involved in a six-year project that initially focused  on development of  case registries and databases. Significant  differences  in mortality rates between surgeons were identified,  and a three-component intervention designed to decrease overall mortality rate was developed. The intervention consisted of "feedback  of  outcome data, training in continuous quality improvement techniques, and site visits" (Pisek, 1997, p 86). Findings showed a twenty-four  percent decrease in in-hospital mortality rates at the conclusion of  the study. Other authors have reported that nurse-physician collaboration may not significantly  improve patient outcomes. Higgins (1999) examined the predictive value of nurses' perception of  nurse-physician collaboration and found  that nurses' perceptions of collaboration were not a significant  predictor of  improved patient outcomes. Paul (2000) examined the effects  of  a multidisciplinary outpatient HF clinic on hospital readmissions, emergency department visits, length of  stay and cost savings. While the number of  total hospital readmissions and total number of  hospital days were significantly  reduced, changes in readmission rate, hospital charges, and emergency department visits for  CHF were not found  to be statistically significant. This critical review of  the literature suggests that there is still much ambiguity and uncertainty regarding the effects  on patient outcomes, of  collaboration between health professionals.  There is an even greater lack of  literature that explores the outcomes of collaborative relationships from  the perspective of  the individual with HF. Given the uncertainty found  in the literature and the lack of  data looking at outcomes of collaboration from  a patients' perspective further  study is warranted. Summary The focused  literature review presented in this chapter supports my statements that little is known about the experience of  collaboration from  the perspective of  the patient, and even less from  the perspective of  a patient with HF. The literature exploring collaboration is largely theoretical in nature, with conceptualizations, and theoretical discussions prevalent in the current literature. The empirical studies addressing collaboration frequently  examines interprofessional  collaboration, or the experience of collaboration with patients from  the perspective of  the health care professional.  There is a paucity of  empirical literature examining collaboration from  the perspective of  patients. Hence the current theoretical literature should be viewed as having limited utility in discussing the experiences of  collaboration from  the patient's perspective, until further study into its relevance and appropriateness has occurred. CHAPTER THREE Method Design A qualitative research design was utilized to examine the research question. "Qualitative research enables us to make sense of  reality, to describe and explain the social world and to develop explanatory models and theories" (Morse &Field, 1995, p 1). A qualitative approach is appropriate when little is known about a phenomenon and further  exploration is required. It is particularly useful  when describing a phenomenon from  an emic or insiders perspective. While the emic or micro perspective is key to nursing practice we cannot dismiss the need to include the etic or macro perspective in nursing research. The etic perspective includes knowledge identifying  common patterns found  within experiences, that represent the core of  nursing practice, knowledge and practical application of  principles, that arise from  our logical empiricist epistemological traditions (Thorne, Kirkham, MacDonald-Emes, 1997). By addressing both perspectives through the research process of  using individual narratives to develop a single interpretive description we develop knowledge that "reflect  a respect for  knowledge about aggregates in a manner that does not render the individual case invisible" (Thome etal, 1997 p 171). Due to the paucity of  literature addressing the patient experience of  collaboration and the nature of  the research question a non-categorical qualitative approach, interpretative description was chosen to direct this inquiry. This method was first described by Thorne, Kirkham and MacDonald-Emes (1997), and provides guidance for the researcher when generating interpretations of  phenomena of  interest to nursing practice, health, and illness. Gillespie (2002) identifies  that interpretive description is suitable when examining previously unexplored experiences and allows the researcher to move beyond participant's descriptions and engage in interpretation of  the participant's experiences from  their perspectives. This approach supports development of  a description of  an individual's perception of  an experience and an interpretation of  the experience to uncover meaning and contribute to nursing knowledge. Further, these individual experiences are examined to identify  what persons in similar positions share and what is particular to the lived experience of  each individual. In this way interpretive description supports the dual epistemological mandates of  nursing practice of  knowing from  both the emic and etic perspectives. Stajduhar et al (2000) identify  "this methodology is particularly useful  in contributing to an understanding of  how people experience health and illness and focus on what nurses can do to make a difference"  (p 1214). Nursing knowledge is driven by the need for  both theoretical constructs to direct practice and the need for  knowledge to be practical or applicable. Interpretive descriptive methodology was designed explicitly to assist in the development of  nursing knowledge, so that nurse researchers "may feel more freedom  to examine methodological questions in the context of  the overall objectives of  nursing science instead of  following  the methodological dictates of  other disciplines" (Thorne et al, 1997, p 171). Interpretive description " gives recognition to the contextual and constructed realities of  the health-illness experience" (Knoll & Johnson, 2000, p 66). The natural, constructed, and human nature characteristics of  experiences are considered (Jacox, Suppe, Campbell, & Stashinko, 1999). This emphasis permits exploration of  the individual's connection to their world and promotes the expression of  self-interpretation. (Vaughan, 1992). The researcher-participant relationship allows for  the expression of shared realities, and outcomes will reflect  the individual experience, as well as shared one (Cohen, 1994). The interpretive description approach indicates that a study be founded  on an analytic framework,  as opposed to a theoretical one (Thorne et al., 1997). This framework  will be developed from  what is already known about collaboration from  the literature, including theoretical conceptualizations, models, and theories describing collaboration. While there is a lack of  theoretical knowledge that specifically  addresses the patient's experience of  collaboration, there is a wealth of  information  available concerning the concept of  collaboration in other contexts. This knowledge will act as a starting point or foundational  forestructure  for  the inquiry. The analytical framework however does not impose rigid structure to the inquiry but "orients the inquiry, provides a rationale for  its anticipated boundaries, and makes explicit theoretical assumptions, biases, and preconceptions that will drive the design decisions" (Thorne et al, 1997, p 173). Henneman et al (1995) conceptualized collaboration in terms of  defining  attributes, antecedents, and barriers to collaboration. This conceptualization was the analytic framework  I utilized to orient my inquiry. To assist in initial analysis I chose to conceptualize defining  attributes as having three distinct components. The three components are a definition  of  the concept of  collaboration, roles of  the client and roles of  the health care professional  in collaboration. These later were constructed into the themes that describe the experience of  collaboration. Selection of  Participants The sample for  the study was obtained using purposive sampling techniques. Purposive sampling "involves the conscious selection by the researcher of  certain subjects or elements to include in the study" (Burns & Grove, 1997, p 306). Purposive sampling allows the researcher to select participants with particular characteristics to gain increased understanding of  the phenomenon of  interest. The use of  purposive sampling allows selection of  participants according to the needs of  the study, based on the desire to obtain maximum variation in the phenomenon being studied (Thorne et al, 1997). Thorne go on to identify  purposive sampling as important to an interpretive description that is meant to generate nursing knowledge as it allows the researcher to capture similarities and differences  in the accounts. Decisions regarding sample size were guided by the principles of  appropriateness and adequacy. Morse and Field (1995) define  appropriateness as the "identification  and use of  the participants who can best inform  the research" (p 80). Adequacy is achieved when there is enough data available to develop a rich description of  the phenomenon, with a goal of  achieving saturation of  the data. Saturation is achieved when " no new data will emerge by conducting further  interviews and all negative cases have been investigated" (Morse & Field, 1995, p 80). Sample size was guided by the ongoing analysis of  the data with a minimum sample six participants established as being appropriate for  the investigation (Sandelowski, 1995). Frequent assessment of  the appropriateness of  this sample size occurred, and sample size was adjusted according to the needs of  the study. Criteria for  Selection The criteria used in selecting the participants in the study included the following: • Adults with a diagnosis of  chronic HF who were participating in an outpatient HFC. • Willing to discuss their experiences of  interactions with the health care team in some detail (both positive and negative). • Participants must be willing to be interviewed and have the interview tape recorded. • Participants must be capable of  communication in English. Selection Procedure The participants were selected from  a HFC located in a major urban hospital located in Western Canada. Prior to enrolment of  participants I presented the nature, purpose, and goals of  the study, criteria for  eligibility, and data collection procedures to the multidisciplinary team of  physicians, nurses, the operations leader, and the clinical nurse specialist. Time was allowed for  the answering of  questions or the expression of concerns and permission was obtained for  people meeting the selection criteria to be approached and enrolled. Initial contact of  potential participants was through the nurses at the HFC, to minimize the possibility of  individuals feeling  coerced to participate. The nurses were willing to identify  potential participants and approach them on my behalf. The nurses were not expected to answer questions regarding the study and were informed that any decision regarding participation was confidential  and that I was unable to disclose such information.  On completion of  the research, findings  and conclusions will be made available to members of  the HFC. HFC nurses were asked to give a copy of  an information  letter that briefly explained the nature and purpose of  the study, as well as participant expectations and contact information  for  the researcher to all individuals that meet eligibility criteria. The information  letter is presented in appendix A. If  an individual expressed interest in participating, the nurse encouraged them to contact me directly or if  they preferred,  gave permission to the nurse to provide me with their name and contact information.  Two of the seven participants contacted me directly by telephone. The other five  participants gave permission to the HFC nurses to give me their name and contact information,  and I then contacted them. All of  the respondents reported receiving the participant information letter. At the time of  initial telephone contact, I provided potential participants with more information  on the study, procedures for  maintaining confidentiality  and protection of human rights, and provided an opportunity to ask any questions they may have had. If  the potential participant agreed to proceed, a date and time for  an initial interview was established. Prior to the start of  the interview, a written consent to participate was obtained from  the participant (See Appendix B). Interviews were conducted in a four-week  period in the month of  March. All but one of  the interviews was conducted in the participant's home environment. Purposive sampling guided participant selection as the study progressed as it allows exploration of maximum variation of  the experience of  collaboration with the health care team. The first five  individuals selected to participate in the study were male. After  initial analysis of these interviews I decided when selecting additional participants, to purposively sample for  participants who met the additional criterion of  being female.  I believed that the findings  would be strengthened by the inclusion of  female  participants and the sixth and seventh participants were of  female  gender. Characteristics of  the Participants A total of  seven people participated in the study. Five of  the participants were male, and two female.  The age range for  the participants was fifty  two to eighty one years old with a mean age of  68.3 years. All were attending the HFC at the time of  the study. Length of  participation in the HFC varied from  two to five  years with a mean attendance of  3.4 years. All of  the participants were diagnosed with HF, although the primary cause varied. Three of  the participants had a diagnosis of  coronary artery disease that precipitated the development of  HF, with two individuals undergoing coronary artery bypass grafting  and the third individual angioplasty. Two of  the participants' HF was a result of  arrhythmias and both had received devices such as permanent pacemakers and/or implantable defibrillators.  One individual's HF was precipitated by valvular disease that had been treated with valvuloplasty. The final  individual's HF was idiopathic in nature. A majority of  the participants reported having other significant  health problems. Two of  the participants were diabetic and one participant who was diabetic also lived with asthma and severe rheumatoid arthritis. One of  the participants was diagnosed with chronic pancreatitis, and another with Grave's disease. Finally one of  the participants had experienced renal insufficiency  intermittently throughout his disease trajectory. All of  the participants describe a crisis or significant  event that precipitated the diagnosis of  HF. A majority describe themselves as being in bad shape prior to coming to the HFC. Three had experienced myocardial infarctions  requiring prolonged hospitalization and interventions. Others describe a sudden decline in functional  capacity with activities of  daily living becoming difficult  and then impossible. One participant described when the gravity of  her condition became apparent. She recalled feeling disoriented, sick, and unable to perform  normal activities. She went on to describe how bad it had gotten; "there was piles of  garbage sitting at the door, and I hadn't gone out for 3 days. I was in pretty tough shape". Common physical experiences included increasing shortness of  breath, lack of  energy, swelling of  the extremities, and difficulty  sleeping. Emotional responses included fear,  anxiety, a sense of  doom or unease, and coming to terms with the possibility of  death. Ethical Considerations Written approval to conduct the study was obtained from  the ethics and research review committees of  the University of  British Columbia and the clinical agency. The rights of  participants were protected in several ways. A member of  the HFC team initiated contact with potential participants in order to minimize the possibility of individuals feeling  coerced to participate. Potential participants were informed  that the clinic team members were in no way involved in the research study except for  the purposes of  recruitment, and that there was no expectation that they disclose their decision regarding participation to them. Additionally participants were informed  that the researcher would not disclose their decision regarding participation to any member of  the clinic. Potential participants were provided with a description and explanation of  the study, including researchers' expectations, and provided opportunities to ask questions or seek clarification  of  the research process from  the researcher. Once an individual had agreed to participate written consent was obtained prior to commencement of  any research activity. The consent form  is presented in appendix B. Participants were informed  that they may choose to withdraw or choose not to participate further  at any time, and that any decision to withdraw will in no way affect  the care they receive. Participants were informed  that any decision to withdraw would not be disclosed to any clinic member, or any member of  the thesis committee. Participants were informed  that only the researcher and members of  the academic committee will have access to any consent forms,  tape recordings, transcripts, and field notes obtained during the research process. Participants were offered  the opportunity to review transcripts of  their interviews, and the opportunity to review research findings. Methods utilized to ensure confidentiality  of  participants included use of  pseudonyms, generalizing descriptions of  settings, and altering information  that could be used to identify  participants. Participants were informed  that they have the right to exclude any information from  the study that they do not wish to share, which includes the right to have any portion of  the audiotape erased at any time. Additionally the entire audiotape will be erased at the completion of  the study Data Collection The data collection and data analysis procedures are discussed separately, however in qualitative research they are not separate entities. Data analysis was ongoing throughout the data collection process and the findings  influenced  data collection. As tentative themes or categories emerge, they influenced  the data collection process. Due to the emergent nature of  the study it was necessary to attempt to clarify  themes by refining the guiding questions used during data collection. The primary data collection method was in-depth, face-to-face,  unstructured or minimally structured interviews with each participant in a location best suited to the participant. As the goal of  an unstructured interview is to allow the participant to tell their story, recommendations made by Field and Morse (1995) to listen intently, minimize interruptions; avoid use of  closed ended questions, jumping, counselling, or presenting the researchers' perspective were followed.  All but one of  the interviews occurred at the participant's home. The interviews were between thirty-five  minutes and one hour in duration, to prevent the participant from  becoming too fatigued.  Participants were encouraged to indicate when the interview was completed, to retain control of  the process. The sequence of  each interview included an introduction period where the study was explained, any questions answered, informed  consent was obtained, and demographic information collected. In addition, a short period of  time was utilized for  me to share information about my professional  background and any relevant personal information.  This allowed the participant to gain contextual information  about me as both a researcher and a nurse. The interviews were audio taped and open-ended trigger questions were used as needed to initiate and maintain the dialogue. Trigger questions were utilized to assist the researcher in obtaining relevant information.  However, they were not designed to limit or control the discussion. Trigger questions were utilized judiciously as a tool to facilitate the research process and as a means of  refocusing  the discussion. Participants maintained primary control of  the interview. Sample trigger questions are presented in appendix C. The participants may at any time request that the audiotape be stopped or information  revealed be deleted. In addition, as described in Morse and Field (1995) if the participants state "just between you and me", or " don't put this in your report", or "I shouldn't have told you that", the information  will be regarded as confidential  and not be utilized in the report. "The researchers first  responsibility is to the participant, the participant has the right to retract information,  or to request that information  not be used in the report, and the researcher must respect the participant's wishes" (Morse & Field, 1995 p. 103). Neither of  these scenarios occurred during any of  the interviews for  this study. Collateral sources of  data included the recording of  detailed field  notes soon after each interview. Field notes are "a written account of  the things that the researcher hears, sees, experiences, and thinks in the course of  collecting or reflecting  on the data" (Morse & Field, 1995 p. 112). Field notes may include portraits of  participants such as physical appearance, mannerisms, or style of  talking. In addition, information  of  the physical setting, impressions the researcher picks up, and non-verbal communication may be recorded. Field notes were utilized to record subjective biases or unsubstantiated hunches, as both may significantly  impact data analysis. Data Analysis The analysis of  data began with the collection of  data (Burns & Grove, 1997). At this stage the researcher is involved in such activities as perceiving, reacting to, interacting with, and reflecting  on thoughts and feelings  shared by the participant during the interview. These interviews were tape-recorded. Within three to four  days, interview tapes were transcribed verbatim. In the process of  comparing transcripts to tapes, recalling observations and experiences during the interview, and reading and rereading transcripts, I became immersed in the data. I began my analysis of  the data by examining the narratives in the context of  the analytic framework.  The narratives were broken down or inductively coded into data that were congruent with the five  broad idea categories described earlier. These five  broad idea categories are conceptualization of  collaboration, client's role in collaboration, health care teams role in collaboration, antecedents to collaboration, and barriers to collaboration. This produced unwieldy amounts of  data that would at best provide a superficial  overview of  the experience of  collaboration, which I feel  would be of  little utility in clinical practice. I considered this the initial analytic step. The next step involved reviewing the data coded into in each of  the broad idea categories for  the presence of  patterns or similarities within the data. Thorne, Reimer-Kirkham and O'Flynn-Magee (2004) identified  that "breadth is more useful  than precision in the earliest coding and organizing processes, permitting groups of  data bearing similar characteristics to be examined and re-examined for  a range of alternatives" (p. 11). Thorne et al (2004) go on to state that when analysing data it "becomes important to move in and out of  the detail in an iterative manner asking frequently,  what's happening here?" (p. 14). Using the techniques described of  moving between the microscopic and macroscopic views, the data were inductively coded into smaller and more specific  subcategories. In this process data was refined  from  five  broad categories into many categories that provided a beginning description of  the experience. I considered this an intermediate analytic step. The intermediate analysis produced categories that were more specific  and provided a greater depth of  information  on the experience of  collaboration. However a coherent description of  the experience was not yet apparent. To prevent premature closure of  the analytic process I occasionally placed data into multiple categories. As the analysis progressed decisions regarding the appropriateness of  data were made and categories became clear. Further analysis of  the data allowed the construction of  several dominant themes and sub-themes from  the more specific  categories developed in the intermediate analysis. This provided a deeper understanding of  the experience of % collaboration and resulted in the development of  the final  interpretive description. Each of  these themes was supported with data from  the narratives. Interpretation of  thematic findings  represents a coherent logic and a traceable audit trail (Thorne et al., 1997). The themes and sub-themes were grounded in the data as interpreted by me. I feel that it is not possible to remove my beliefs  and values from  the data analysis and development of  the final  interpretive description. I approached the analysis of  the narratives with an awareness of  the need for  reflexivity  throughout the process. Thorne et al (2004) stated, it is the researcher who ultimately determines what constitutes data, which data will arise to relevance, how the final  conceptualizations portraying those data will be structured, and which vehicles will be used to disseminate the findings"  (p. 12). Rigor Rigor in qualitative research is often  discussed using Lincoln and Guba's model of  examining truth value, applicability, consistency and neutrality (Morse & Field, 1995, p. 143). Sandelowski (1986) further  explicates rigor in qualitative research and provides guidance when assessing rigor. The following  discussion will describe approaches used to ensure rigor throughout the study. Sandelowski (1986) describes truth value as credibility where a "study is credible when it presents such faithful  descriptions or interpretations of  a human experience that people having that experience would immediately recognise it" (p 30). A major threat to truth value is described as going native, when the researcher becomes so involved with their subjects that they have difficulty  separating their experiences from  the experiences of  the subjects. One approach that was utilized is repeated review and challenging of  the analysis process and findings  by the thesis committee and myself. Sandelowski (1986) describes applicability as fittingness,  which is described as " findings  can fit  into contexts outside the study situation and when its audience views its findings  as meaningful  and applicable in terms of  their own experiences" (p. 32). Threats to fittingness  include elite bias and holistic fallacy.  