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The importance of nurse caring behaviors as

perceived by patients receiving care at an


emergency department
Gy∂⁄ a Baldursdottir, MS, RN,a and Helga Jonsdottir, PhD, RN,b Reykjavik, Iceland

BACKGROUND: Increased workload at the emergency department (ED) and the shortage of nurses
may leave some patients without proper care. The importance of patients’ perceptions of caring is vital
when organizing nursing practice under such circumstances.
PURPOSE: The purpose of the study was to identify which nurse caring behaviors are perceived by
patients in an ED as important indicators of caring. The nurse caring behaviors were categorized in
terms of relative importance with respect to demographic variables and perceived illness. Watson’s the-
ory of caring was used as a theoretic framework for this quantitative and descriptive study.
METHOD: A 61-item questionnaire designed on the basis of Cronin and Harrison’s Caring Behaviors
Assessment tool, which reflected the 10 carative factors of Watson’s theory, was mailed to 300 ED
patients. The response rate was 60.7%.
RESULTS: Results showed that subjects scored the items “Know what they are doing”, “Know when
it is necessary to call the doctor”, “Know how to give shots, IVs, etc.”, and “Know how to handle equip-
ment” as the most important nurse caring behaviors. The subscale “human needs assistance” was
ranked highest.
CONCLUSION: In line with several previous studies, subjects considered clinical competence to be the
most important nurse caring behavior, which further emphasizes the notion of caring as a moral stance
integral to all interactions with patients. (Heart Lung® 2002;31:67-75.)

D eclining quality of hospital care is of great


concern to patients and health workers
alike. Hospitals are increasingly functioning
with far too limited resources. Increased demand
This situation exists particularly in emergency
departments (EDs). Rising patient admissions,
longer stays in the ED because of lack of hospital
beds in medical and surgical units, and premature
for cost-effective hospital management and steadi- discharge have made nurses question their capac-
ly growing numbers of older patients, who present ity to meet the needs and expectations of patients.
new and more complex health problems, has Increasing workloads make nurses prioritize care to
raised concerns as to where health care service is the most seriously ill patients, which risks leaving
going. Rising numbers of patient admissions to some patients neglected; however, neglect is unac-
hospitals, cuts in the number of hospital beds, and ceptable to both nurses and patients. Increasing
an increasing shortage of nurses only aggravate this patient consumerism only adds to the prevailing
situation and thrust much of management’s frustra- pressure on health care workers, leaving little or no
tions to the hospital units where there is limited leeway for mistakes.5-7
margin for increased productivity.1-4 Patients’ perceptions of how they want to be
cared for is reflected in many studies on quality of
From the aEmergency department at University Hospital and care.6,8-16 Complaints of poor attitude among
bUniversity of Iceland and University Hospital.
health care workers toward patients appear to be
Reprints are not available from author.
increasing in Iceland because of the perception
Copyright © 2002 by Mosby, Inc.
0147-9563/2002/$35.00 + 0 2/1/119835 that health care professionals are increasingly dis-
doi:10.1067/mhl.2002.119835 tancing themselves from patients and giving

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Nurse caring behaviors Baldursdottir and Jonsdottir

