THE core assumption of the model of Relationship Based Care (RBC)* is that those who care for the most vulnerable populations do so because they want to provide care that is competent and compassionate.1 This study of the profile of caring nurses was done prior to implementation of the RBC care delivery model within a professional practice framework at New York-Presbyterian Hospital/ Columbia University Medical Center.
This secondary analysis of the baseline assessment of the work environment before implementation of RBC provides a profile of the nurses who were reported to convey care and love during care delivery. Both qualitative and quantitative data were used to identify the demographics and environmental perceptions of those caregivers who received the highest score of caring as identified by the patients they served. Eighty-five nurses who provided the majority of care to selected patients were paired with those patients to form 85 dyads. Nurses responded to the Health Environment Survey (HES), while patients responded to the Caring Factors Survey (CFS).† Correlations of the 85 pairs were examined to identify the relationship of the nurse's report of the environment to the patient's report of caring. Resultant data may be used for future research to examine the impact of nurses who are effective in caring on patient and organizational outcomes.
This baseline profile analysis and report is part of a larger initiative to integrate the RBC program within patient services at New York-Presbyterian Hospital/Columbia University Medical Center. The RBC program is premised on a patient-centered care delivery model that focuses on relationships among 3 roles: the patient, nurse colleagues, and the nurse-self as caregiver. The specific intention of the program is to create a culture of caring that is pervasive across all employees and processes of New York-Presbyterian Hospital/Columbia University Medical Center. By early 2009, all 23 inpatient units of the New York-Presbyterian Hospital/Columbia University Medical Center will have implemented RBC.
The structure of RBC incorporates a professional nursing practice model, promotes collegial relationships among all members of the team, and provides a framework for the organization of patient care and resource utilization. Collegial relationships within RBC are fostered through the development of unit practice councils on each participating unit. A critical success factor of the RBC change process for all staff involves an educational retreat, Reigniting the Spirit of Caring, a 3-day inspirational/educational experience that enhances awareness of the dimensions of caring essential to RBC and promotes healthy interpersonal relationships.
It is vital for caregivers to understand what patients value in care so they can apply that knowledge in practice to help patients feel cared for. Interviews with more than 6000 hospitalized patients from 62 different facilities revealed that, more than anything, patients desire the “soft” side of healthcare-–a relationship with their care provider(s) during hospitalization.2
Nurses and patients agree that caring behaviors of the nurse enhance the desirable nurse-patient relationship.3 However, studies of patients' and nurses' descriptions of caring relationships indicate that perceptions differ between the two groups.4–12 Hegedus7 found that, at every level of patient anxiety, depression, quality of life, and perception of health, patients desired behaviors that recognized them as individuals and welcomed family involvement, whereas nurses valued helping patients express and/or vent their feelings.7 Larsson et al9 found that patients and nurses did agree that anticipatory and comforting behaviors were among the most important aspects of caring.9
One reason for the difference between patients' and nurses' perceptions of a caring relationship is that the needs for care change during the period of illness, physical care, emotional care, and spiritual care needs come and go as the state of the patient changes. A key related finding in several studies, consistent with Watson's Theory of Caring, was the alignment of patients' needs with Maslow's Hierarchy of Needs. Essential physical needs were reported by patients to be most important to them in the caring relationship, followed by the higher order needs of emotion and love.11,13–15
On the basis of the theoretical framework each respective nurse was taught within nursing school, it has been proposed that nurses care from a variety of perspectives.16 Some researchers have proposed that it is possible that the intentionality of the nurse and patient in the relationship may predict agreed upon caring behaviors.3,17 These proposals and the findings reported below from this study indicate there could be considerably more to learn about differing perspectives of caring behavior.
Healing is related to the patient-caregiver humanistic caring relationship and interaction.18,19 The intent of this study was to create a profile of nurses who are effective in caring within Watson's18,19 recent framework of Caritas: that is, acknowledging caring and love as integral aspects of a dynamic mutual, humanistic caring interaction. Identifying the essential characteristics within such a dynamic patient-nursing humanistic context that portrays caring and love has implications for understanding the power of human health and healing, as well as for gaining knowledge of the environment in which this level of Caritas nursing can occur.