Elite bias occurs when participants that are the most articulate, high status, and accessible members of  their group compromise representativeness of  the data. Other less articulate or accessible members of the group are then not represented in the findings.  Holistic fallacy  where data is perceived by the researcher to "look more patterned or regular or congruent then they are. The researcher's conclusions do not contain all the data well but are presented as representing all the data" (Sandelowski, 1986, p 32). Methods to increase fittingness  that were used in this study include triangulating across data sources for  congruence and representativeness, and ensuring typical and atypical data sources are represented. It is also important to utilise current theoretical and conceptual knowledge to support fittingness  of  findings.  By expanding, modifying,  or explicating current theory the researcher strengthens support for  fittingness  or applicability of  findings. Consistency is described by Sandelowski (1986) as auditability, which is defined as " a study and its findings  are auditable when another researcher can clearly follow  the decision trail used by the investigator in the study" (p. 33). The presence of  a clear audit trail including descriptions of  how participants were chosen for  inclusion in the study, bracketing or acknowledging researcher biases or influences,  and journaling of  decision making during the analysis process are important. In addition data collection procedures, nature of  the data collection setting, and information  on how categories are developed were addressed. Neutrality is described as confirmability  by Sandelowski (1986), which "refers  to the findings  themselves not to the subjective or objective stance of  the researcher," (p. 34). The idea of  freedom  from  bias in qualitative research is troublesome as "qualitative research emphasises the meaningfulness  of  findings  achieved by reducing the distance between investigator and subject and by eliminating artificial  lines between subjective and objective reality" (Sandelowski, 1986, p. 34). "Confirmability  is achieved when auditability, truth value, and applicability are established (Sandelowski, 1986, p. 33). Summary The method utilized for  this study was based on the non-categorical, qualitative research approach, interpretive description described by Thorne et al (1997). The sample for  the study was obtained using purposive sampling techniques, based on the desire to obtain maximum variation in the phenomenon being studied (Thorne et al, 1997). In total seven participants were interviewed over a one-month period and their narratives used to construct the interpretive description. Procedures to protect human rights and maintain confidentiality  were adhered to. Data consisted of  transcribed audio tape recordings and field  notes. Data analysis occurred throughout and subsequent to data collection. The decision trail for  data analysis was presented and the analytic framework  utilized to guide the inquiry was discussed. Procedures to ensure rigor of  this qualitative study were discussed in terms of  truth value, applicability, auditability, and confirmability. CHAPTER FOUR Findings In this chapter I present an interpretive description of  the experience of collaboration with members of  the health care team in the setting of  a HFC as perceived by individuals living with HF. The description was constructed from  the narratives of  the individuals who participated in the study. As outlined in the methodological framework described in Chapter 3, the interpretive description was constructed by repeated review of the transcripts and immersion in the data. Data was broken down into units of information  that were inductively coded into broad idea categories. Properties or components of  the idea categories were then identified  from  the data. From these categories the information  was synthesised into themes that provides a coherent description of  the experience. As the researcher I acknowledge my influence  on both the individual narratives and the construction of  the single written interpretive description. My beliefs  and values, both personal and professional,  influenced  the interpretation of  the narratives are embedded in this interpretive description. Findings I was struck initially by the uniqueness of  each of  the participants' experiences, and was concerned with how to proceed with the analysis without negating the individual. As I proceeded with the analysis I realized that I could not view each narrative as a discrete entity, but as part of  a multidimensional whole with each contributing to the final  common interpretive description. I began to recognize similarities in the narratives, which as the analysis progressed were synthesized into common themes that could then be applied to each individual's experiences. By highlighting the similarities and differences  I hope to capture the meanings of  the experience for  the study participants. These common themes may then provide useful insights into the experience of  collaboration that may have meaning in other situations for other people. As stated earlier each narrative was unique. Collaboration was experienced differently  amongst the participants. Some of  the participants described themselves as passive and did not feel  that they were collaborating with the health care team. Others described themselves as active participants with the health care team. Regardless of  how they situated themselves on the continuum of  collaboration several common categories emerged from  the data. To assist in the organization of  data collection I first  identified five  broad idea categories that formed  the analytic framework  for  analysis of  the narratives and assisted me in constructing the interpretive description. The idea categories were: conceptualization of  collaboration, clients role in collaboration, health care team's role in collaboration, antecedents to collaboration, and barriers to collaboration. Together these broad idea categories provided a starting point for  analysis and as a way to facilitate organization of  the data. Themes for  each of  the broad idea categories were then constructed from  the narratives. Five dominant themes describing the experience of  collaboration were constructed from  the narratives. These themes provide a description of  what was salient to the experience and will be used to guide the discussion of  what the experience of collaboration was like for  the participants. The five  themes identified  were mutual goals, working together, communication with the health care team, being accountable, and sharing power. I finish  the interpretive description with a discussion of  antecedents and barriers to the collaborative process as experienced by the participants. Two themes describing antecedents of  collaboration were constructed from  the narratives. These themes were open communication style and trust. Finally, the themes describing barriers to collaboration are discussed. The themes were lack of  time, difficult  communication styles and inequity of  power sharing. Experience of  Collaboration The first  section of  the findings  will present a description of  the experience of collaboration with the health care team in the setting of  a HFC. By presenting both similarities and differences  in the narratives I hope to capture the experience of  the individual while providing insight into the global experiences of  collaboration. To facilitate  the discussion I have organized the presentation according the five  dominant themes of  mutual goals, working together, sharing power, communication with the health care team, and being accountable. As I completed each interview and later during transcription and repeat immersion in the narratives I was struck that each of  the participant's was extremely positive about their experiences in the HFC. Each of  the participants indicated that overall the experience was positive. Several of  the participants indicated that they enjoyed going to the HFC One participant stated "Well sometimes I look forward  to going down there" another indicated "I quite enjoy it. Well I may not enjoy it but I feel comfortable".  Descriptions such as "it was just a revelation" and "We come away on a high. My wife  and I we come away on a high. We say wasn't that good. Wasn't that something, how lucky we are" were found  throughout the narratives. Other participants were more explicit in their descriptions and credit the HFC with saving their lives. One participant stated " I must say they have kept me alive since May 1999". He continued by saying "I owe a great gratitude to them for  where I am today.. .alive". I felt  it was important to the interpretive description that this be explicitly identified.  It provides important contextual information  that must be taken into consideration throughout the discussion of  the findings. Mutual Goals Each individual described having certain a priori expectations of  the HFC, based on information  given by the referring  physician. A majority of  participants were told to expect alterations to their medication regime and counseling on lifestyle  modification. Some were apprised that the HFC might perform  diagnostic testing such as echocardiograms and angiograms and offer  specific  interventions if  applicable. All of  the participants expressed that their primary goal for  attending the HFC was an improvement in their functional  capacity and to "feel  better". What differentiated  the HFC experience for  the participant was a sense that the health care team was working towards the same goal of  making them feel  better. Participants spoke of  feeling  that members of  the health care team were there for  them and were actively working to maintain their health. Because he is there to keep you healthy. He is not there for  any other purpose. And the nurses are all the same. They are there for  you. they are concerned for  my well-being, they seem to have a genuine concern for  my health, how am I doing, how am I feeling. Knowing that they were not alone but were part of  a team with congruent goals, and working toward the same outcome appeared to be an important aspect of  the experience for  participants. One participant described that from  his perspective helping him through the experience was a primary motivation for  the team to do their work. you get the feeling,  just from  the couple of  nurses right up there to the doctor that they want to help you. And that they are prepared to help you if  you do your part. Like we are here to help you. Welcome we are here to help you. Tell us what you are going through and we will help you. We will help you get better. That was just, that was just obvious. That was the motive up front. We are here to help you and we will help, and we are going to get you better we have ways and means. We have meds we have knowledge, and we know what to do. From fluid  intake to medicine One participant described working towards mutual goals as not only beneficial  to the individual, but also for  others attending the HFC. He talked of  the team being able to help him and being able to apply the knowledge gained from  his individual case to assist others. Well I'm building a lot of  experience there, and I'm sure that you know that having these problems and being able to discuss them with you people will help you to help somebody else. I feel  I am doing something worthwhile, not only for  myself  but for  the clinic. I mean they use that experience and pass it on to somebody else. It helps them This perspective is important as the participant describes the benefits  of  working towards a common goal as reaching beyond the individual and encompassing others with HF, and the health care team. This is congruent with my experiences as a nurse in the HFC. I frequently  apply knowledge gained from  one individual to other similar cases, and feel  that this knowledge is invaluable. Participants spoke of  sharing mutual goals as an important aspect of  building a relationship with the health care team. Participants described that sharing mutual goals made them feel  that they were engaged or part of  the team. Additionally they spoke of feeling  that the team was there for  them. Whether the mutual goals had an individual or broader focus  it was a common element of  the experience of  collaboration for  most participants. Working Together The theme of  working together was constructed from  the descriptions of  the participants' experiences in the HFC as feeling  that they belonged to a team. Most participants described a strong sense of  teamwork and a desire to work together as central to their experiences. Several participants identified  that working together and feeling  part of  a team was an important aspect of  what differentiated  their experiences in the HFC from  those with health care professionals  in other settings. Throughout the narratives the participants frequently  discussed working together as being comprised of  two distinct aspects. Participants frequently  described their experiences as a joint or team effort.  One participant stated " there is no I in team, it's a team" when describing his experiences. A majority of  participants also described working together as being willing to participate or cooperate in the relationship. One participant, when asked to describe how he worked with the health care team replied, "well by cooperating, listening to them, and doing what we agreed to do". A majority of participants indicated that a willingness to participate in the relationship was necessary for  them to feel  engaged or part of  the team. To facilitate  the description of  the experience of  working together I will utilize the sub-themes identified  from  the narratives as a framework  for  the discussion. Therefore working together will be described as comprised of  the sub-themes of  joint venture and willing participation. Joint Venture. Participants almost universally described the relationship they had with staff  in the HFC as a feeling  that they belonged to a team. Many of  the participants identified  that this was what made their experiences in the HFC unique and differentiated it from  experiences with other health care professionals.  Some participants described the experience as a joint or team effort. Well their demeanour is very acceptable. It makes me feel  as a patient comfortable,  and it makes me feel  that we are jointly doing this you know. Their manners are excellent and their approach is soft,  OK. And it makes me very comfortable.  As a lawyer I have to do the same thing with my clients, you know to make them comfortable  so they can confide  in me. Same thing as my relationship with the team. It is like a joint team effort  where everybody does something that creates the best care. Very professional. I know exactly what I'm supposed to do when I go there. I'm not a stranger. That shows you know that there is a team spirit. Patient and staff together The experience of  working together while common was not universally reported. One participant indicated that he did not feel  that he was part of  the team and described how "mainly they look at me go away and they don't tell me nothing so (laughing) it's like any other place you know". In contrast another participant described himself  as feeling  fully  involved and an equal team member. The other participants describe their experiences of  being involved in a joint endeavour as falling  somewhere along that continuum. When asked to describe how the team functioned,  several of  participants reported remarkably similar experiences. Most saw the cardiologist as the head of  the team who ultimately made many of  the decisions. The nurses were often  seen as supportive and giving information  to both the participant and the cardiologist. I would say it is a team effort  but the big one is the cardiologist, but the specialist nurse that comes (nurse's names) they would thoroughly investigate what I had been doing. Like if  I was going there on a monthly visit they wanted to know how much I walked, they also monitored my water, because I was only allowed to have 6 to 8 glasses because I have a leaky valve. I had to submit this to (nurse's Name) for  about 6 months every week how much water. Well I think they take down all the information.  I am not sure I am going to make the assumption they ask the questions they may or may not advise the doctor. Maybe I'm old school. I don't know maybe I guess again I don't know. I guess it would depend on the relationship between the nurse and the doctor. You know they ask me the questions you know don't really have anything to hide. Tell me whatever and I am assuming that they either give their report to Dr (doctor's name) or shorthand it for  him. And when then he makes the call. There appears to be a common perspective amongst the participants that having clearly defined  roles for  each of  the team members facilitates  the process of  working together. Several participants described feelings  of  increased comfort  knowing that everyone knew what their roles were. Others described how clearly defined  roles promoted a sense of  teamwork. One participant summed it up as "it is like a joint team effort  where everybody does something that creates the best care". One participant talked about how the experience of  working together in the HFC differed  from  other experiences with health care professionals.  He described the experience as not the same old-fashioned  relationship he had experienced with other health care providers. Given the team we are talking about. We are not talking about some thing old fashioned.  No, you're not to read, your not to read anything about this. No, No the only thing you get is from  me. It hasn't happened in your team. This participant described how he was able to be an active participant in his care, with questions being welcomed, and his opinion being viewed as important to the team. Other participants confirmed  that being involved in decisions made them feel  as part of the team. One participant noted, "I feel  that I'm involved and that's good. It makes me feel  good. When you feel  good you get better a lot faster". Willing Participation. All of  the participants reported that they were willing to cooperate with the health care team at the HFC. Most participants expressed a strong desire to help the health care team in any way they could, and indicated that it was an important aspect of  working together. Willing participation was most often  described as cooperating with the health care team. One participant described how he helped the team, "by cooperating, listening to them and doing you know what we agreed to do". This included freely  sharing information  and generally doing what had been agreed to during the clinic visit. So I did participate all the time. I am not one of  those who ah hold back any information.  I just tell it like it is. In that way by telling them what's wrong with me I got very involved into my diagnosis Participants often  described the need for  them to provide a detailed description of symptoms they were experiencing, and most indicated that it was important not to withhold information.  All participants describe needing to honestly answer questions regarding adherence to lifestyle  modifications  such as fluid  restrictions, sodium restrictions, and weight changes. Participants also reported that an important aspect of willing participation was to adopt recommendations made during each clinic visit. One participant described how he came to the decision to willingly participate with the health care team. He described that by being a willing participant he was benefiting  both him and the members of  the health care team. He went on to describe that he felt  that by not working together he was only hurting himself. You can be difficult  to be get along with from  the beginning but there's, no it doesn't help the people trying to help you or yourself.  So I thought that if  I feel  that they know what they are doing I'll cooperate. With them and I think we can get somewhere A majority of  the participants confirmed  this participant's view that being willing to participate in the relationship was beneficial.  Most described that by being willing to participate they would increase the possibility of  achieving improved outcomes for themselves. One participant described that he viewed maintenance of  lifestyle modifications  as mandatory and that if  he did not, he would not "feel  comfortable  being in the team. So I am compelled to do certain things". As previously described all of  the participants had experienced a crisis event that had precipitated the diagnosis of  HF. One participant stated, "we are all very sick people you know". The acknowledgement of  the gravity of  their condition was confirmed  by all of  the participants. Another participant stated "but when you hear that there is something wrong with your heart you just freak  out. You know what I mean. Well it's a very vital organ". Most participants also indicated that the seriousness of  their diagnosis acted as a strong motivator to willingly participate. This willingness to participate was often reinforced  by a dramatic improvement in the participant's condition after  enrolling in the HFC. Several participants reported immediate improvement in their condition. One participant characterized it as "it was like a curtain opened really" She goes on to describe realizing that she was "not going to keel over tomorrow". Several of  the participants also described the members of  the HFC as willing to participate in the relationship. Some of  the participants focused  on the nurses in the HFC. I found  them very cooperative. The first  nurse I saw was (nurse's name) and I liked that because I spent quite a bit of  time with her about an hour or hour and a half P: but the nurses were all very cooperative and very helpful. R: In what ways? P: Well they listened they asked me good questions and they could see two sides to it. Which was very nice. Participants who described the health care team as willing participants frequently focused  on the amount of  time the team members spend with them. Most participants reported being surprised and pleased with the amount of  time they were given during eaich appointment to the HFC. One participant compared her experiences at the HFC with a prior experience that had felt  rushed. She stated "to have somebody sit down and talk to me when I go there. I never feel  like this other doctor made me feel" Other participants described the interactions in terms of  how the team responded to them and their questions. Most participants reported that an important aspect of  the relationship with the HFC was the ability to ask questions and receive meaningful answers. One participant stated, "any question I've ever had was, was, was answered, was discussed, absolutely well just satisfactory,  well answered you know" He went on to state: When I come with a piece of  paper in my hand and say what about that. He would say let me tell you well let me explain something. Not like I don't want you to read nothing, right. First visit. First handshake with Dr (doctor's name) Definitely  I noticed the difference.  