impersonal care.17 It is, therefore, of the utmost human trait, reflecting caring as “a part of human
importance to know how Icelandic patients per- nature, and essential to human existence.”30 In the
ceive hospital nursing care and to compare these second category, caring is regarded as a moral
results with previous studies on the subject, imperative or ideal and referred to as a fundamen-
because nursing care is the single most significant tal value in nursing. The emphasis is on preserving
factor in the patient’s perception of high-quality the individual’s dignity or integrity. The third cate-
hospital care.9,18-23 gory emphasizes that the nature of caring has its
origin in emotional involvement and compassion-
LITERATURE REVIEW ate or empathic feeling for the patient’s experi-
Caring as a concept ence. This perspective reflects nursing as a female
profession with historical roots in religion. The
Caring as an essential element of nursing is fourth category considers caring to be an interper-
widely accepted among nurses.24-28 Nurses’ caring sonal relationship and indicates that caring is a
approach is believed to enhance the patient’s mutual endeavor of the nurse and the patient,
health and well-being and to facilitate health pro- encompassing both the feelings and the behaviors
motion.10,25,29 As yet, no universal definition or con- that occur within relationships. Caring as a thera-
ceptualization of caring exists,30,31 but several have peutic intervention is the last category; it is
been put forward. One of these is Watson’s theory patient-centered and action-oriented. As Morse et
of caring. al30,32 pointed out, it is difficult to locate writings on
Underlying Watson’s theory is a value system on caring in the nursing literature that encompass only
the basis of deep respect for the wonders and mys- 1 of these categories. Watson’s theory may primari-
teries of life.28 Recognition and acknowledgment of ly be considered a moral ideal, but it also stresses
the value of caring in nursing practice come before the notion of caring as an interpersonal relation-
and presuppose actual caring. The essence of the ship and therapeutic intervention.
theory is reflected in Watson’s proposition of caring
as the moral ideal of nursing, in which the result is Nurse caring behaviors
enrichment and protection of human dignity. This Cronin and Harrison10 were the first to develop
ideal involves values, will and commitment, knowl- an instrument that they named the Caring Behavior
edge, caring actions, and consequences. These Assessment (CBA) tool, on the basis of Watson’s
premises guide nursing practice and are manifest- theory, that reflects Watson’s carative factors. The
ed in it, particularly as they relate to the nurse instrument consists of 63 nursing behavior indica-
being responsive to the uniqueness of each indi- tors distributed across 7 subscales, instead of the
vidual and to the preservation of feelings for oth- 10 described by Watson. The subscales are human-
ers.28 The following 10 carative factors, combined ism/faith-hope/sensitivity, helping/trust, expression
with a scientific knowledge base and clinical com- of positive/negative feelings, teaching/learning, sup-
petence, guide nursing actions to promote health, portive/protective/corrective environment, human
prevent illness, care for the sick, and restore needs assistance, and existential/phenomenologi-
health: humanistic-altruistic system of values; faith- cal/spiritual forces. The tool was used in this study
hope, sensitivity to self and others; helping-trust- as the operationalization of the caring concept.
ing, human care relationship; expressing positive Four previous studies using the CBA instrument
and negative feelings; creative problem-solving have been done, all in the United States (Table I).
caring process; transpersonal teaching-learning; Thus this is the first international study using the
supportive, protective, and/or corrective mental, CBA tool.
physical, societal, and spiritual environment; human As Table I shows, the item “Know what they are
needs assistance; and existential-phenomenologi- doing,” which belongs to the humanism/faith-
cal–spiritual forces.27 hope/sensitivity subscale, scored highest as a sin-
In addition to Watson, many researchers have gle item in 4 of 5 studies and “human needs assis-
conceptualized the caring of nurses from a variety tance” rated highest as a subscale. The study that
of perspectives. In an attempt to synthesize the dif- deviated from the group showed that patients
ferent perspectives into a coherent structure, with HIV/AIDS regarded “treat me as an individual”
Morse et al30,32 analyzed the content of 35 authors’ as the most important item.15 According to
definitions of caring and the main characteristics of Mullins,15 the results indicated that, because of the
each perspective. Five categories of caring were nature of the disease, persons with HIV/AIDS might
identified. The first category describes caring as a be in more need of being accepted and cared for

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Baldursdottir and Jonsdottir Nurse caring behaviors

Table I
Studies using the caring behaviors assessment tool (CBA)

Results

Most important Highest ranked


Authors Subjects (No.) CBA item CBA subscale

Cronin and Patients after myocardial 1. Know what they are 1. Human needs
Harrison, 1988 infarction (22) doing assistance
2. Make me feel someone is 2. Teaching/learning
there if I need them
Huggins, Gandy, Patients visiting ED 1. Know what they are doing 1. Human needs assistance
and Kohut, 1993 (288) 2. Know how to handle
sudden emergencies
Parson, Kee, Perioperative 1. Know what they are doing 1. Human needs assistance
and Gray, 1993 patients (19) 2. Be kind, considerate 2. Teaching/learning
Mullins, 1996 HIV/AIDS patients (46) 1. Treat me as an individual Not reported
2. Know what they are doing
Marini, 1999 Older adult residing in 1. Know what they are doing 1. Human needs assistance
institutional settings (21) 2. Know when it is necessary 2. Humanism/faith-hope/
to call the doctor sensitivity

with respect and dignity than various other groups by Cronin and Harrison,10 referring to “Those things
of patients. that a nurse says or does that communicate caring
to the patient.”
STUDY PURPOSE AND RESEARCH
QUESTIONS Assumptions
The purpose of the study was to identify nursing The following assumptions were made:
behaviors that patients perceived to be indicators 1. Basic components of nursing care provided
of caring in the ED and to categorize these indica- in the ED where the study took place are the
tors in terms of relative importance. same for each patient, regardless of which
The following research questions are the basis nurse provides the care.
for the study: 2. Potential participants are able to identify the
1. Which nurse caring behaviors are perceived professional status of the nurses as distinct
as most important and least important by from both licensed practical nurses and
patients in the ED? nursing students.
2. Do patients’ perceptions of nurse caring
behaviors differ according to demographic METHODOLOGY
factors, that is, age, residence (capital city vs Study design
outside the capital city area), educational
level, gender, and perception of illness? This study was a nonexperimental, quantitative,
descriptive study using an instrument developed
Theoretic definitions and applied earlier by Cronin and Harrison.10
The definition of caring used in this study is the Although in part a replication study, this study dif-
one used by Cronin and Harrison,10 originating fers from Cronin and Harrison’s work in that it was
from Watson28: “Caring is the process by which the conducted on the basis of a much larger sample
nurse becomes responsive to another person as a size with a broad range of illness experiences and
unique individual, perceives the other’s feelings, age spectrum. This study was also carried out in a
and sets that person apart from the ordinary.” The health care system different from the previous one
definition of nurse caring behaviors was developed (ie, in Iceland). The University Hospital in Reyk-