The setting for this study was New York-Presbyterian Hospital/Columbia University Medical Center. Both qualitative and quantitative data, collected using the participative action research (PAR) process, were used to create a profile of caring nurses, consistent with Watson's notion of Caritas and loving kindness as context for healing relationships. Nurses were selected on the basis of the amount of time they cared for a patient during his or her inpatient stay. Patients were selected on the basis of their admission to 6 medical surgical patient units and 1 mental health unit that were about to embark on efforts to integrate RBC to improve care. All study procedures were approved by the institutional review board, and both patients and nurses signed either a paper or an electronic consent to participate.
Measurements of unit-based employee job satisfaction and patients' perception of caring were used to understand the baseline status of nurses and patients in the care delivery environment. In conjunction with the PAR process, the HES was distributed to managers, nurses, nursing attendants, intensive care unit technicians, and unit assistants of each unit studied to understand the unique aspects of the work environment as perceived by these respective staff members. The HES is a valid and reliable 86-item instrument used to obtain staff members' perception of the work environment, including relationships with coworkers, unit manager, physicians, and nurses, professional patient care, autonomy, staffing and scheduling, executive leadership, learning opportunities, organizational rewards, pride in the organization, intent to stay with the organization, and workload. Nurses used a 7-point Likert-type scale to report degree of disagreement or agreement with the statements provided. An example of a question from the HES is, “My nurse manager often gives me recognition for a job well done.” The more staff agrees with the statement, the higher the score, whereas disagreement is noted by lower scores. Respondents can use the number “4” to denote neutrality. Reliabilities of the HES have been shown to perform adequately in reliability testing (Chronbach α = .96).20
The HES also has questions about staff demographics, hours worked, and employee disposition. The instrument collects responses to statements about what staff enjoy about their work, what creates the most stress for them within their work, what makes them want to leave the organization, and what makes them want to stay. Responses to each of the 4 statements were examined for themes.
The second instrument used in the study, the CFS, is a 20-item instrument used to assess patients' perception of the care received from nurses who indicated a caring and loving consciousness toward them as a whole person, including unity of mind-body-spirit. An example of a question from the CFS is, “When my caregivers teach me something new, they teach me in a way that I can understand.” The CFS, like the HES, used a 7-point Likert-type scale with the same methods for scoring degree of agreement or disagreement. The CFS was developed to reflect Watson's most recent theory of Caritas, which incorporates and extends her original caritive factors as the core of professional nursing.19 Reliabilities of the CFS have been shown to perform adequately in reliability testing (Chronbach α = .97).20 For purposes of this study, the higher the score reported by the patient on the CFS, the more evidence of Caritas was inferred. That is, the patient viewed the more caring nurses as those who honored their individual wholeness and unity of mind-body-spirit.
To create a profile of nurses whom patients reported to be the most caring, dyads consisting of a patient and his or her nurse were formed, and data from the 2 instruments were linked for each dyad. Correlation tables were used, using Pearson's r, to identify what environmental and demographic data as reported by nurses related to the CFS scores of patients within the 85 dyads. The primary interest was to understand which nurse factors related to the CFS score. Descriptive statistics and comparisons of environmental and demographic data using t tests and analysis of variance were used to understand nurses who received high scores of caring by the patients they cared for.
Qualitative data from the HES was themed and examined for factors reported most often by nurses who received a high score from the patient they cared for. Because of the sample size of 85 patients-nurse pairs, the analysis required an α of .15, power of 0.8, and effect size of 0.25.
Results were later presented to managers and staff from the participating units. The PAR process was used to design, collect, examine, and interactively present the findings in relationship to the operations and infrastructure. The outcomes from this research will assist the application of findings into the process of organizational improvements. In addition, managers and practitioners may be able to provide useful interpretation of the data and how it coincides with their daily operations that the researchers who conducted this study were previously unaware of.
Both the HES and the CFS used in this study provided good reliability, with a Chronbach α of .95 and .97, respectively. The only subscales within the HES that fell below .70 were staffing and scheduling, disposition, and intent to stay, which revealed a Chronbach α of .58, .56, and .65, respectively.
The researchers examined both quantitative and qualitative demographic data about nurses who received high scores on the CFS to create a profile of nurses who were effective in caring. Data from nurses with high scores on the CFS were compared with data from nurses with low scores on the CFS.