You know the man sits next to you, leans forward.  He's got your file and he leans forward  and says Hi. The doctor takes a look at you and says OK this is not just something the cat dragged in right so. I can talk to him like another human being, who is ill and who comes to me for  help, right A majority of  the participants described similar experiences where they felt treated as human beings and invited to participate in the relationship. One participant stated that "you can talk to them, about other thing other than your heart, age, menopause And I don't feel  that I am strictly a name on a file".  Another participant confirmed  that from  her perspective an important part of  working together was being viewed as more than a patient with a disease. She stated, "I'm just not boobs or I'm just not an arm or a chest or something. I'm a person". Communication with the Health Care Team The theme of  communication with the health care team appeared core to the participants' experience of  collaboration. All of  the participants agreed that without communication no relationship would be possible. Many of  the participants identified that communication with the health care team as one of  their primary responsibilities within the relationship. The theme of  communication with the health care team was constructed from  the narratives. With immersion into the narratives I began to see communication being described as either sharing experiences or symptoms with the health care team and/or as a means to increase knowledge. I will utilize the sub-themes identified  from  the narratives as a framework  to assist in the description of  this aspect of  the experience. Therefore  communication will be discussed in terms of  the two sub-themes sharing experiences with the health care team and gaining knowledge. Sharing experiences with the Health Care Team. All participants in the HFC are asked to share significant  amounts of  information  with the health care team. This information  is used to assist the health care team in making decisions on the direction of medical care, and alter the plan of  care as necessary. Participants are asked to share information  on adherence to lifestyle  modifications  such as fluid  restrictions, sodium restrictions, and weight fluctuation.  They are also asked to share their experiences with medications such as medication adherence and reporting side effects  of  the regime. Participants are also asked to report significant  symptoms of  heart failure  in a timely fashion.  Symptoms of  interest include shortness of  breath, development of  edema, palpitations, dizziness, changes in functional  capacity, paroxysmal nocturnal dyspnea, and orthopnea. In addition participants also are asked to report on any other significant experiences that are unique to their illness. Given the amount of  information  participants are asked to communicate it is not surprising as one participant stated, "my role was to assist the staff.  Honestly to tell them how I feel".  This was echoed in other participants' narratives and was frequently identified  as one of  their primary responsibilities. Participants described that reporting of  self-management  skills was an important aspect of  communication with the health care team. All participants reported being asked to report on their adherence to lifestyle  modification.  Most participants indicated it was important for  the health care team to know how they were doing, as it provided guidance for  decisions about their care. It is very important for  them to know if  I have been to the emergency and how much exercise I am doing, how much water I am taking I tell them how I sleep at night, how much pillows I use, It asks me about my breathing difficulties.  Whether it is worse the same, ah you know there is You do your little sign in, how good, how bad you have been since you have last been here. And ah then you have your sit down and you have ah your BP, and heart rate and a run through the meds. What has changed ah if  anything. I would call it prepared the discussion and the nurse shares with the doctor Several participants, after  the interview had finished,  shared their fluid  and weight diaries with me. These participants reported bringing the diaries to every HFC appointment and spoke of  how they shared this information  each time they were communicating with the health care team. One participant described faxing  fluid  and weight logs to the HFC on a weekly basis during a recent period of  instability. Another participant shared the electronic diary he had created that he occasionally emailed to the nurses at the HFC. Several of  participants described the importance of  sharing difficulties  with the medication regime with the HFC. This included response to changes in the regime, and overall adherence to the regime. If  I had real side effects  or something I would, I think I would obviously pick up the phone and say I'm having a real problem with this medication. When they do give me a new pill or whatever I really tune in. When I take it over one, two, three, or four  days. I really take account, is it really doing me any good or bad you know. Other participants confirmed  the importance of  communicating with the health care team any challenges with the medication regime, in their narratives. One participant described how by sharing information  the team was able to find  the best medication regime for  him. He stated, "when they would find  out how I reacted, I would tell them and then there was a time when the medicines all fit" All participants described reporting symptoms of  HF to the HFC. Most identified this as one of  the most important aspects of  communicating with the health care team for them. As one participant summed up, "well if  I am having trouble breathing, they don't know that unless I tell them". I help by telling them what my symptoms are. OK. And unless you tell them your symptoms you cannot diagnose it. And I felt  I played a big part by telling them my symptoms correctly as best as possible so they could give me the best treatment. Well I thought if  I can tell you about what I am experiencing with this shortness of  breath or with my heart problems, my medications they would listen to me. Well last Friday I called (nurse's name) because I was, I looked like an elephant. My legs looked like, because they had taken me off  the atacand, the spironolactone and the Lasix, and she was so great. She talks away asked me how I was, told me what to do and so that part of  it. I feel  I have no hesitation if  there is something wrong. Participants reported that they were encouraged to share symptoms they were experiencing, not only at HFC appointments by also by telephone. Several participants described telephoning the nurse to notify  them of  a change in their condition. One participant phoned due to a dramatic change in weight, and a worsening of  symptoms. Another participant described, "I was going for  a walk OK and I did receive some pain in my chest I called her and I did describe to her. In that sense, she immediately told me to go to the emergency". Gaining Knowledge. Participants frequently  described how much knowledge they had gained by attending the HFC. One participant stated, "the information  giving is great". Participants described obtaining information  on admission to the clinic, where basic information  on the pathophysiology of  heart failure  and self-management  education was initiated. All participants also reported gaining information  by the frequent  asking of questions. A majority of  participants described the intake appointment, where a HFC nurse initiates HF pathophysiology and self-management  education, as a great opportunity to gain knowledge. Most of  the participants describe this focus  on them gaining knowledge as unique to the HFC. One participant when describing the intake appointment, which consists of  a HFC nurse reviewing medical history and initiating self-management education prior to the first  visit with a doctor, stated "They explained to me all about nutrition, and liquids in food.  They educated me". When I first  went into the clinic we really had no idea. My husband was with me, and we really had no idea what was going on. And it was (nurse's name) was the one we first  saw And she was great. Explained everything Well they gave me instructions. Like the amount of  liquids I should be taking, and making sure that I take my pill when I should take them. Through the good efforts  OK of  explaining to me that it is important and mandatory to me that you must walk, and you must take less water, and things of  that nature. And how to handle the pain , like there I am fully,  they have taught me to recognize all the signs of  an MI. During the time I spent with several of  the participants they shared with me their copies of  the educational material they had originally received on intake to the HFC. These materials included pamphlets on fluid  restrictions, sodium restrictions, and an overview of  self-management  including signs of  decompensation and when to seek help. These participants reported that they still periodically reviewed the information,  which assisted them in maintaining the lifestyle  modifications. Consistently the participants' identified  the most important way that they gained information  was the asking of  questions. All participants reported the asking of  questions. Most reported that they asked questions at every appointment at the HFC. So specifically,  I can only say that I have always been interested in what meds do I take and why. What do they do, and what if  anything I have to watch, and what side effect  there would be, if  any, etc. And all of  this has always and well explained by Dr (doctor's name) and (nurse's name) or any other nurse that's been in attendance There was something that I had forgotten  to ask and it was and it was not the nurse that I had seen but another one and the nurse is off  on Friday and I'd asked my couple of  questions and she gladly answered them the doctor comes and goes through it and goes over his physical check and runs through everything right down to the funny  question, and the last time, would you believe it the last silly question was, How long do I got, I've got so many things to do, so how long do I got. Dr (doctor's name) (laughs). And we came right down to it. The most common questions the participants reported had to deal with medications. One participant when asked to describe questions he might ask stated, "Well I guess it could be some of  the medications Why they were changing and I you know and maybe adjusting some of  them" Other questions focused  on diagnostic procedures or interventions such as surgery. One participant stated "Yeah I must have been going to the clinic when I had the surgery, because I checked in there when I had it done.. .and they are jut really good at explaining stuff  to you and I was scared to death". One participant reported doing research on the Internet on his condition, and his medications. He stated, "What I do is when we discuss any thing or ah any meds. I go home and study them I punch in the net. I am a voracious reader. So I want to know". He then describes taking question stimulated by this research to the HFC. Well any given med you ask a question both the patient coordinator and the doctor. They take the time to explain what it is, where it has been used, for  how long, and how successful  it has been, and if  it belongs in the major gold standard group, etc. And you don't get that I guess from probably the majority of  doctors. All participants reported that they had gained knowledge during their time at the HFC. A majority of  the participants indicated that they had gained knowledge on HF self-management  and medications. However one participant indicated that he did not feel his questions about medications had been answered. He stated, "I'd like to sit down with somebody and here are the pills I take are their any of  them I can eliminate". He went on to describe himself  as "illiterate to pills", and described the frustration  of  asking about his medications and still as he states "I have no idea (laughs) I have no idea". Being Accountable The theme of  being accountable was constructed from  repeated immersion in the participants' narratives and their descriptions of  the responsibilities of  being a HFC patient. A majority of  participants report that they felt  that they had taken some responsibility for  their health status. Most reported recognizing the importance of  making lifestyle  modifications,  or practicing self-care  behaviours. The two lifestyle  modifications most frequently  described were restricting fluid  and sodium intake followed  closely by getting enough exercise. Other self-care  behaviours included quitting smoking and loosing weight. Some participants also reported that they felt  that they were accountable to not only the HFC staff  but also to themselves. One participant summarized this by stating, "Yeah I think you have to take responsibility for  your life". I will utilize the two sub-themes constructed from  the narratives as a framework to guide the description of  the experience of  being accountable. Therefore  being accountable will be discussed in relation to the two sub-themes self-care  behaviours and taking responsibility. Self-care  Behaviours. Most participants reported attempting to adhere to lifestyle modifications,  or self-care  behaviours that had been recommended by the HFC. As previously indicated the most common self-care  behaviours described were restriction of fluid  and sodium and getting enough exercise. One participant stated, "My role in the heart function  clinic is to do my side of  it. It is to eat a proper diet, get exercise and look after  myself'. Honestly to tell them how I feel,  how much exercise I've done. I'm only cheating myself.  And I had to force  myself  to do exercise, limit my water, and I took my medicines regularly. This is how I helped them, in what they asked me to do. Well my, my major role is to respond to what has been suggested or told. The weight. The weight fight  has been the toughest as you can imagine. But I'm down something like 40 lbs, I've got 20 more to go It's ah that's ah subject to Christmas, Easter, birthdays (laughs) It interferes doesn't it. Festivities interfere.  No that's number one. To take care of  myself.  To make sure I take my medications, which I do faithfully.  To quit smoking, to do my exercise. To I guess aside from  the heart side its just taking better care of  myself. I did a lot of  walking, ah religiously. I would walk 3 miles a day and I would do it very very well. But then I had this bout last July, and it slowed me up a lot. And right now I have this hernia that is giving me hell, so I 'm lucky if  I get in a 15 - 20 min walk every day. But I try to do a little if  I can. So my role in it is to yeah is to look after  myself  as best as I can, and with the help of  my good wife  it happens. Most participants described achieving success with the self-care  behaviours. However few  found  the changes easy. Several participants described forcing  themselves to adhere to the modifications.  This was especially reported during the initiation of  the lifestyle  changes. One participant summed it up by stating, "I cut down on salt and water, which just about killed me". Another participant reported that she remained smoking. As she stated, "Well you know you are supposed to stop smoking. I'm not an idiot". A few  of  the participants shared with me their techniques for  adhering to the lifestyle  modifications.  One participant placed a container on his counter that had a mark indicating six cups of  fluid.  He reported adding water to the container whenever he had fluid  and when the water came to the six-cup mark he stopped drinking for  the day. Other participants reported utilizing gum and ice cubes to minimize thirst, which helped them adhere to the fluid  restriction. Two of  the participants also credited their spouses with assisting in their adherence to the self-care  behaviours. Taking Responsibility. As indicated earlier, some of  the participants felt  that they had taken responsibility for  their lives. One participant had stated, "Yeah I think you have to take responsibility for  your life".  Some participants reported that if  they did not they felt  would be cheating themselves and preventing the HFC staff  from  doing their jobs. One participant stated, "I try not to cheat in my water. I try not to cheat in my exercise. Because I am only cheating myself'.  Other participants described it as their duty. It's my duty to react to the doctor's hints, demands, issues right. If  I didn't do that I shouldn't have the joy of  being a patient of  that doctor you know. Given the team we are talking about. I think to be honest like you know; you know how much you are smoking. Like there is no point if  I'm smoking a package a day there is no point in saying I only have 10 cigarettes a day or I only have 5 cigarettes per day. So I, I it is my duty to respond to that, my duty to do my very best of  the doctor patient relationship as a team. Two of  the participants described taking responsibility for  their lives as being a prerequisite for  attending the HFC. One participant indicated that he would not feel comfortable  being part of  the team if  he did not take responsibility. The other described that he shouldn't belong to the HFC if  he did not take responsibility for  his life.  For these participants it seemed that they felt  they had to earn their place in the HFC. Another participant focused  on being honest with herself,  and the HFC. She described this in relation taking responsibility for  decisions such as continuing to smoke. She described not taking responsibility, as "That's just ludicrous". She went on to state: So I don't know why people lie about it, because I'm sure when they listen to you chest they can tell, they probably can tell that you smoke anyway. I guess to be honest. I guess if  you are asked a question you know whether they have this disapproving look or they don't, so be it. This participant appeared to describing that from  her perspective part of  taking responsibility in the relationship with the HFC was admitting when recommended lifestyle  modifications  were not being adhered to. This perspective was unique to this participant as other participants reported doing what they had been told to do. Other participants did not explicitly state during the interview, that they felt  that they were taking responsibility for  their lives. However on reviewing field  notes I noted that I had described conversations with participants that indicated how important it was for  them to take responsibility for  their lives. Sharing Power The final  theme that was constructed from  the narratives is that of  sharing power. This theme represents the aspect of  collaboration that participants demonstrated the widest variance in their descriptions of  the experience. At one end of  the continuum participants characterized themselves as "only a patient" and felt  that they had little to offer  in decisions about care. One participant stated, "Well I can't think of  one where I felt  really involved". At the other end of  the continuum a few  participants described themselves as active participants and equal partners. The others situated themselves somewhere between the two extremes. However with repeated immersion in the data I noticed that a majority of  participants described experiencing increased control as they gained knowledge. One participant stated "Finally I know what is going on and somebody is interested enough to do something for  me, and it was just a revelation". A few  of  the participants also felt  that they shared in the decision making process regarding their care. Again I will utilize the two sub-themes constructed from  the narratives as a framework  to guide the description of  this aspect of  the experience. I shall discuss the theme of  sharing power utilizing the two sub-themes of  gaining control and shared decision-making. Gaining Control Many participants described themselves as not being involved in decisions in their care or feeling  that they were able to share power with the HFC staff. However several participants indicated that increasing the knowledge of  their condition increased their sense of  control over the situation. Well a little more assurance. I felt  better about myself,  well I felt  OK with myself,  but about my heart condition because I found  out a little more about it If  they change my medication, which they haven't done that often.  But if they do change it, they tell me why and usually it is for  the better the doctor sat down and talked to me and I talked to a number of different  people, and I felt  oh wow. Finally I know what is going on and somebody is interested enough to do something for  me, and it was just a revelation. As discussed in an earlier section the gaining of  knowledge was an important aspect of  the experience of  collaboration for  the participants. Several participants reported that by knowing more about their condition they felt  better. Some reported that they were better able to handle untoward events. One participant described learning about "how to handle the pain, like there I am fully,  they have taught me to recognize all the signs of  an MI". He goes on to describe that because he knew what to look for  he feels  he sought help in a timely fashion  during his last heart attack. Other participants reported that knowing what to expect with changes to their medication regime was important to them. One participants stated, "if  I consider myself  a fully  informed  patient I want to know what it does, and why and I have never had anybody hold short on giving me a full  explanation on anything". Other participants confirmed  the importance of  knowing what to expect from  their medication regimes throughout their narratives. Several participants described that having questions answered allowed them to feel  a sense of  increased control. One participant described that having information presented honestly and in a straightforward  manner increased her sense of  control, because when she had the knowledge she could chose how she was going to react to it. She stated: They are pretty honest, which I like. Like don't sugar coat it, just tell me the worst case scenario, just lay it on the table, and I'll deal with it I won't deal with it or I'll comprehend it in my own way but you know like don't go around in circles, just tell me something just out with it Despite several participants describing an increased sense of  control this was not a universal experience. One participant who was experiencing the end stages of  HF and confined  to a wheelchair reported that he felt  he had little control over his fate.  He stated: I made a decision after  the last heart attack that every day that I wake up is another day cause I shouldn't have made it. I went through a very a less than two percent chance of  getting out, they called the families  in I was in that bad a shape and fourteen  hundred tubes sticking out of  my body. So I figure  I'm just glad that the good lord give me these extra days. And I've got no fear  of  the other side right so I just take every day at a time. Despite this he reports feeling  happy and enjoying his life.  He reports that his faith  is important to him, which suggests that this may be his way of  gaining control. He stated: That's five  years of  my life  and I enjoyed it very well thank you very much. I got my aches and pains and everybody says well put the guy out of  his misery. Well their not as I'm enjoying myself.  I don't enjoy the pain but I enjoy life. Shared Decision Making. As indicated earlier, some of  the participants did not identify  themselves as being involved in decisions at the HFC. Many of  the participants characterized themselves as somewhat passive, and trusted the decisions made for  them by the HFC. One participant stated, "I am just very accepting of  any decisions that are made on my behalf'.  