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Nurse caring behaviors Baldursdottir and Jonsdottir

javik, Iceland (UHI) was chosen as a place of entry, known to the person by whom he or she is being
the ED in particular because of the variety of addressed. The second item is “Visit me if I move
patients who visit it, many of whom are entering the to another hospital unit,” which was not relevant,
hospital, a strange and unfamiliar environment, for because to be included in the study one had to be
the first time. discharged home after the ED visit. The items in
each subscale ranged from 3 to 12, and the 2
Sample and setting dropped items in the Icelandic version were both
The population was defined as adult patients from the same subscale, helping/trust, which con-
who received service in the ED at UHI. The sample tains 9 items in the present study instead of 11 as
was a nonprobability convenience sample of adult in Cronin and Harrison’s study.10
patients (18 years or older) who received care in The instrument, now consisting of 61 items, was
the ED at UHI during a 1-month period and were pilot tested with 20 patients aged 20 to 75 years,
discharged from the ED without being admitted to but these results were not incorporated into the
another hospital unit. Patients admitted to other main study. Several minor comments were submit-
hospital units were excluded to avoid influence ted and some used for revision, such as sugges-
from care received at other units. tions about the layout of the instrument.
A list with the names of prospective participants
was obtained from the ED at UHI after approval Procedure
from the Ethical Committee of UHI. Three hundred Subjects were requested to rate their percep-
patients who were admitted to the ED during 1 tion of each of the nurse caring behavior items on a
month fulfilled the above criteria. The instrument, 5-point, Likert-type scale of relative importance. In
in the form of a questionnaire, was mailed to their addition, patients were given an opportunity in the
homes. questionnaire to make brief additional remarks to
the open-ended question of whether there was
Instrumentation anything else that nurses could say or do to make
The instrument that was used for data collection the patients feel cared for. Demographic informa-
was a questionnaire developed by Cronin and Har- tion on age, residence, gender, and education was
rison, the CBA tool, described earlier. Cronin and collected as well. Responses to the open-ended
Harrison10 established face and content validity of question did not add new perspectives to the
the CBA tool using a panel of 4 content specialists responses in the questionnaire itself and have
who were familiar with Watson’s theory. Internal been omitted from this article.
consistency reliability was determined by using the Two weeks after being discharged, every patient
study sample responses to calculate Cronbach α in the sample received an envelope in the mail
for each of the 7 subscales. Cronbach α ranged from that contained the following:
0.66 to 0.90. In the present study, internal consis- 1. A questionnaire
tency reliability was determined in the same way, 2. A letter from the first author that explained
with reliability coefficients ranging from 0.69 to 0.89. the study and requested the patient’s con-
In translating the CBA tool from English to Ice- sent to participate in the study. If the
landic, attempts were made to account for transla- patient decided to answer the questionnaire
tion equivalency, congruence in value orientation, and return it, this was considered to be
and careful use of colloquialism.33 Three bilingual signed consent.
nurses who were familiar with the topic made the 3. A return envelope, stamped and addressed,
translation into Icelandic. Two bilingual persons for the patient to return the completed
were then asked to make sure that the Icelandic questionnaire.
version was understandable for a layperson. Then 2 Two weeks later, a follow-up letter and a new
bilingual persons, a nurse and a non-nurse familiar copy of the questionnaire were sent to the
with the topic, but not familiar with the English ver- patients, urging the return of the questionnaire.
sion, back-translated the Icelandic version. Finally, After 2 more weeks, a third and last letter and a
the group of 7 persons refined both transla- new copy of the questionnaire were sent out, again
tions.33,34 The group agreed that 2 items should be urging a return.
omitted from the Icelandic version: The first item is The mailing of 300 questionnaires resulted in a
“Ask me what I like to be called,” because in Ice- 60.7% (n = 182) response rate usable for data analy-
land everyone is called by his or her given name sis. Of the 300 prospective participants, 56.7% (n =
and not by family name, regardless of whether 170) were women and 43.3% (n = 130) were men. Of