The cumulative findings were used to create a profile of nurses who were perceived as caring by the patients for whom they provided care. Nurses reported to be caring by their patients were found to:
- report the greatest frustration with every work environment variable measured, especially workload;
- have the most hospital and professional experience;
- work their scheduled hours of work, not more than scheduled hours;
- be of any age, not just older or younger nurses;
- be the most affected by stress in the relationship with the patient, especially “difficult patients”;
- be those who most enjoyed coworker relationships; and
- be those who most often provided continuity of patient care from admission through discharge to the respective unit.
Patients within this study were hospitalized from 1 to 27 days, with a mean (average) number of hospital days of 7. It should be noted that a mental health unit was included within this study, thus extending the mean value. The mode (most commonly reported number) was 2 days in the hospital. Nurses who were paired with these patients were the primary care provider anywhere from 1 to 16 of the days the patient was hospitalized.
DISCUSSION AND IMPLICATIONS
There were several unexpected and interesting results in this study. Primary among these is the negative relationship of every variable in the HES with the CFS. These negative relationships were previously identified by one of the authors of this study in a study of caring and the work environment that was conducted for another organization. However, the findings from that study were thought to be possibly due to chance because of a small sample size (8 units), with the unit as the level of analysis. The current data reveal similar negative correlations of the HES with the CFS, but with a much larger sample size, while using dyads of nurses and patients. The authors of this study speculate that nurses who received the highest CFS level of caring/love may be frustrated because the healthcare environment and practices are incongruent with values and goals of caring. Furthermore, frustration among high scoring CFS nurses may also arise from recognizing that authentic caring (“Caritas nursing”) takes more time and resources than are available.
These findings of a negative correlation between CFS and HES factors warrant further inquiry and hypothesis testing. Authors of this study seek to repeat the above study with additional controls to validate that the caring is contained within the humanistic interaction of the patient and the nurse. In addition, New York Presbyterian Hospital/Columbia University Medical Center is seeking to increase continuity of care by implementation of primary nursing within a model of RBC and restudy the impact of continuity of care on the perception of caring as reported by the patient.
The authors of this report proposed that understanding the profile of “Caritas nurses” (those who receive high scores from their patients on the CFS) is an essential step to understanding and refining work environment systems and processes of caring and healing. Results were presented to managers and staff to identify the findings within each participating unit that are most meaningful for relationships between nurses and patients on that unit. Success factors and needs, which varied from unit to unit, were used to create action plans and allocate resources on the basis of unit-specific operational strengths and vulnerabilities.
There were few limitations to this study. This is the first study the authors are aware of that has examined the attributes of nurses who are reported to be effective in caring by the patients they care for. Because this is such a new area of inquiry, mid-range theory about caring attributes is also in its very early and developmental stages. Because the theoretical structures are not yet fully developed, there are several potentially confounding variables that were not measured, as they do not yet have a “placeholder” within any proposed theoretical structure. Another limitation is that liberal statistical parameters were used, including an α of .15, power of 0.80, and effect size of 0.25. These liberal parameters were required because of the small sample size of 85 patient-nurse pairs.
Creating a profile of so-called “Caritas nurses,” who are reported by patients to be effective in caring, has implications for further testing of the theory that caring and love are important, if not critical, elements of healing and patient outcomes. Furthermore, understanding the characteristics of a “Caritas nurse” may assist educators in their evaluation and development of a curriculum that seeks to prepare future nurses in Caritas competencies consistent with patient needs and new professional practice models of caring-healing. In addition, preceptors who understand competencies in caring will be able to coach new nurses according to what has become understood about the profile of effective caring. Lastly, findings from future studies that connect the profile of effective caring to patient outcomes such as healing, pain control, symptom management, and length of stay can be used to show the relationship between caring and cost outcomes. These data can be used in helping hospitals and practitioners alike to restore core values and practices of caring back into healthcare.
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*Relationship Based Care is a program of Creative Health Care Management, Minneapolis, Minn.
†The copyright for the HES is owned by Healthcare Environment. The copyright for the CFS is co-owned by John Nelson, Jean Watson, and Inova Health System.