However this was not unanimous. Several of  the participants described themselves as actively sharing in the decisions about their care. One participant described the experience of  deciding whether or not to have a blood test that could quantify  the severity of  his HF. The test is B-type natriuretic protein (BNP), and is a marker that provided the HFC with an objective measure that describes the severity of  the patient's HF. The participant had asked the physician at the HFC how long he had to live which prompted the discussion. And we came right down to it, after  we discussed the various tests. He said, I actually really wanted to say something about that today to you to. We have a test. Oh OK explain it. And then he explained the BNP test, and I really want you to go downstairs today and ah have some blood drawn. And, we'll just see. We find  it is a very good predictor or indicator to some degree of  reliance, ah of  whether you will keel over tomorrow. I said interesting, and I will go down and do that. This participant went on to describe how he felt  he had been very involved in the decision to go ahead with the BNP test, as he had been the one to initiate the discussion of  prognosis. Another participant described himself  as not a team man. He indicated that it was difficult  for  him to relinquish control. The following  are excerpts from  his narrative describing his experience of  sharing control over his life. you know I'm not necessarily a team man if  you want to put it that way because I like to be in the driver's seat. But you can't always be in the drivers seat because maybe there is somebody who can drive better. I am going there and am in the hands of  professionals.  I'll play ball with them. I'll collaborate because they know what they are doing we can both solve a problem. P: We go down there and we know that we are going to people that are going to help us out. And by doing that we have to play ball with them. R: By play ball what do you mean Can you tell me. P: Collaborate it's the same thing.. By playing ball you collaborate. He had described that he was a professional  who was used to making decisions and being in control. For this participant it was not gaining the sense of  control that was a challenge but rather giving some of  the control to the members of  the HFC. He described the experience of  making decisions about his care with the health care team. R: Can you tell me a little more about how decisions are made about your care in the clinic? And your involvement in the decisions? P: Well I'm pretty decisive. I don't take long to make up my mind, but I will ask them the right questions if  it's a percentages and what he is going to do for  me and then we see And I'll say to go ahead or not. But I you know if  they weren't. If  they gave me some sound reasons why certain steps should be taken I was fine. Antecedents and Barriers to Collaboration This final  section of  the interpretive description describes the participants' perceptions of  the antecedents and barriers to collaboration with the health care team. Participants shared their perceptions of  what supported or inhibited the development of  a collaborative relationship throughout the narratives. From the narratives, a coherent description of  antecedents and barriers to collaboration were constructed. I first  present the antecedents to collaboration as experienced by the participants. Finally I present the participants' experiences of  barriers to collaboration. Antecedents to Collaboration Participants as described earlier were overwhelmingly positive when discussing their experiences with the HFC. As one participant stated, "I am just so prepared to stand on a rooftop  and say how great this place is". Participants generally described feeling  like being part of  a family,  and feeling  safe  with members of  the HFC. Throughout the narratives participants described several key antecedents that promoted the development of  a collaborative relationship with the health care team. From the narratives two themes were constructed that describe participants' perceptions of  antecedents to collaboration. The first  antecedent to collaboration that will be explored is the use of  a non-intimidating communication style. The second antecedent to collaboration that will be discussed is, trusting the health care team. Non-Intimidating Communication Style. Participants almost unanimously described communication with members of  the health care team as a positive experience that promoted a sense of  teamwork and collaboration. Participants frequently  described members of  the health care team as friendly,  willing to listen, and pleasant. One participant described communicating with the health care team as, "there is no hostility, roughness, there is no duress, there is no intimidation". Other participants echoed this experience throughout their narratives. Their manners are excellent and their approach is soft,  OK. And it makes me very comfortable. It is their demeanour and as I said they have open minds. They are not, you know not trying to play god. the nurses were the ones I met there had open minds. They were willing to listen to me, and that's a great thing. And I if  you get good doctors with a good attitude and a good sense of caring and understanding then hey you are lucky. And that is how I felt with the heart clinic. So the difference  in the attitude and the caring I think of  the people at the heart function  clinic. All of  the participants identified  that they felt  comfortable  when communicating with staff  at the HFC. When asked about the interactions with staff  at the HFC many participants described finding  the staff  easy to talk to because of  their gentle approach. Some participants described the staff  at the HFC as having a good attitude. Others identified  that they perceived the staff  as having open minds and being willing to listen. One of  the participants described her experiences in the HFC as unique, indicating she had never felt  this comfortable  communicating with health care professionals  in the past. Another participant summed up his experiences by stating "Absolutely not one, not one interaction that was not positive. I've never come away from  there in any feeling  of dismay or negativity or anything what so ever. Everything just every visit was good". One participant described how important a non-intimidating communication style was to him. He stated: P: But as far  as I'm concerned it's the pleasantries that helps us through this stuff  and that is what I call it what you've got here is the pleasantries. And it is even better than medicine sometimes you know It's cause they all treat me so great. I don't know why (laughs) but they do every one of them. R: So tell me a bit more about what you mean by the pleasantries? P: They smile and, and in general terms there are nice people out there and I've never sat here and seen any of  the nurses or doctors holler at somebody I thought I told you to do this or this like an old country doctor. This is all nice, this is all pleasantries. I still say it's a lot to do with the healing of  the person themselves is always treated instead you know instead of  a piece of  meat they are trying to put together, you can feel  the caring and that they are really trying to do something for  you. And that is what I enjoy with this here. I enjoy coming here. This participant described a non-intimidating communication styles as an important aspect of  getting through the experience of  living with HF. He described the communication style as making him feel  like the staff  at the HFC viewed him as a person, and genuinely cared for  him. This experience is confirmed  in the narratives of  the other participants. Participants described how a non-intimidating communication style made them feel.  Several participants described feeling  comfortable  and safe  while others stated they felt  lucky and it was a great thing. One participant described how important it was for  her to feel  comfortable  with members of  the health care team. I think I liked him first  for  his personality, and then thought of  him second as a doctor. I think it is more important for  me to feel  comfortable  with somebody And I think it goes a lot to not actually hold back, but I think that if  you feel  comfortable  with somebody you feel  comfortable  giving your answers. When probed, several of  the participants indicated that an important aspect of feeling  comfortable  with the health care team was their sense of  humour. Three of  the participants in particular identified  humour as important to them, as it made them feel comfortable  communicating with the team. P: I have friends  that get so stressed when they go to a doctor or have something happen to them. But I just feel  comfortable,  and I don't have any worries when I go in there. R: Can you think of  what they do that makes it such a comfortable experience? P: I like people with a sense of  humor, and I find  Dr (doctor's name) I get a real kick out of  him. I'm trying to think of  what it is. But you know right why I walked into the room the last time I was there and felt  like Oh, You can talk to them. And amongst all this seriousness there's room for  joviality and you know we have a couple of  laughs. Every time I come I write a little joke on the bottom, or a silly question you know. What do you want to ask the doctor today, you know. Every time I have something lighthearted or silly or funny.  Which is my style. My wife  says do you have to write that (Laughs). But that's what I do that's what I do and that's part of  it and the team, they accept that and are nice and responsive to that. I like his sense of  humor. Like I understand that sense of  humor. I guess he's what's the word. I guess depending on the person all the time I guess you know your audience but you know we just I don't know I have a really great sense of  humor and he just strikes my funny  bone and I think that really helps when you get someone with that kind of  relationship with somebody. Trusting the Health Care Team Participants identified  that developing trust in the health care team was a key antecedent to a collaborative relationship. All of  the participants described themselves as trusting the health care team and having confidence  in decisions made about their care. While each participant experienced developing a trusting relationship differently,  all indicated that without trust there would be no relationship. As one participant stated "Yes I confide  in them because they make me comfortable.  I feel  that there is a lot of  trust there". Another participant stated, "I've never found  anything that would disclaim them you know a point of  view you know. They've been good. It's hard, maybe I trust too much or whatever". From immersion in the narratives two important aspects of  trusting the health care team emerged. A majority of  the participants described the health care team as having a great deal of  expertise and knowledge, which allowed them to feel  comfortable  and develop trust in the health care team. In addition participants described experiencing close follow  up and frequent  monitoring which promoted confidence  and trust in the team. From these descriptions two themes describing the participants' experiences of developing trust in the health care team were constructed. The first  theme is that of expertise of  the health care team. The second theme is vigilance of  the health care team. Expertise of  the Health Care Team. As stated earlier all participants described feeling  a great deal of  confidence  in the expertise of  staff  at the HFC. For several participants this began to develop prior to actually coming to the HFC. These participants described how the physicians referring  them to the HFC would praise the expertise of  the staff.  One participant described how his family  doctor described the HFC as "one of  the top heart clinics in the country". Another participant was told he was lucky to have been accepted into the HFC. Other participants, who did not have a priori expectations, describe this confidence  in the expertise of  the health care team as developing early in the relationship. P: Well the first  interview I had with (nurse's name) She gave me a lot of confidence  in the whole thing R: And what made you feel  so confident  based on that one interview? P: Well I felt  that she knew what she was doing, and subsequent people were the same. So walking in to the reception: friendly  courteous, helpful,  kind and low and behold then comes (HFC nurse name) and you say is this possible? They have such a concerned wonderful  person, informed  and informative. And then you have Dr (doctor's name) and we walked out the first  time and said Oh my god how lucky can we be for  this to happen to us. And we felt  in good hands, very good hands. They are just not the ordinary nurses. I see a big difference  between an ordinary nurse and these specialists. Very big difference,  and these people are highly knowledgeable in the heart disease. So one feels  very comfortable  when someone knows what they are doing. And automatically there is a trust that builds up Well after  the first  and second visits. Right away I felt  at home. I said these people are in a position to help me, they are all professionals.  And as I say a professional  is to me is someone who knows what he or she is doing, not the degrees they have. These participants all identified  that they perceived the staff  at the HFC as knowing what they were doing. They used descriptions such as highly knowledgeable, professional,  and informed.  When asked what affected  their perceptions of  expertise several participants commented on the consistency of  information  that they received from the staff  at the HFC. Most of  the participants described receiving consistent information on medications from  the staff  at the HFC. One participant stated: Well any given med you ask a question both the patient coordinator and the doctor. They take the time to explain what it is, where it has been used, for  how long, and how successful  it has been, and if  it belongs in the major gold standard group Several participants described it as routine that self-management  skills, such as fluid  restriction, sodium restriction, and daily weights were discussed and reinforced  at each visit not only by the nurses but the physicians. Others commented on how each member of  the team would review tests such as blood work or echocardiograms at each visit. Another important aspect of  developing a trusting relationship was the perception that participants continued to benefit  from  the decisions made with the health care team. Several participants indicated that they trusted the health care team because their suggestions or directions had improved their situation, or at least done no harm. As one participant stated "I've never found  anything that would disclaim them". Other participants confirmed  this perception that health care team had never let them down or suggested anything that might have caused harm. Well, I guess it's it comes back to again it is my body and my health that we are talking about. And I needed help badly, and they looked after  me. And I just felt that hey these are good people. I can trust them. And ah they have never betrayed that as far  as I am concerned. I can't think of  any decision that they could have made that you know that would have changed the outlook of  things you know. I suppose If  I they had said drink 80 glasses of  water a day, or you know but everything they've said or everything they've done I've agreed with. I suppose if  they had told me I had to. I don't know what they could have said that would make me think, No I'm not going to do that or whatever. Since then I have started to feel  better. Several of  the participants described trusting that the staff  at the HFC would intervene when other physicians made changes to treatment regimes. Other participants described how they developed trust in the HFC when they were able to correctly identify what was causing an episode of  decompensation. One participant described the role the HFC played in her being diagnosed with a thyroid dysfunction: P: Well they were the ones that found  out what it was. I mean I had been going to my GP for  probably a month and ah a bit before  and I was getting increasingly worse. And it was (nurse's name) and Dr (doctor's name) idea to have the thyroid test. So if  it hadn't been for  that I would still be sitting here wondering what the heck was happening to me. R: So how did it make you feel  when they figured  it out? P: Oh great, I think they are just wonderful.  Well of  course you know that Another participant recounted how the HFC had assisted in the diagnosis and treatment of  his chronic pancreatitis after  he started experiencing severe stomach pain. whatever other problems I had I would relate it to them and they would refer  my OK, To either the Vascular surgeon (doctor's name) or the GI (doctor's name). This is all done through the heart clinic where I complain about my stomach pains, which apparently was diagnosed as chronic pancreatitis. Other participants described similar experiences with the HFC, where they had intervened when other health care professionals  had not. One participant described using a sarcastic tone how it made her feel  when a cardiologist was unsure of  how to proceed in her care, and how the HFC was able to diagnose and treat the problem. Well when I first  got diagnosed with the problem with the heart it was for arrhythmia problems, and they sent me to the specialist and he tried all these different  medications, I can't remember who it was at the time. He tried all these different  medications and then just couldn't get it down to where regular heartbeats. Finally it was basically just I just don't know what to do with you. Well yeah that is really special to hear the heart specialist say that to me, Like that really made me feel  good Generally participants expressed that they trusted the expertise of  the staff  at the HFC, and felt  confident  in decisions made about their care. As one participant summed up "So I thought they between them and Dr (doctor's name) they helped me a great deal. It gave me confidence  it gave me a lot of  confidence". Vigilance of  the Health Care Team. Several participants described that the staff  at the HFC were vigilant in monitoring of  their conditions. One participant stated, "they really really monitored me very carefully.  I was watched very carefully".  When asked how this made him feel  he responded "Oh trust and feeling  safe".  He went on to describe how he was monitored. They have a continuous follow  up from  the previous to right now and any thing that If  I have some discrepancies, It is noted down and briefed  to the cardiologist they are always take a blood test from  me. Sometimes the would before  I come there I would have to fast.  That would mean that they were going to take my cholesterol you know, my HDL and LDL major reports form other doctors would always go to them. They would always check my medicines on every visit they would they would monitor my weight, OK. And they would they very carefully  put down all of  this information  and give it to the cardiologist. They do it through very thorough ah research and analysis on me, OK. And then they find  out, they did my blood monitoring a lot the specialist nurse that comes (nurse's names) they would thoroughly investigate what I had been doing. Like if  I was going there on a monthly visit they wanted to know how much I walked, they also monitored my water, ah because I was only allowed to have 6 to 8 glasses because I have a leaky valve. I had to submit this to (nurse's name) for  about 6 months every week how much water This participant's experience was congruent with the experiences of  other participants. A majority of  the participants reported frequent  monitoring of  weight, adherence to self-management  skills, effects  of  medication changes, and blood work by staff  at the HFC. This was frequently  described as part of  the routine of  coming to the HFC. More importantly participants also described how this vigilance increased the level of  confidence  in the staff  at the HFC and promoted a collaborative relationship. One participant characterized the relationship as ongoing and described how the staff  at the HFC had been vigilant in their monitoring to ensure that he kept recovering. He stated: what I see the clinic, their function  is. I've been with them for  4 years now, it seems to me that their function  is OK we check this guy out we figure  he needs the heart operation. Ah we did it, he recovered, and we are going to make darn sure that he keeps recovering. I don't know when they will stop seeing, or when they will say I don't think we need to see you any more. Because at my age I am not all of  the sudden become 50 year old, or a 60 year old but I see it as an ongoing thing. Participants reported experiencing vigilant monitoring outside of  scheduled HFC appointments. Participants were encouraged to telephone with any changes in status, and reported that the nurses would frequently  check on them if  they were experiencing a period of  instability. One participant described frequent  telephone calls to check on his condition when he was experiencing an episode of  renal insufficiency.  He reported that nurses asked for  information  such as changes in weight, and descriptions of  symptoms he was experiencing. He also reported that the nurses shared information  on the latest blood work results and recommended changes to the treatment regime via telephone. Another participant characterized the relationship by stating "I feel  that I can call when something has gone awry and they deal with it. So I think the relationship is great". Barriers to Collaboration Participants describe very limited experiences with barriers to collaboration within the HFC. As stated previously the participants were very positive when describing their experiences with the HFC. However, when probed, each participant was able to articulate episodes from  past experiences where they had experienced a barrier to, or lack of  collaboration with health care professionals.  Barriers to collaboration were characterized by the participants as either arising between individuals or from  within the participants themselves. From the narratives three themes describing the participants perception of  barriers to collaboration were constructed. The first  barrier to collaboration that will be described is lack of  time. A second barrier to collaboration that will be explored is communication styles that do not support collaboration. The third barrier to collaboration that will be discussed is inequity of  power sharing. Lack of  Time Several of  the participants reported experiences where they felt  that a lack of  time prevented the development of  a relationship with health care professionals.  Generally participants did not describe this as a concern at the HFC. They indicated that the staff  at the clinic took the time that was necessary to answer questions, explain medications, test results, and what to expect. As one participant stated when describing her experiences in the HFC, "I don't feel  that they are one step out the door as you are still talking". Other participants confirmed  that they did not generally experience time pressures at the HFC. The majority of  the participants described experiences with other health care professionals  where lack of  time was a concern. One participant described being told that she has heart failure  after  an angiogram, and the experience of  the cardiologist not making time for  her. She reported not being able to ask questions and described the way the cardiologist looked at his watch after telling her she would not live as long as other people. P: Well that is probably a very good point. When I had the angiogram I mean I was really scared. I had no idea what was going on. It was kind of  a sudden thing and this doctor had probably done 10 angiograms that day. And came and sat on my bed and asked do you have any questions, and I didn't know what to ask him. And I said well what's going on? Ah well you have an enlarged heart and da da da OK got to go. And the next time I saw him after  the angiogram I said well what are my chances of  survival, what's going on, what's wrong. Oh you just won't live as long as most people. And that was it. That was, and then he looked at his watch, it was lunchtime and he was out R: The experience with the other cardiologist. How did that make you feel? P: Very very angry, very angry and very ah ah, upset I guess because I didn't know what was going on, and he didn't explain it. It was like I was a piece of  rock or something that he just you know. You won't live as long as most people, so goodbye. I have six minutes for  you and then I have to see my next patient. Actually I walked out of  his office  and there was a bench out front.  My husband was picking me up and I sat on this bench and I started to cry, and I never cry. I was so upset. The lack of  time from  the cardiologist had a profound  affect  on this participant. She reported becoming angry, crying, and at the end of  the interactions still having little information  about her condition, and no idea of  what to expect. When she was recounting the experience of  the cardiologist looking at his watch after  telling her she wouldn't live as long as other people, she was shaking her head and tapping her watch, suggesting that the experience continued to affect  her. She described feeling  that she had been treated like a rock, implying that the experience had been dehumanizing. This participant also reports not knowing what was going on, with no self-management  education, discussion of  prognosis, discussion of  treatment options, or emotional support apparently being offered. Another participant described an experience with a physician who had just told her that her father  had inoperable brain tumors. She described how the physician walked away without answering questions, discussing prognosis, or the possibility of  other treatment options. But it's just the way he said it to me like you moron what else would it be. And I was so angry at that point and I said just excuse me and he says of course he has 4 or 5 tumors you know. And then he went to walk away and I said I'm not finished  yet, you know. And what I felt  like saying to him was I've been sitting here for  the last 10 hours, and you can't give me the frigging  time of  day. I mean, I realize that you have to be detached but cold is not the word for  it. This participant describes the effect  of  having the physician trying to walk away and not giving her the time of  day as "making her so angry". This experience also prevented the participant from  having questions answered, and left  her unsure of  what was going to happen next. The participant alluded to the lack of  control or power she experienced, and how difficult  the experience had been. Although a majority of  participants described not experiencing time constraints in the HFC one participant did describe an experience where he felt  rushed. The physician in the HFC did not adequately answer his questions regarding a medication change and he described how he felt. P: Well you see no I didn't feel  to bad you now I felt  he was you know that's it. Just a couple of  times. R: Sort of  shut down the conversation a bit? P: Well not entirely but I guess he was in a rush R: And how did that make you feel? P: Well I was wondering about that you see. well just wondering you know if he could spend a little more time and just calm down. I suppose he is human like anybody else. You see maybe he was tired. R: But how did it make you feel? P: Well I felt  that way and said well it probably does know what he is doing so I'll try. I could have told him to take his medication and do something with it. But I didn't think it was right. This participant also described how feeling  rushed made him angry, and prevented him from  asking questions and receiving answers. All of  these participants described how a lack of  time on the part of  the health care professional  prevented them from  having questions answered. This is described as a significant  aspect of  the relationship with members of  the health care team by all of  the participants in this study. The lack of  time as experienced by these participants also had aspects of  being dehumanizing, which prevented the development of  a therapeutic relationship. Development of  a collaborative relationship in such instances appears difficult  if  not impossible. Communication Styles that do not Support Collaboration Several participants described experiences with health care professionals  where the style of  communication prevented or inhibited the development of  a collaborative relationship. Participants had indicated that an important aspect of  developing a relationship with the health care team was a non-intimidating communication style. Several of  the participants reported that communication with the health care team at the HFC was a positive experience. However, several participants described experiences when communication styles of  health care professionals  interfered  or prevented the development of  a therapeutic relationship. Several participants described feeling intimidated by health care professionals.  One aspect of  this intimidation was the use of technical language, which made it difficult  for  participants to understand what was being discussed. I'm illiterate to pills. They give me this, this, this and this and I know what they are and I've looked at them, and I make sure that I get this, this, this and this. But if  you tell me what is that one and I have no idea. I just, I can't understand big words put big words together. when it come to these, these heavy medications OK Ah they found  mine, and Spiritonal, that is a diuretic you know. That makes the heart. I used to take 1 per day, now I take 12.5 every other day. And it works well. OK, He was very, very good about explaining that (doctor's name). That he says I want to find  the best for  you, and he was very technical after  that with all the blood work, and this work, you know. Other participants also reported that use of  technical language would leave them confused  and intimidated. As one participant indicated he felt  the use of  technical language indicated that the health care professional  lacked confidence  or expertise and was using jargon to inhibit further  conversation. He stated, "Actually they are probably people who are not sure of  themselves a little lack of  confidence". Several of  the participants described experiences of  health care professionals  as being unfriendly,  or difficult  to approach. As one participant stated when describing a physician, "He's nice enough but I don't think he's the friendliest  person, but I know he is a really busy guy". She goes on to state, "I haven't run across it very often,  but every once in a while you get somebody like who is so cold". So anyway, talk about cold fish.  Anyway he comes through and he has got 3 or 4 interns he is training. Anyway he whips the curtains around my father  and we are asked to step out, which was OK. I guess I was still with my ex and we are standing off.  Anyway it was like a 10-minute examination, and said to him, you know has the cancer spread. Of  course the cancer has spread. Excuse me; well we didn't know what was giving him these blinding headaches. Because he had lung cancer right. But we didn't know it had gone up to his head.. But it's just the way he said it to me That night nurse. Well they had moved me into the ward after  I had had my operation. And I got up, I was able to get out of  bed every once in a while and I was in quite a bit of  pain. Mainly in my leg and I asked her if  I could have a bit more morphine for  the pain, and she said no you can't. And I said I really feel  I need it and she said well I am sorry you are just not getting it. She was very blunt with it, and I am sitting there on the side of  the bed, feeling  so weak that I wish someone would pick me up and put me in bed. And I felt  sorry for  myself,  and I guess I pissed her off  too. Both participants described that the outcome of  the interaction could have been dramatically different  if  the approach of  the health care professional  had been gentler. Other participants also reported experiences where health care professionals  were unfriendly  or difficult  to approach. One participant stated when describing an interaction with a physician at the HFC, "well I suppose he was a little abrupt". He went on to describe how this had shut the conversation down. Participants unanimously described a friendly,  open communication style where they felt  able to ask questions, and have input into decisions as conducive to developing a collaborative relationship. Communication styles that were closed, confrontational,  or aggressive were seen to prevent development of  a collaborative relationship. One participant described experiences of  being talked down to by health care professionals.  The participant had extensive experiences with health care professionals  as she was living with multiple medical problems including HF, diabetes, and rheumatoid arthritis. She stated: Unfortunately  I find  that sometimes specialists will talk down to you. And I understand that they are educated, gone to university but by the same token I am a person, and don't speak down to me. Like you don't know me from  a hole in the ground. Like don't talk down to me. The participant describes that she felt  quite competent with managing many of  her medical conditions and was frustrated  when health care professionals  would not listen to her or recognize her expertise. Her narrative suggests that being talked down to was dehumanizing, and a significant  barrier to developing a collaborative relationship, as her experiences and expertise were trivialized. Inequity of  Power Sharing Many participants described experiences where they felt  unable to share in decisions, or have input into the care they received. Participants often  described how they did not perceive that they had the power to become involved in decisions. Some participants describe experiences where members of  the health care team did not permit participation in decision-making. Other participants described how they had assumed a passive stance, which prevented involvement in decision-making. From the narratives two themes were constructed that describe the experience of  inequity of  power. The first theme describing inequity of  power sharing is the health care team not sharing power. The second theme describing the experiences of  inequity of  power sharing is assuming a passive stance. Health Care Team not Sharing Power. Several participants describe experiences where health care professionals  did not allow participation in decision-making. One participant stated. "I like to be asked as opposed to being told I think there are ways that you can put it to somebody. That we would like you to, as opposed to this is what you are doing". One participant described his experiences of  being told that he would not be resuscitated in the event of  a cardiac arrest. They said they're going around telling they used to go around telling if you wanted to be resuscitated or not, when you die And maybe I got the wrong angle on it but now there telling me we will not resuscitate you. No choice of  your own. That's the (name of  hospital) When I had my last heart attack I died about 2 or 3 times on the way to the emergency, and if they had had a standing order of  no resuscitation then I wouldn't be here today. Another participant recounted his experience with a cardiologist where he was unable to participate in decisions about his care. The following  are excerpts from  his narrative. And I went in to Dr (doctor's name) and after  a couple of  visits I mentioned to him that I had read up on the net, and he took me to task. And told me he wasn't going to deal with people who went onto the net and he was the doctor. This fine  cardiologist sat behind a desk with gold plated rings and expensive figures  and figurines  on his desk. And I sat across from  him like a schoolboy. He took a piece of  paper and drew a heart upside down so I could see it. At which point I went into a state of  shock. I said yeah I happen to know what it looks like Doctor. And ah my feeling  was that there were no specifics,  no specifics.  Not interested in being specific  about any given drug. My questions were not welcomed, and ah when I went home I started up and found  something. I made a printout went to his office,  went to his nurse with a nice little note, and said Nurse X would you would be kind enough sometime to slip this to the doctor. And the question was on the note. I read that such and such is in the forefront,  and is here any chance that this might be good for  me or applicable to my heart. And ah he wrote me a note and copied it to (doctor's name) that ah he doesn't want to be questioned about anything about this, blah, blah, blah. So I wrote him back. R: How did that make you feel? P: Well let me tell you. I told him I think if  your response to the report that I sent to you from  the website, it's NEJM. (Reading from  a letter) It is my sincere hope that I did not annoy you and it was not my intent. The appointment with (doctor's name) that you suggested has been made and that consultation was informative.  My dear father  in law for  over 20 years I had the privilege to be with him, and maybe he spoiled me and my family  with the aid of  his fine  colleagues. However he also drilled into me that as a patient I should stand firm  and had to be a team with my physician, I hope you did not misinterpret my motive but I was quite sure that this report was well know to you. Albeit that I had hope to hear from you that just maybe, it was aldosterone, might be a drug that could prolong my life.  Since you think this is not the case there is always hope for  future developments. In this fascinating  age of  computers there is so much more to learn for  patients, isn't there. Thank You. When probed how this experience had made him feel  he stated, "It was actually devastating for  me, you know". These two narratives describe vividly the effects  of  a significant  inequity of  power. These participants described feeling  powerless, angry, and experienced a loss of  control over their lives. While less dramatic, other participants described similar experiences of  the health care team not sharing power. One participant described a physician in the HFC as "well there is a couple of  times right I've felt  that one of  the doctors was a little pushy. However I think he may have been right so". He goes on to conclude that being unable to participate in a decision regarding his care was a disturbing experience. Assuming a Passive Stance. Several of  the participants identified  that they were content to allow the health care team make the decisions about their care. Frequently participants indicated they trusted the health care professionals  at the HFC to make the decisions for  them. Others were more explicit in their descriptions, and characterized themselves as being passive rather than active participants in their care. One participant stated, "Well, I guess I'm pretty easy because I take direction beautifully  from  them". He went on to describe himself  as a good patient. Another participant stated, "I am just very accepting of  any decisions that are made on my behalf'.  The following  are excerpts from the narrative of  this participant. I just feel  that I guess I must be kind of  a passive person, because when I go whatever information  they give me, or whatever they tell me to do, you know I do So as far  as being a participant in this I sort of  look upon myself  just as the patient. And that's about it. R: What do you see your role as? P: Acquiescence, which I guess I feel  that they know what they are talking about and after,  especially after  this experience at (name of  hospital) I feel well that it is such a relief  to have someone who tells me what to take and what to do, and how to do it. As I've said before  I am kind of  a passive person Other participants also identified  themselves as being passive rather than active participants in decisions regarding their care. One participant characterized himself  as, "I'm a mild meek type person generally". When asked how important it was for  him to be involved in his care he replied "not really important". Several participants indicated that they thought they should be more involved in decisions about their care, but trusted the decisions made for  them by the health care team. These participants acknowledged that by taking a passive stance they were creating barriers that it may prevent development of  a collaborative relationship. No I don't think. I've got no qualms of  anything and it's wrong. Well maybe in some people's eyes it is a wrongful  trust because they do make mistakes, and I should be more involved. I guess I feel  involved only in as much that I trust them and what they are doing. You know I can't argue with them at all. I guess I just trust, I guess I make the assumption that the doctor knows what he is doing. So if  he says to me this is what you need to be on, I don't think I would turn around and say no I don't think so. Because I'm not the specialist As previously discussed this experience was not shared by all of  the participants. Some participants described themselves as active collaborators and therefore  did not identify  this as a barrier to collaboration. Others identified  that in their experience a passive stance was an important barrier to collaboration. This was the barrier to collaboration that demonstrated the greatest variance amongst participants, similar to the variance found  in theme of  sharing power where participants situated themselves along a continuum between the two extremes. Summary Initially as I immersed myself  in the narratives I was struck by the uniqueness of each of  the participants' experiences. However, with repeated immersion in the data several themes emerged and an interpretive description of  the participant's experiences of collaboration was constructed. Participant's described their experiences of  collaboration with members of  the health care team in terms of  five  dominant themes that were constructed from  the narratives. These themes provide a description of  what was salient to the experience and guided the discussion of  what the experience of  collaboration was like for  the participants. The five  themes identified  were mutual goals, working together, communication with the health care team, being accountable, and sharing power. As previously mentioned each participant's experience was unique, with some participants identifying  themselves as passive and others as actively involved in decisions regarding their care. When describing working together most participants' spoke of  it as a joint venture that involved willing participation. Participants frequently  described this experience as teamwork. When discussing communication with the health care team, important aspects of  the experience were identified  as sharing experiences and gaining knowledge. The most frequently  identified  aspect of  gaining knowledge, and the aspect that participant's identified  as being most important to them was the ability to ask questions. Participants describe being accountable as comprising of  self-care  behaviours and taking responsibility. Frequently participants identified  this as their most important role. The theme of  sharing power displayed the widest variation amongst the participants. Several participants described themselves as "only a patient" while a few  viewed themselves as active participants in decision-making. Next antecedents and barriers to collaboration were explored. Participants identified  antecedents to collaboration as being comprised of  non-intimidating communication style, and trusting the health care team. When discussing trust participants described the expertise and vigilance of  the health care team as key to the development of  trust. Finally barriers to collaboration were presented. Participants identified  three barriers to collaboration as being lack of  time, communication styles that do not support collaboration, and inequity of  power sharing. The experience of  inequity of  power sharing was described by participants in terms of  the health care team not sharing power, and participants taking a passive stance. CHAPTER FIVE Discussion of  the Findings I chapter five  I discuss the findings  presented in chapter four  in relation to the published work of  other authors. The reason for  this discussion is to situate the findings of  my study within the current body of  knowledge related to the experience of collaboration with the health care team. In chapter two I explored the literature relating to the concept of  collaboration, experience of  patient heath care team collaboration, and outcomes of  collaboration. As identified  previously there is a paucity of  empirical literature that explores individuals with HF and their experience of  collaboration with the health care team. The existing literature provided a predominantly theoretical understanding of  the experience of collaboration, but did not address how the experience may differ  for  those living with HF who attend a HFC. Therefore,  my primary intent was to explore the experience of collaboration from  the perspective of  individuals attending a HFC, to enhance the understanding of  the experience, and present how the findings  support or refute  the current theoretical perspectives on this experience. This discussion is aimed at demonstrating how an understanding of  the experience of  collaboration from  the perspective of  an individual attending a HFC. It is presented in the interpretive description and augments the existing understanding of  the experience. The organizational framework  utilized in chapter four  is used to guide the discussion of the findings. Experience of  Collaboration In the current study I found  that the experience of  collaboration with the health care team by individuals attending a HFC seemed to be comprised of  the experiences of mutual goals, working together, communication with the health care team, being accountable, and sharing power. Antecedents to the experience of  collaboration included non-intimidating communication style and trust in the health care team. Barriers to the experience of  collaboration identified  were lack of  time, communication styles that do not support collaboration, and inequity of  power sharing. Significant  findings  from  each of  these themes are discussed in relation to the existing body of  knowledge on collaboration. As previously stated there is a paucity of  literature exploring the experience of  collaboration from  the patients' perspective. The current literature is predominantly theoretical in nature, or comprised of  case studies which provide limited insight into the experience from  the patients' perspective. Mutual Goals All of  the participants in the current study identified  their goals in attending the HFC to be improving their health status or making them feel  better. All participants also indicated that in their experiences the goals of  the staff  at the HFC were congruent with their own goals. Most described a sense of  teamwork, and a sense that the staff  at the HFC were there for  the purpose of  keeping them healthy. Participants in the current study reported that staff  at the HFC were concerned for  their health and some described that helping patients at the HFC motivated the health care team. This is also congruent with my experiences as a nurse in the HFC, and I feel  that congruence of  goals is necessary for a collaborative relationship to develop. Although none of  the participants in the current study described a formal  process of  goal setting, all reported that in their experiences all parties were working towards a common goal. I feel  that without a process to establish goals of  care the health care team and the individual with HF may work together less effectively,  or possibly not work together at all. The importance of  having a mutual goal on which to base the collaborative relationship described in the current study is congruent with much of  the existing theoretical literature on collaboration. Several authors describe the importance of  having mutual goals in a collaborative process. Henneman et al (1995) in a concept analysis of collaboration identifies  that "collaboration requires that individuals view themselves as members of  a team, and contribute to a common product or goal" (p. 104). Gardener and Cary (1999) identify  having shared goals as one of  the four  operating processes of collaboration. They go on to indicate that collaboration must begin with an agreement on the goal or purpose of  the collaborative relationship. Lindeke and Block (1998) conceptualize collaboration as "a process of  shared planning and actions towards common goals" (p. 213). Henneman et al (1995) and Lindeke and Block (1998) conceptualize achieving mutual goals as the outcome of  collaboration, indicating that measurement of  success of  a collaborative venture rests on achieving the goal. Gardener and Cary (1999) view a mutual goal as necessary to initiate and guide the collaborative relationship, and view common goals as both a process of  collaboration and an outcome. This is an important distinction in the context of  the current study, as all of  the participants indicated that it would be unrealistic to achieve the goal of  improved health indefinitely.  The participants in the current study indicated that they were acutely aware of  the fragility  of  their health status, with most reporting multiple episodes of decompensation. One participant stated, "there is probably something along the line that they won't be able to fix  but that their doing the very very best that they can do". Empiric literature examining collaboration is also congruent with the findings  of the importance of  mutual goals. Most of  the current literature describing mutual goals as part of  the experience of  collaboration is from  the perspective of  health care providers. Paavilainen and Astedt-Kurki (1997) examined collaboration in the client -nurse relationship in a public health setting from  the perspective of  the nurse. They describe the collaborative relationship as "beginning with trust and proceeds towards the common goal" (p. 139). They identified  the common goal of  nursing as clients' well-being and ability to cope. Nurses in the study reported using this as an outcome measurement with success being described as achievement of  the goal. Barr and Threlkeld (2000) utilize the patient-practitioner collaborative model to frame  a case study examining a collaborative relationship between a person with a physical disability and therapists involves in the care. The model describes four  phases of  collaboration, one of  them being finding common ground through negotiation. This phase of  the model " describes a process of mutual goal setting and negotiation to choose interventions that patients are likely to follow,  given identified  barriers" (Barr & Threlkeld, 2000, p. 257). Again achievement of the mutual goals was seen as evidence of  a successful  collaboration. Akhavain et al (1999) utilized Bowen's family  systems theory to examine collaboration in an interdisciplinary psychiatric treatment team. Bowen's theory conceptualized collaboration as " the ability to combine assertiveness and cooperativeness and to remain true to individual principles while working toward a common goal" (Akhavain et al, 1999, p. 4). In the case study achievement of  the goals of  the treatment plan were presented as indicating successful  collaboration. There is a paucity of  literature examining the experience of  collaboration from  the perspective of  patients, and even less exploring the experience of  how a patients goals were elicited and utilized in the decision making process. Clark and Mass (1998) examined clients' experience of  collaboration at the Comox Valley Nursing Centre. Clark and Mass (1998) characterize collaboration as, "a partnership characterized by mutual goals and commitments" (p. 218). However, they fail  to explicate how patients' mutual goals were identified  or considered as part of  the experience of  collaboration. Clark and Mass (1998) instead focus  on the outcomes of  collaboration, with no discussion of whether the outcomes represented, or were congruent with the goals of  the patients. Hutchings (1999) also fails  to identify  how a client with advanced multiple sclerosis experienced mutual goals as part of  the collaborative process, when co-presenting an in-service on the importance of  patient empowerment. We are left  to assume that the goal of the health care professional  and the client were congruent; as there was no discussion provided identifying  why the patient wanted to participate in the in-service. Both of  these studies focused  on positive outcomes, implying that these represented the mutual goals of the client and the health care team. However as discussed earlier this perspective does not appear to be consistent with the findings  of  the current study. Findings of  the current study instead support the view of  mutual goals as supporting the initiation of,  and providing guidance to, a collaborative relationship, rather than an outcome of  the relationship. I feel  this is an important distinction as I conceptualize collaboration as both a process and an outcome. Therefore,  utilizing goals to guide the relationship rather than as an evaluation tool is congruent with my own beliefs  and the findings  of  the study. Working Together The findings  of  the current study indicate that participants perceived working together as an important component of  the experience of  collaboration. Two aspects of working together emerged as significant  throughout the participants' narratives. The two aspects or sub-themes of  the experiences of  working together were: joint venture, and willing participation. I now discuss each of  these sub-themes in relation to the existing body of  knowledge. Henneman et al (1995), Clark and Mass (1998), Gardner and Cary (1999), and Akhavain et al (1999) conceptualize one defining  attribute of  the experience of collaboration as being a joint venture. Findings in the current study indicate that a majority of  participants view the experience of  collaboration as a joint venture, which provides support for  these authors conceptualization of  collaboration. Henneman et al (1995) states that, " a significant  attribute of  collaboration is that two or more individuals must be involved in a joint venture, typically one of  an intellectual nature" (p. 104). They go on to describe how collaboration requires individuals to view themselves as belonging to or being members of  a team. Significant  portions of  the participants' narratives contained descriptions of  how they felt  part of  a team, which further  supports the relevance of  Henneman, et al's conceptualization of  collaboration as a joint venture. The findings  of  the current study are consistent with the findings  of  Clarke and Mass (1998), that participating in a joint venture led to patients feeling  supported, more secure and better about themselves. Participants in the current study frequently  described themselves as feeling  comfortable  and safe  because of  the team approach. The feeling  of safety  is particularly important to individuals with HF, as during the course of  the illness they may experience frequent  episodes of  decompensation, and the HFC can provide the safe  harbor as described by Zambrowski (2003). No literature describing the individual with HF experience of  collaboration was found.  One of  the only studies describing collaboration from  a patient's perspective was Sharkey's examination of  the experiences of  a patient with the diagnosis of  severe and enduring mental illness. Sharkey (2002) reported that the participant did not experience collaboration or a sense of  working together with the health care team, and went on to conclude that "it is more honest to acknowledge that either collaboration does not happen when they are acutely ill or aspects of  it occur on our terms" (p. 54). The findings  in the present study do not appear to affirm  Sharkey's perspective, as only one participant reported not feeling  like he was part of  the team, and in general participants' described their experience as that of  a joint venture. A second aspect of  working together described in the findings  of  the current study is that of  willing participation as an important aspect of  the experience of  collaboration. This confirms  Henneman et al (1995) and Clark and Mass (1998) conceptualization of willing participation as one of  the defining  attributes of  collaboration. Henneman et al (1995) states that collaboration is a "cooperative endeavor in which the participants willingly participate in planning and decision making" (p. 104). Findings from  the current study suggest that participants and staff  at the HFC willingly participated in collaboration. Participants indicated that they would help the health care team in any way they could, and felt  the health care team would reciprocate. All of  the participants had experienced a crisis or significant  event preceding the diagnosis of  HF. This is congruent with the findings  of  Stull et al (1999) who describe becoming a patient of  HF as a process with five  stages. The five  phases were identified  as a crisis event, diagnosis, patients and family's  response to the diagnosis, acceptance and adjusting to the diagnosis, and getting on with life.  A majority of  the participants reported that the desire to avoid episodes of  decompensation acted as a strong motivator to willingly participate in the relationship with the health care team. These findings  are consistent with the findings  of  Stull et al (1999) where they describe the phases of acceptance and getting on with their lives as occurring when patients made changes and worked with the health care team to avoid decompensation and regain control. I feel  that the desire to avoid episodes of  decompensation is a key aspect of  the experience of collaboration for  the participants in the current study. It provides not only a goal to work towards but defines  much of  the relationship between the individual with HF and members of  the health care team. An important aspect of  willing participation for  most participants was adherence to lifestyle  changes, and practicing positive self-care  behaviour. Participants generally reported that by adherence to lifestyle  changes and medication regimes, they were demonstrating willing participation. As one participant indicated, he would not feel comfortable  as part of  the team if  he did not adhere to the treatment regime. The current study are consistent with Clark and Mass (1998) findings  that" the willingness of  clients to accept responsibility for  their own role in addressing health concerns and implementing self-care  strategies led to the development of  partnerships with the nurses" (p. 221). This suggests that by engaging in behaviors that facilitate  self-care  in individuals with HF, health care professionals  may also be fostering  the development of  a collaborative relationship. Communication with the Health Care Team The findings  from  the current study suggest that from  the participants perspective communication with the health care team is a key component of  the experience of collaboration. As stated earlier, participants described communicating with the health care team as one of  the important roles in the development of  a relationship. It is important to note that participants were not describing the effects  of  communication style, but rather the content of  the communication when describing their experiences. The effects  of  communication style are discussed in a separate section on antecedents and barriers to collaboration. The experience of  communication with the health care team was described in two sub-themes that were constructed from  participants' narratives. I discuss the sub-themes of  sharing experiences and gaining knowledge in the context of the current body of  knowledge. Participants in the current study describe the importance of  communicating the experiences and symptoms of  HF with the health care team. These included communicating adherence to self-management  strategies, tolerance of  medication regimes, and symptoms of  decompensation. Participants reported that this information was utilized to assist the health care team in making decisions on the direction of  medical care, and alter the plan of  care as necessary. The current study affirms  the finding  of  Barr and Threlkeld (2000) that "understanding and knowing the patient are essential components of  the clinical reasoning process" (p. 256). Bar and Threlkeld (2000) describe the patient-practitioner collaborative model as composed of  four  phases: establishing the therapeutic relationship, diagnosing through mutual enquiry, finding common ground through negotiation, and intervening and following  up. They report that knowledge of  the patient's experiences and symptoms was critical to the collaborative decision making process. Participants in the current study described sharing their experiences and symptoms of  HF as an important aspect of  the relationship with the health care team. Participants indicated that without sharing their experiences, decisions about their care might be compromised. As one participant stated, "well if  I am having trouble breathing, they don't know that unless I tell them". This suggests that participants' viewed themselves as having expertise on the experiences and symptoms of  HF, and contributed in a meaningful  way to decisions regarding their care, by sharing this expertise, although none of  the participants explicitly identified  themselves as experts. This finding strengthens the relevance of  Henneman et al (1995) and Clark and Mass (1998) conceptualization of  the contribution of  expertise as a defining  attribute of  collaboration. Hutchings (1999) hypothesized, " the prolonged and complex nature of  chronic conditions results in clients being uniquely familiar  with how the illness or disability relates to their overall life  experiences. Clients become the best experts about themselves" (p. 130). Participants in the current study did not generally identify themselves as experts in HF. However, they acknowledged that they were uniquely familiar  with the effects  HF had on their lives, which is congruent with Hutchings' hypothesis. Participants in the current study reported that an important facet  of communicating with the health care team was the gaining of  knowledge. Participants reported gaining knowledge by participating in education sessions and asking questions. Participants reported receiving education on the pathophysiology of  heart failure, medications, signs of  decompensation, and self-management  skills. However, consistently the participants identified  the most important way that they gained information  were the asking of  questions. In my experiences as a nurse at a HFC, patients initially are hesitant to ask questions, and only after  a relationship had developed do they appear less hesitant to ask questions. By listening carefully  to the questions our patients ask I feel  that we can gain valuable insight into what is important and relevant to them, which may improve care and facilitate  collaboration. Content of  education sessions, as reported by participants in the current study, appeared to be congruent with education offered  at other HFCs (Dahl and Penque, 2000, Venner and Seelbinder, 1996, Paul, 2000, Levine and Hall, 1998). Participants reported receiving detailed verbal and written instructions on admission to the HFC. Participants frequently  described themselves as lacking knowledge, fearful,  and experiencing uncertainty regarding their future  prior to coming to the HFC. This supports the relevance of  Stull et al (1999) findings  that HF patients at the beginning of  the illness experience, during the phases of  crisis event and diagnosis, experienced uncertainty, and "because of the change in their life  situation, leaving them with a need for  information  about this condition/situation and how to proceed with life"  (p. 287). One participant of  the current study described the effect  of  the information  giving as "like a curtain lifting".  The current study confirms  the relevance of  Stull et al (1999) findings,  that during the phase of  acceptance and adjustment, there is time spent on learning and maintaining lifestyle modifications. Participants found  the asking of  questions was an important aspect of  the process of  communicating with the health care team. Most reported that they asked questions at every appointment at the HFC. Participants described asking questions as a way to increase knowledge, and assist in understanding decisions regarding the direction of  care. The current study's findings  are consistent with Clark and Mass (1998) findings  that patients' valued getting useful  information,  and as a result of  gaining information  became more knowledgeable about their conditions and reported more confident  communications with health care providers. Barr and Threlkeld (2000) applied the patient-practitioner collaborative model to a relationship between a patient with chronic back pain and therapists involved in his care. They reported finding  that the ability of  the patient pose questions, and raise concerns throughout the process is a key aspect of  collaboration. The present study appears to confirm  the relevance of  the findings  of  Barr and Threlkeld, that asking questions is an important characteristic of  the experience of  collaboration. Being Accountable A majority of  participants in the current study reported that they that they had taken some responsibility for  their health status. Most reported recognizing the importance of  performing  self-care  behaviours, including fluid  restrictions, sodium restrictions, exercising, and performing  daily weights. Other participants in the current study reported that they felt  that they were accountable to not only the HFC staff  but to themselves. One participant summarized this by stating, "Yeah I think you have to take responsibility for  your life".  The experience of  being accountable was described in two sub-themes. These themes are self-care  behaviours and taking responsibility. Next I examined each of  these sub-themes in relation to the existing body of  knowledge. The participants in the current study described performing  many self-care behaviours on a daily basis. Some participants indicated that they adhered to the self-care behaviours because they were part of  the team, and they were doing their part. Other participants described it as taking responsibility for  their lives. Most participants saw performing  self-care  activities as important to their experience of  collaboration with the health care team. As one participant stated, "My role in the heart function  clinic is to do my side of  it". This suggests that the participant viewed self-care  as one of  the responsibilities that arose from  being a part of  the team at the HFC. The conceptualization of  self-care  as a component of  collaboration is not explicitly identified in the current theoretical literature, however can be thought of  as roughly analogous to sharing responsibility. Henneman et al (1995) states collaboration requires participants to "offer  their expertise, share in the responsibility for  outcomes" (p. 104). There is a paucity of  empirical literature discussing the experience of  self-care  as an aspect of  collaboration, however the experience of  self-care  is well documented in the literature. The efficacy  of  the self-care  behaviours described by the participants in the current study is well supported by the current literature addressing self-care.  Hicks and Holm (2003) state " appropriate self  management may slow disease progression and prevent repeated and expensive hospital admissions" (p. 70). Other authors discuss the benefits  of  self-care  as being reduction of  physical symptoms but also decreased anxiety and increased sense of  control (Zambrowski, 2003; Evangelista, Berg, Dracoup, 2001; Dracoup et al, 2003). Self-care  is defined  as "the practice of  activities that individuals initiate and perform  on their own behalf  in the interest of  maintaining life  health, continuing personal development and well being" (Artinian, Magnan, Sloan, Lange, 2002). Common positive self-care  behaviours reported by the participants of  the current study included include restricting fluid,  restricting sodium, daily weights, adherence to medication regimes, exercising and if  applicable smoking cessation and avoidance of alcohol. Riegel and Carlson (2002) found  that staying out of  the hospital, maintaining control and improving health status were strong motivators to perform  self-care.  Likewise participants in the current study indicated that avoidance of  hospitalization and maintaining health status motivated self-care  behaviours. Participants in the current study generally reported that practicing self-care  behaviours was beneficial  in the prevention of negative symptoms. From my perspective as a nurse in a HFC, the importance of  positive self-care  behaviours is well supported anecdotally. Frequently patients who initiate positive self  -care behavoiours experience dramatic improvements in their symptoms. This contradicts the findings  of  Franz (2004) who reported that the individual in the case study perceived self-care  activities as doing nothing at all, and did nothing to prevent hospitalization. Generally participants reported adherence to self-care  behaviours, however some participants continued to smoke, and report non-adherence to dietary restrictions. The current study confirms  the relevance of  Zambrowski (2003) findings  that participants generally reported a range of  positive self-care  behaviours, but several participants reported negative self-care  behaviours such as smoking and food  and water binging. Zambrowski (2003) goes on to report that negative self-care  behaviors were often attributed to stress, boredom, and frustration.  The participant in the current study who continued to smoke confirms  this finding  and reported the use of  cigarettes as a means to reduce stress and boredom. One participant in the present study stated, "I cut down on salt and water, which just about killed me". This corresponds with the findings  of  other authors, such as Evangelista et al (2001) who reported "more patients had difficulty  with dietary and exercise recommendations than any of  the other prescribed activities" (p. 300). The present study provides support for  the recommendations by Evangelista et al (2001) that strategies such as ensuring patients understand the treatment regime and designing interventions to promote self-management  should be rigorously pursued. Some of  the participants in the current study reported the importance of  taking responsibility for  their lives. Two of  the participants described taking responsibility as a prerequisite for  attending the HFC, and if  they did not take responsibility they were not acting as part of  the team. This suggests that for  some of  the participants in the present study taking responsibility was a key aspect of  the experience of  collaboration with the health care team. The existing body of  theoretical knowledge explicating the concept of collaboration seems to be consistent with the findings  of  the current study that taking responsibility is part of  the experience of  collaboration. Henneman et al (1995), Clark and Mass (1998), Gardner and Cary (1999), conceptualize shared responsibility as a defining  attribute of  collaboration. Clark and Mass (1998) identify  critical attributes of collaboration as including " assuming responsibility and accepting accountability" (p. 218). Paavilainen and Astedt-Kurki (1997) theorize that the client and nurse can discuss problems together, but "it is the client who needs to make the decisions and take responsibility for  them" (p. 140). Some of  the participants in the current study describe themselves as taking responsibility for  their lives, however none identify  themselves as the primary decision makers and they characterize the decision making as shared. Many of  the participants in the current study reported simply doing what they were told, suggesting they did not perceive themselves as taking responsibility. They reported viewing themselves as passive rather than active participants in decision-making about the direction of  their care. This experience will be explored in greater detail in the discussion of  experiences of  barriers to collaboration. Of  note, participants in the current study describe the desire for  the health care team to take responsibility for  decision-making, particularly during episodes of  decompensation. This is congruent with Zambrowski (2003) findings  that during periods of  increased symptom severity individuals with HF looked to health care professionals  to provide guidance and make decisions regarding their care. Zambrowski (2003) describes this, using nautical terminology to frame  the discussion, as "during periods of  increased turbulence or increased symptom severity, the presence of  a skilled pilot can promote finding  a safe harbor" (p. 39). The skilled pilot is described as the health care professional,  and a safe harbor is thought of  as freedom  from  distressing symptoms. Sharing Power The theme of  sharing power represents the aspect of  collaboration that demonstrated the widest variance in the experiences of  the participants in the current study. This is congruent with my experiences as a nurse in a HFC. Anecdotal evidence from  my practice suggests that sharing power is experienced along a continuum, which is also a finding  of  this study. Sharing power was described as being experienced along a continuum ranging from  participants that characterized themselves as "only a patient" to a few  participants that described themselves as active participants and equal partners. From the narratives two sub-themes were constructed that described participants experiences of  sharing power. These sub-themes are the experience of  gaining control and shared decision-making. I next explored these sub-themes with reference  to the existing literature. Current theoretical literature provides strong support for  the conceptualization of shared power as a defining  attribute of  collaboration (Henneman et al, 1995, Clark and Mass, 1998, Gardner and Cary, 1999). Whitehead (2001) however, cautions that while the concept is sound it "requires professional  groups to relinquish their reductionist power-base and actively acknowledge the client as an equal member of  the collaborative team. Other authors support the view that enacting and promoting collaboration between patients and health care professionals  is challenging (Sharkey, 2002; Paterson, 2001). This experience will be discussed in detail in the section on barriers to collaboration. Several of  the participants in the current study described the effect  gaining knowledge had on their experiences. These participants indicated that increasing the knowledge of  their condition increased their sense of  control over the situation. They described feeling  more assurance, confidence  and as one participant stated "it was a revelation". Some of  the participants also reported improved health status. Clarke and Mass (1998) reported that participants who formed  empowering relationships with nurses at the health center becoming more knowledgeable about their conditions, took actions on their own, and improved physically and mentally. Participants described that one aspect of  this experience was getting useful  information  (Clark & Mass, 1998). The current study confirms  the relevance of  the perspective of  Artinian et al (2002) that "knowledge is a necessary foundation  for  self-care  that enables an individual to perform  self-care"  (p, 162). As previously discussed the experience of  gaining control was not universal amongst the participants of  the current study. One participant reported having a fatalistic view and placed himself  in the hands of  a higher power. This enabled him to feel  at peace and content with his life.  Zambrowski (2003) also reports participants using a belief  in God as a resource to help them navigate their experience of  living with HF. Many of  the participants in the present study did not identify  themselves as being involved in decisions at the HFC. One participant stated, "I am just very accepting of  any decisions that are made on my behalf'.  This is congruent with my experiences in the HFC. Many patients seem relieved when decisions are made for  them. This could be affected  by the severity of  their illness, values and beliefs  surrounding health care professionals,  and perhaps from  taking a passive stance. However, other participants did not share this experience. A few  of  the participants described themselves as actively sharing in the decisions about their care. Henneman et al (1995) and Clark and Mass (1998) identify  one of  the defining  attribute of  collaboration are shared planning and decision-making. The findings  of  the present study provide support for  the conceptualization of  shared decision making as a defining  attribute of  collaboration. Those participants in the current study that described sharing in the decision-making, report working together with the health care team to make the best decisions. One participant described that it was difficult  to relinquish control and he was used to being in the drivers seat He went on to state, "but you can't always be in the driver's seat because maybe there is somebody who can drive better". The present study supports the findings  of  Clark and Mass (1998) that patients entering into collaborative relationships with nurses had an increase awareness of  how to improve their condition, and the ability to make decisions and cope more effectively.  Findings of  the present study also confirm the relevance of  Gardener and Cary (1999) conceptualization of  collaboration as a "process of  joint decision-making reflecting  the synergy that results from  combining knowledge and skill" (p, 68). Antecedents to Collaboration Henneman et al (1995) state that, "a significant  number of  personnel and environmental factors  influence  whether or not collaboration occurs" (p. 106). These are described as antecedents, and may be thought of  as factors  that must be present for collaboration to occur. The present study suggests that from  the participants' perspective there were two key antecedents to collaboration. The first  antecedent to collaboration that I will explore is the use of  a non-intimidating communication style. The second antecedent to collaboration that I will discuss is trusting the health care team. I discuss each of  these antecedents in the context of  current literature. Non-intimidating Communication Style Participants in the current study consistently described communication with the health care team in the HFC as a positive experience. They described staff  as friendly, willing to listen, and open-minded. Participants indicated that a friendly  non-intimidating communication style was important to them, and promoted working together. Many participants suggested that it was essential for  a therapeutic relationship to develop. There is strong theoretical support in the literature for  the findings  of  the current study, that a non-intimidating communication style is a key antecedent to collaboration (Henneman et al, 1995, Clark and Mass, 1998). These authors conceptualize excellent communication as an antecedent to collaboration. Gardener and Cary (1999) provide additional support for  the findings  by identifying  strong interpersonal communication skills as a core competency necessary for  collaboration to occur. Participants in the current study described several communication styles that promoted the experience of  collaboration. One participant described communicating with the health care team as, "there is no hostility, roughness, there is no duress, there is no intimidation". Other participants described the importance of  the health care team being willing to listen and respond to their lived experiences. Interactions where this occurred were generally perceived as positive, as were experiences where participants described the health care teams' approach as gentle. This corresponds with the findings  of  Van Ess Coeling and Cukr (2000) that an attentive communication style promoted collaboration, and contentious and dominant styles act as barriers to collaboration. Participants in the present study describe feeling  comfortable  and safe  with the health care team; thus the findings  of  the current study support the recommendations by Van Ess Coeling and Cukr that members of  the health care team should develop and use an attentive communication style. Strategies such as making it obvious that they are listening, refraining  from participating in other activities while communication, and devoting time and attention to communication may be utilized to promote an attentive communication style (Van Ess Coeling and Cukr, 2000). Trust in the Health Care Team. Participants in the present study identified  that they trusted and had confidence the health care team at the HFC. Most participants described trust as a key antecedent to a collaborative relationship, and that without trust no relationship was possible. This finding  is congruent with my experiences in the HFC. I feel  that without trust it is difficult  if  not impossible to develop any relationship. Participant s described two aspects of  developing trust as key to their experiences. A majority of  the participants described the health care team as having a great deal of  expertise and knowledge, which allowed them to feel  comfortable  and safe.  Participants also described experiencing close follow up and frequent  monitoring which promoted confidence  and trust in the team. I constructed two themes describing the participants' experiences of  developing trust in the health care team: expertise of  the health care team and vigilance of  the health care team. I now explore each of  these themes with reference  to the current body of  knowledge. Literature on the concept of  collaboration suggests that trust is an essential antecedent to collaboration. Akhavian et al (1999) theorized "collaboration flourishes  in an atmosphere where there is a high level of  trust" (p. 2). Paavilainen and Astedt-Kurki (1997) conceptualized collaboration as a relationship where over time a sense of  mutual trust and confidence  develops. Gardener and Cary (1999) identified  trust building as one of  the seven stages of  collaboration where participants determine the degree on which they can rely on others. Findings from  the present study appear to be congruent with these authors' perspectives of  the importance of  trust as an antecedent to collaboration. The present study identifies  that one aspect of  developing trust was confidence  in the ability of  the health care team. Participants generally described the health care team as possessing a great deal of  knowledge and expertise. The current study is consistent with Clark and Mass (1998) finding  that a key antecedent for  clients was "trust in the abilities or expertise of  the nurses in the Centre" (p. 221). Gedney-Baggs and Schmitt (1997) in a grounded theory study examining nurse and resident physicians perception of collaboration, found  a key antecedent of  collaboration was appropriate knowledge. They found  that "providers were more likely to collaborate with people who they perceived had pertinent knowledge" (Gedney-Baggs and Schmitt, 1997, p. 74). I feel  that while findings  of  this study should not be generalized to the current study they provide additional support for  the perception that appropriate knowledge is an antecedent to collaboration. Several of  the participants in the present study reported perceiving decisions made at the HFC did not result in harm and therefore  were seen as positive. However, many participants reported experiences with other health care professionals  where decisions were perceived as potentially harmful  and seen as negative. The experience of  trusting that the staff  at the HFC would not harm them enhanced the feelings  of  trust reported by the participants. The current study provides confirmation  of  Zambrowski (2003) findings that trust and confidence  was negatively affected  when health care providers were perceived as having less than adequate skills. Several participants in the current study reported that staff  at the HFC were vigilant in the monitoring of  their conditions. One participant described how the close monitoring made him feel  safe  and increased the trust in the staff  of  the HFC. Participants describe how staff  would contact them by telephone to assess their status, and one participant reported faxing  logs to the HFC, while another reported frequent email communication with the HFC. In my experiences in the HFC frequent  monitoring was an important aspect of  developing and maintaining trust. I have many anecdotal accounts of  how close monitoring prevented hospitalization, or episodes of decompensation. It is my concern that with the overwhelming number of  patients attending the HFC, this vigilance will be decreased, and this may negatively affect collaboration. Some of  the participants in the present study reported that vigilance by the staff  at the HFC had prevented hospitalizations and one participant indicated that it had kept him alive. This indicated that participants perceived that they could rely on members of  the health care team to help when necessary. This supports the conceptualization of trust as the stage of  collaboration where individuals involved in the collaboration "determine the degree to which reliance on others can be achieved" (Gardner & Cary, 1999, p. 68). Participants reported being encouraged to telephone with any changes in status, and indicated that nurses at the HFC would frequently  check on them if  they were experiencing a period of  instability. The suggestion by Paavilainen and Astedt-Kurki (1997) that as a trusting relationship grew participants felt  that they could always turn to the health care professional  with a problem were confirmed  in the present study. Participants described the health care team as available to assist with any difficulties,  and frequently  monitored their condition for  changes in health status. Barriers to Collaboration Participants reported experiencing few  barriers to collaboration with the health care team at the HFC. As stated previously participants in the current study were very positive when describing their experiences at the HFC. The majority of  participants however had experiences with other health care professionals  that were described as negative, and where they had experienced a barrier to, or lack of  collaboration. It was predominantly from  these experiences that the themes describing barriers to collaboration were constructed. I identified  three themes describing barriers to collaboration that emerged as significant  throughout the participants' narratives. These themes were: lack of time, communication styles that do not support collaboration, and inequity of  power sharing are I explored them in the context of  the current body of  knowledge. Lack of  Time Several of  the participants in the current study reported experiences where they felt  that a lack of  time, or failure  to take the time prevented the development of  a relationship with health care professionals.  Generally participants did not describe this experience at the HFC. One participant stated when describing her experiences in the HFC, "I don't feel  that they are one step out the door as you are still talking". Paavilainen and Astedt-Kurki (1997) conceptualized the collaborative relationship as needing time to develop. They describe collaboration as developing gradually and deepening over the longer term. Gedney Baggs and Schmitt (1997) found  that adequate time for  collaboration to develop was a key component of  the antecedent of  being available. They found  that being available required providers to have the time, and willingness to interact with one another. Clark and Mass (1998) found  that clients that formed  a collaborative relationship valued nurses taking the time to allow them to express themselves and be understood. Paterson (2001) reported that time with health care professionals  is a critical factor  in allowing clients to participate and collaborate in decision making. All of  these authors confirm  the importance of  adequate time as an antecedent to collaboration. Many of  the participants described how they had experienced a lack of  time to ask questions, and felt  that health care professionals  appeared to be too busy for  them. This experience presented a significant  barrier to collaboration from  the perspective of participants. This perspective is consistent with the findings  of  Paterson (2001), who reported that participants "agreed that participatory decision making was severely constrained whenever practitioners scheduled appointments so there is little time to ask questions, share ideas or dialogue about available disease management options" (p. 579). Participants of  the present study report being angry, confused  and devastated by health care professionals  not having, or making the time to communicate. One participant described feeling  that she had been treated like a rock, with not time to ask questions or participate in decision making, implying that the experience had been dehumanizing. The present study supports the relevance of  Paterson (2001) finding  that not taking or allowing time indicated that practitioners were unwilling to enter into a collaborative relationship with persons with chronic illness, or allow them to be active participants in their care. Paterson (2001) goes on to report finding  that "practitioners who view time as a commodity to be juggled in health care present barriers to the enactment of empowerment in health care" (p. 579). Communication Styles that Do Not Support Collaboration Several participants in the current study described experiences with health care professionals  where the style of  communication prevented or inhibited the development of  a collaborative relationship. As previously discussed the present study found  that a non-intimidating communication style promoted collaboration. These findings,  as previously discussed, were supported by several authors (Henneman et al, 1995, Clark and Mass, 1998, Gardner and Cary, 1999). These authors conceptualize excellent communication as an antecedent to collaboration. The majority of  participants reported that communication with the health care team at the HFC was a positive experience. However, several participants described feeling  intimidated by health care professionals.  One aspect of  intimidation was the use of  technical language, which made it difficult  for  participants to understand what was being discussed. As one participant in the current study indicated he felt  the use of technical language indicated that the health care professional  lacked confidence  or expertise and was using jargon to inhibit further  conversation. Riegel and Carlson (2002) identified  that the lack of  knowledge and misconceptions over what self-care  activities they should attend to was a significant  barrier to self-care  for  patients with HF. They describe how participants could not comprehend what was being said, and could not get answers to their questions in a way that promoted comprehension. They go on to describe how participants described receiving too much detailed information  increased confusion and led to the interaction as being perceived as unsupportive. The current study also confirms  the relevance of  Paterson (2001) findings  that "when practitioners spoke in medical jargon they could not understand, they perceived it as accentuating the power differential  between the practitioners and themselves" (p. 578). Several of  the participants in the current study described experiences of  health care professionals  being unfriendly,  cold, or difficult  to approach. These participants described that the outcome of  the interaction could have been different  if  the approach of the health care professional  had been gentler. Van Ess Coeling and Cukr (2000) described that use of  dominant or contentious communications styles acted as a barrier to collaboration. Dominating communication styles are defined  as "speaking frequently, strongly, in a dominating and take charge manner" (Van Ess Coeling and Cukr, 2000. p. 68). A contentious style is defined  as argumentative, challenging, and precise in manner (Van Ess Coeling and Cukr, 2000). As indicated previously several participants in the current study indicated experiencing dominant and contentious communication styles, and confirmed  that it had acted as a barrier to collaboration. Findings of  the current study are consistent with the recommendations by Van Ess Coeling and Cukr that members of the health care team should develop and use an attentive communication style. One participant described experiences of  being talked down, or condescended to by health care professionals.  The participant describes that she felt  quite competent with managing many of  her medical conditions and was frustrated  when health care professionals  would not listen to her or recognize her expertise. The present study is congruent with Paterson's (2001) findings  that many health professionals  dismiss a patient's knowledge and expertise and reacted with skepticism or anger when participants attempted to assume an active role. The present study also supports the relevance of Paterson's (2001) suggestion that "practitioners should be taught how to enact empowering practices and behaviours" (p. 579). Inequity of  Power Sharing Many participants described experiences where they felt  unable to share in decisions, or have input into the care they received. Participants often  described how they did not perceive that were not given the power, or permitted to become involved in decisions. Other participants described how they had assumed a passive stance, which also prevented involvement in decision-making. Regardless of  the cause an imbalance of power preventing collaboration was experienced by all of  the participants in the current study. I constructed two themes from  the narratives that describe the experience of inequity of  power: the health care team not sharing power and assuming a passive stance. I next explore these themes with reference  to the current literature. There is strong support in the theoretical literature on collaboration that sharing power is a key or defining  attribute of  collaboration (Henneman et al, 1995; Clark & Mass, 1998; Gardner & Cary, 1999). Henneman et al (1995) conceptualize collaboration as being one extreme of  interpersonal conflict  styles that involve varying levels of assertiveness and cooperation. Collaboration occurs in the presence of  high levels of cooperation and assertiveness. Gardener and Cary (1999) described collaboration in a similar manner. They described differences  of  interpersonal conflict  styles based on degree of  concern with self  and degree of  concern with others. Collaboration is then conceptualized as occurring when high levels of  concern with self  and high levels of concern with others are present (Gardner & Cary, 1999). Several participants in the present study described experiences where health care professionals  did not allow participation in decision-making. One participant stated. "I like to be asked as opposed to being told". Other participants described experiences where they felt  that they had no say in decisions regarding their care. One participant described an experience where he was berated for  asking a question and recounted that he felt  like schoolboy that was being punished. The present study provides is consistent with Paterson's (2001) findings  that practitioners' often  scolded people with chronic illness when discussing self-care  decisions they had made. Paterson (2001) goes on to state " such practitioner behaviour emanates from  professionals'  belief  that they know best" (p. 575). Participants in the present study described this experiencing the lack of  power sharing by the health care team as a significant  barrier to collaboration. Two participants in the current study reported ending relationships with health care professionals  because of  this inequity of  power sharing. Henneman et al (1995) conceptualized this experience as competition, which occurs in the presence of  high levels of  assertiveness and low levels of  cooperation, and identifies  that this experience as a significant  barrier to collaboration. The results of  this lack of  power sharing by the health care team by participants in the current study was described as causing them to feel  powerless, angry, and experience a loss of  control over their lives. The present study supports the relevance of  the findings of  Sharkey (2002) who described that a patient with severe and enduring mental illness experienced an almost complete lack of  collaboration and described how the health care team did not empower him to become involved in decision making in any way. Sharkey (2002) concluded that collaboration in this case occurred only on the terms of  health care professionals,  if  it occurred at all. Several of  the participants in the current study identified  that they were content to allow the health care team make the decisions about their care. These participants indicated they trusted health care professionals  to make the decisions for  them. Others characterized themselves as being passive rather than active participants in their care. One participant stated, "Well, I guess I'm pretty easy because I take direction beautifully from  them". Thorne and Paterson (2001) describe a developmental process similar to moving from  childhood, adolescence and finally  toward an adult approach of  taking responsibility for  disease management. They identify  that in the earlier more passive and dependent stage participants required more support form  health care professionals  than in later stages. This confirms  the findings  of  the current study, and may help explicate why some participants perceive themselves as passive participants. Gardener and Cary (1999) report that one barrier to collaboration is development of  a hierarchy or formal  power differences.  Several of  the participants in the current study described perceiving the health care team as the experts and described themselves as only the patient. This suggested the participants deferred  to the health care team and created a hierarchy of  power. The participants in the current study that identified  themselves as passive did identify  that collaboration may be hindered by this stance. However, all of these participants described themselves as content, and just wanting someone to tell them what to do. The preset study provides support for  the relevance of  Zambrowski (2003) findings  that during periods of  increased symptom severity individuals with HF looked to health care professionals  to provide guidance and make decisions regarding their care. Summary In Chapter Five I have discussed my findings  that were presented in Chapter Four, in relation to the existing body of  theoretical and empirical literature related to the experience of  collaboration. The existing literature provided a predominantly theoretical understanding of  the experience of  collaboration, and did not address how the experience may differ  for  those living with HF who attend a HFC. The experience of  collaboration is unique to each individual but is generally comprised of  five  main themes. These themes are: mutual goals, working together, communication with the health care team, being accountable, and sharing power. Antecedents to the experience of  collaboration included non-intimidating communication style and trust in the health care team. Barriers to the experience of  collaboration identified  were lack of  time, communication styles that do not support collaboration, and inequity of  power sharing. The findings  on the whole tend to support the current perspective on the experience of  collaboration with the health care team. However the findings  that suggested the importance of  being accountable, and the value participants' placed on the gaining of  knowledge provided additional insight into the experience of  collaboration form  the perspective of  a person with HF. In Chapter Six, I present a summary of  the main conclusions of  the study. In addition I discuss the implications of  the findings  for  nursing practice, education, and research. CHAPTER SIX Summary Conclusions and Implications I designed this study to explore the experience of  collaboration from  the perspective of  individuals with HF attending a HFC. My interest in this subject arose from  experiences in my clinical nursing practice. As a nurse working with a HFC I was aware of  the literature supporting the benefits  of  lifestyle  modification,  monitoring of weights on a daily basis, and medication adherence. The current body of  knowledge supports multidisciplinary team management, and frequent  follow  up of  individuals with HF, such as those provided in HFCs, as an effective  way to decrease mortality, decrease hospital readmissions, and decrease episodes of  instability. There is also strong evidence in the current literature describing the benefit  of  collaborating with the health care team for  individuals with HF. However, there is a paucity of  literature describing the experience of  collaboration from  the perspective of  individuals with HF attending a HFC. I chose interpretive description as described by Thorne et al (1997) as the research methodology because it was appropriate to answering the research question, "how do individuals with HF, experience collaboration with the health care team in the setting of an outpatient HFC?" This approach directs development of  a description of  an individual's perception of  an experience and an interpretation of  the experience to uncover meaning and contribute to nursing knowledge. Further, these individual experiences are examined to identify  what persons in similar positions share and what is particular to the lived experience of  each individual. I reviewed the current body of  literature to provide myself  with a familiarity  with the existing knowledge on the experience and concept of  collaboration. In addition literature exploring HF, HFCs, and outcomes of  collaboration was reviewed. Literature from  a wide range of  disciplines including nursing, medicine, social work, physiotherapy, and psychology were reviewed. The initial inquiry was guided by the analytic framework derived from  immersion in the existing theoretical and empirical literature. The literature review informed  the study by assisting the construction of  the findings,  and establishing links to existing knowledge. The data were collected by means of  in-depth semi structured interviews with a total of  seven participants. Interviews were tape rerecorded and transcribed verbatim. Data analysis occurred concurrently with data gathering, using a process of  inductive analysis. The findings  informed  and guided the data collection and analysis process and enabled the construction of  the interpretive description. The narratives revealed five  dominant themes describing the experience of collaboration by individuals with HF attending a HFC. These were mutual goals, working together, communication with the health care team, being accountable, and sharing power. Antecedents to the experience of  collaboration included non-intimidating communication style and trust in the health care team. Barriers to the experience of collaboration identified  were lack of  time, communication styles that do not support collaboration and inequity of  power sharing. I discussed the findings  of  the current study in relation to the existing body of theoretical and empirical knowledge. The findings  of  this study generally support the relevance of  current theoretical perspectives of  the experience of  collaboration. However, certain findings  of  the current study indicated the need for  further  exploration, and suggested implications to practice, research and education. Conclusions from  the Findings Here I first  list the main findings  from  the current study are listed and then discuss them in terms of  implications to practice, research, and education. 1. The existing body of  theoretical knowledge explicating the concept of collaboration generally seems relevant and applicable to individuals with HF attending a HFC. 2. The experience of  collaboration, as perceived by people with HF attending a HFC, is unique for  each individual. 3. People with HF attending a HFC describe the experience of  collaboration with the health care team according to five  main themes, mutual goals, working together, communication with the health care team, being accountable, and sharing power. 4. People with HF attending a HFC describe antecedents to collaboration in terms of  non-intimidating communication style and trust in the health care team. 5. People with HF attending a HFC describe barriers to collaboration according to three themes, lack of  time, communication styles that do not support collaboration and inequity of  power sharing. 6. People with HF attending a HFC describe the experience of  working together as a joint venture where all involved willingly participate in the collaborative relationship. The willingness to work with the health care team is influenced  by a desire to avoid episodes of  decompensation 7. People with HF attending a HFC describe sharing experiences and gaining knowledge as important aspects of  the experience of  communications with the health care team. The ability to ask questions is a critical aspect of  the collaborative relationship. 8. People with HF attending a HFC may describe taking responsibility for  their lives as a key aspect of  the experience of  collaboration with the health care team as it promotes an increased sense of  control. By adopting positive self-care  behaviours they become active participants in the collaborative relationship. 9. The experience of  sharing power as an aspect of  collaboration is unique to each individual, and can be described as occurring along a continuum from  perceptions of  a lack of  power to full  partnership in decision making. 10. Gaining knowledge about their condition enables people with HF attending a HFC to experience an increased sense of  control, which may promote power sharing and development of  a collaborative relationship. 11. Trust in the health care team is a critical antecedent to collaboration for  people with HF attending a HFC. The experience of  gaining trust is influenced  by perceptions of  the expertise and vigilance of  the health care team. 12. Inequity of  power sharing is experienced as a significant  barrier to development of  a collaborative relationship and is influenced  by the assumption of  a passive stance by people with HF attending a HFC, and the perception that members of the health care team are not willing to share power. Implications for  Practice, Education and Research Implications for  Practice I have found,  using the findings  of  the current study to guide me a number of implications for  current nursing practice. I shall discuss the implications and provide recommendations for  changing practice. The relevance of  the current knowledge of  the concept of  collaboration is generally supported by the findings  of  this study. However, the current study emphasizes the importance of  nurses and other health professionals taking an individualized approach when establishing and maintaining a collaborative relationship with people with HF attending a HFC. By recognizing that individuals experience collaboration differently,  nurses can develop an understanding of  what is both common and unique to the experience, and use this knowledge to individualize care. I have found  based on the findings  of  the current study that the aspect of  collaboration that demonstrated the greatest variance was the experience of  sharing power. The current study findings  suggest that some individuals do not place great importance on sharing power and may want the health care team to assume control during periods of  instability or increased uncertainty. Other individuals place great importance on being active participants in decision-making. ! therefore  recommend that nurses individualize the approach taken based on where the individual falls  on the continuum of  sharing power. Strategies that promote empowerment such as increasing sense of  control by increasing knowledge, and assessing what decisions individuals want input into may be effective regardless of  where the individual places themselves on the continuum. One aspect of  individualizing the approach is identification  of  the goals an individual with HF has for  attending a HFC. I recommend based on the study findings that nurses practicing in HFCs formalize  the process of  identifying  goals, and incorporate this discussion into each interaction. Asking what do you hope to achieve from  attending the HFC, and recording the responses would assist in the identification  of  current goals, and provide a basis for  future  discussions. I also recommend, based on the support of  the findings  the development of  a written communication tool that explicitly identify individuals' with HF goal statements, which would promote ongoing review, and if applicable, revision of  the goals by individuals with HF, nurses, and other health care professionals. The findings  of  the current study suggested to me that the development of  a collaborative relationship was promoted when nurses, and other health professionals engaged in behaviours that facilitate  self-care  in individuals with HF. The current study confirms  the relevance of  findings  in the current literature that positive self-care behaviours are effective  at decreasing episodes of  decompensation and increasing the sense of  control in individuals with HF. This study also indicated that by taking responsibility for  self-care  behaviours individuals with HF were better able to collaborate with the health care team. Therefore  I recommend that HFC nurses make every effort  to facilitate  the development and maintenance of  positive self-care  behaviours. This may include strategies to increase knowledge about FEF, increase knowledge of  what constitutes positive self-care  behaviour, and explore the potential benefits  of  engaging in these behaviours for  individuals with HF. One strategy that may increase knowledge and prevent confusion  is the avoidance of  technical jargon, which can lead to individuals feeling  intimidated and unable to comprehend self-care  instructions. I also recommend based on the findings  of  the study that providing adequate time for  individuals with HF to ask questions and thereby increase knowledge is key to the development of  successful self-care  behaviours and a collaborative relationship. The reality of  increasing workload challenges nurses to be creative in developing strategies to allow individuals with HF adequate time to ask questions and share experiences of  self-care  behaviours. Strategies such as increased use of  nurse only clinics, alternate forms  of  communication such as telephone and email, and development of  peer support groups could facilitate development of  positive self-management  behaviours. I found  that the current study suggests that adherence to self-care  behaviours is often  difficult  for  individuals with HF, and suggests that nurses must provide strategies to assist the individual in achieving success. Strategies discussed in the literature include suggestions on how to decrease the experience of  thirst, how to incorporate favorite  foods into the diet, and techniques to minimize side effects  of  medications. However, the current literature indicates that health care professionals  frequently  evaluate the success of  collaboration based in terms of  compliance, and some authors report that patients may withhold information  concerning failure  to adhere to self-care  behaviours to prevent feeling  berated or criticized. Therefore  I recommend that nurses working with individuals with HF make every effort  to shift  the focus  from  evaluating compliance to developing a more empowering relationship where successes and challenges can be openly discussed. The current study supports nurses focusing  their resources on promoting self-care behaviours that the client sees as a priority, and limiting interventions for  behaviours that the client does not see as important. One strategy that I recommend that may assist nurses is the development and use of  tools that assess the individuals' readiness to change in relation to various self-management  behaviours. Implications For Education I have found  a number of  implications arising from  the study findings  that are relevant to nursing education. One of  my recommendations for  nursing educators based on the findings  of  the current study is to ensure adequate time is provided for  students to explore the concept of  collaboration, and related concepts such as empowerment and teamwork as it relates to the experience of  individuals with HF. Of  particular importance is the need to be aware that the experience of  collaboration is a complex phenomenon that is unique to each individual. Thus I recommend to educators to promote opportunities for  students to listen to the narratives of  individuals with HF and critically reflect  on the similarities and differences  between the narratives and the current theoretical and empirical literature on collaboration. As the current study indicates there may be discrepancies between theoretical literature and the experience of  individuals with HF collaborating with the health care team Thus nursing students should be given the skills to critically examine the relevance of  current theoretical knowledge in the context of  their practice. One important finding  from  the present study is that use of  communication styles that do not promote collaboration acts as a barrier to collaboration. Therefore  it is my recommendation that nursing educators promote the understanding and use of  attentive and non-intimidating communication styles with students. Additionally students should be encouraged to critically examine theories describing communication and apply these to their individual communication style. The findings  from  the current study also suggests nursing educators should provide students with guidance on how to avoid communication styles that act as a barrier to collaboration. The present study found  that adoption of  self-care  management behaviours by individuals with HF is an important aspect of  collaborating with the health care team as it increases the experience of  sense of  control and contributes to sharing power. Therefore  I recommend that nursing educators provide information  to students on what positive self-care behaviours entail. This should include information  on common self-management behaviours and the rationale for  the behaviours. In addition students should be familiar with theories on adult learning and concepts important to patient teaching. Student should be given the opportunity to apply relevant theories to individual cases, and be encouraged to critically evaluate the relevance of  selected theories. Implications for  Research Finally, I make recommendations based on the findings  of  this study for  future nursing research activities. First the experience of  collaboration for  individuals with HF who do not attend a HFC is poorly understood, and research into this perspective may provide insight into the global experience of  collaboration as experienced by individuals with HF. This may include the experiences of  individuals who are hospitalized for  acute exacerbations, or those who choose not to attend HFCs. Second, due to the exploratory nature of  the current study it was impossible to determine the effects  of  age, gender and race on the experience of  collaboration. Each of these factors  may significantly  influence  the experience of  collaboration. I recommend the need for  further  research designed to explicate the influence  of  each of  these variables on the experience of  collaboration from  the perspective of  individuals with HF. Third, the findings  of  the current study were based on individuals who had been diagnosed with HF for  a minimum of  two years. The influence  of  time since diagnosis is poorly understood on the experience of  collaboration. The experience of  collaboration may be very different  for  those newly diagnosed with HF and suggests opportunities for further  research. The effects  of  the severity of  the symptoms of  HF are also imperfectly understood. Individuals with few  symptoms and infrequent  exacerbations may experience collaboration differently  that those individuals who experience frequent  and severe exacerbations of  HF symptoms. I suggest that additional research may offer  insight into how the experiences may differ  between these individuals. In addition research into this aspect of  the experience may provide guidance for  nurses who care for  individuals with HF. The current study suggests that there is wide variation in the experience of  sharing power as an aspect of  collaboration with individuals with HF attending a HFC. The current study provides some insight into this variation however I suggest that further research into the experience of  sharing power could provide further  insight into the experience. In addition further  research could provide guidance for  nurses as to how best to facilitate  the sharing of  power and thereby empower individuals with HF. Finally, the findings  of  the study suggest further  research into the question I asked in this study. Further research may include further  exploring the relevance of  each of  the major themes identified  as describing the experience of  collaboration, as well as the antecedents and barriers to collaboration from  the perspective of  other individuals with HF attending a HFC. The findings  of  this study would be broadened by theoretically sampling for  individuals who perceive themselves as passive participants in collaboration and comparing such experiences with individuals who perceive themselves as active participants. Broader and more focused  studies such as these would both enrich and broaden the understanding of  the experience of  collaboration for  individuals with HF attending a HFC. Despite the limitations of  this study that were described in chapter one, this study has contributed in a small way to the understanding of  the experience of  collaboration. It has also contributed to nursing knowledge in the fields  of  nursing practice, education and research. The findings  of  this study may contribute to the theoretical understanding of  the concept of  collaboration, and has provided insight into the experience of  collaboration as experienced by individuals with HF who attend a HFC. Thus this contribution to the existing knowledge about the experience of  collaboration from  the individual with HF may provide additional insight into and expand the understanding of  the experience and thereby enhance the care of  similar individuals. 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Appendix A: Participant Information  Letter Study Title: Individuals with Chronic Heart Failure Experience of Collaboration with the Health Care Team: An Interpretive Description Hello I would like to take the opportunity to introduce myself, and the study that I asking you to consider taking part in. My Name is Terina Werry. I am a registered nurse currently working in the Heart Center at St. Paul's Hospital. I am also a student in the Masters of Science in Nursing program in the University of British Columbia. As part of my studies I am currently conducting a study that I hope you will consider becoming a part of. This letter briefly outlines the study; it's purpose, and what you can expect if you choose to participate. My contact information is provided if you would like to discuss the study or would like more information to help you make your decision. Description of the Study Overview I am focusing on the experiences of individuals who are currently patients of the Heart Function Clinic (HFC) at St. Paul's Hospital. I am interested in talking to you about your experiences while you have been a patient in the HFC. I am specifically interested in hearing about your experiences of collaboration with members of the health care team (this can include doctors, nurses, receptionist or dietician). Collaboration can be thought of as you and the health care team working together when making decisions or planning your care. Other people may think of it as being listened to or forming partnerships with the health care team. Why am I interested in looking at your experiences of collaboration? Unfortunately there is not much information available on how people living with heart failure experience collaboration. By talking to you and others living with heart failure I hope to better understand your experiences with collaboration and what that might mean to you. I hope that information from this study may give the members of the health care team a better understanding of this experience and enhance care for all patients living with heart failure. Appendix C Trigger questions: Tell me about your experiences with the people you see at the heart function  clinic Tell me about how decisions are made about your care in the heart function  clinic Tell me about experiences where you felt  involved (or listened to) in decisions made about your care. Tell me about experiences where you did not feel  involved (or listened to) in decisions made about your care. Are there any questions you would like to ask me? Is there anything else I should have asked you? Possible Probing Questions (If  the topic is brought up by the participant) Any number of  things can affect  whether or not you feel  listened to or part of  the team. Tell me about what you felt  needed to be present in you before  you started feeling  that you were being listened to or part of  the team. Tell me about when you felt  ready to be part of  the team and be involved in decisions about your care. Tell me about what the people at the heart function  clinic did to allow you to be come involved in decisions Tell me about what you felt  needed to be present in the people at the heart function  clinic before  you started feeling  that you were being listened to or part of  the team. Tell me what is was about those experiences that made you feel  involved, or part of  the team Tell me about how if  made you feel  when you were involved or part of  the team. Tell me what is was about those experiences that made you feel  not involved, or part of the team 

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