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Baldursdottir and Jonsdottir Nurse caring behaviors

Table II
The mean and standard deviation (SD) for the 10 most important nurse caring behaviors

Item Mean (SD)

1. Know what they are doing 4.94 (0.28)


2. Know when it is necessary to call the doctor 4.93 (0.26)
3. Know how to give shots, IVs, etc. 4.91 (0.39)
4. Know how to handle equipment 4.91 (0.36)
5. Answer my questions clearly 4.85 (0.41)
6. Treat me as an individual 4.83 (0.40)
7. Give my treatments and medication on time 4.83 (0.43)
8. Do what they say they will do 4.80 (0.45)
9. Be kind and considerate 4.77 (0.53)
10. Check my condition very closely 4.77 (0.52)

Table III
The mean and standard deviation (SD) for the 10 least important nurse caring behaviors

Item Mean (SD)

1.Talk to me about life outside the hospital 3.15 (1.23)


2.Touch me when I need it for comfort 3.78 (1.19)
3.Praise my effort 3.81 (0.99)
4.Know when I have “had enough” and act accordingly 3.87 (1.08)
(for example, limiting visitors)
5. Help me understand my feelings 3.88 (1.12)
6. Be sensitive to my feelings and moods 3.99 (0.95)
7. Ask me how I like things done 4.02 (0.94)
8. Encourage me to talk about how I feel 4.03 (1.00)
9. Help me plan for my discharge from the hospital 4.03 (0.99)
10. Encourage me to believe in myself 4.09 (0.96)

the 182 usable questionnaires, 57.1% (n = 104) were according to the demographic variables of age,
from women and 42.9% (n = 78) were from men par- gender, residence, educational level, and per-
ticipants. ceived illness. The level of significance (α) was set
at P < .05.
Data analysis
Mean scores and standard deviations were cal- RESULTS
culated for each questionnaire item to find the Ratings of CBA items
most and least important nurse caring behaviors
and item variability. All items were then grouped For each of the 61 items in the CBA tool, mean
into subscales and the overall mean for each indi- scores and standard deviations were calculated.
vidual was calculated for each subscale. Overall Summaries of the 10 most important and 10 least
item means for each of the subscales were also cal- important behaviors are listed in Tables II and III.
culated to determine the rank distribution of the Means ranged from a high of 4.94 for the most
subscales. The nonparametric Mann-Whitney U important item (“Know what they are doing”) to a
test and Kruskal-Wallis one-way analysis of vari- low of 3.15 for the least important item (“Talk to me
ance were used to examine response to the CBA, about my life outside the hospital”).

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Nurse caring behaviors Baldursdottir and Jonsdottir

Table IV
Ratings for the CBA subscales

Rank Subscale No. of items Mean (SD)

1 Human needs assistance 9 4.68 (0.379)


2 Supportive/protective/corrective environment 12 4.41 (0.655)
3 Teaching/learning 8 4.38 (0.612)
4 Humanism/faith-hope/sensitivity 16 4.35 (0.483)
5 Helping/trust 9 4.32 (0.523)
6 Existential/phenomenological/spiritual forces 3 4.27 (0.784)
7 Expression of positive/negative feelings 4 4.12 (0.756)

Table V
Results of subscale comparisons by sex and residence

Sex Residence

Subscale U P U P

1. Humanism/faith-hope/sensitivity 2966 .002* 1383 .446


2. Helping/trust 3268 .025* 1510 .859
3. Expression of positive/negative feelings 3132 .008* 1142 .059
4. Teaching/learning 3500 .112 1360 .383
5. Supportive/protective/corrective environment 2886 .001* 1521 .899
6. Human needs assistance 2939 .002* 1214 .123
7. Existential/phenomenological/spiritual forces 3353 .054 1.356 .383

U, Mann-Whitney U test.
*P < .05.

Ratings for the CBA subscales to gender and residence, demonstrate that women
When items had been grouped into the 7 sub- score significantly higher than men in subscales 1,
scales, a mean for all items in each subscale was 2, 3, 5, and 6 (Table V) and that no significant resi-
calculated for each patient. The overall subscale dential differences were found with respect to any
means and standard deviations for each subscale of the subscales.
were then calculated on the basis of the patient The results of the Kruskal-Wallis one way analy-
means. The subscale rating is shown in Table IV, sis of variance on the subscales in relation to age,
demonstrating that “Human needs assistance” is educational level, and how the subjects perceived
the most important subscale and “Expression of their illness (Table VI) showed significant age differ-
positive/negative feelings” is the least important. ences for every subscale (ie, the higher the age of
subjects’, the greater the importance of nurse caring
Differences in perceptions of caring behaviors). Significant educational differences were
Seven subscales that measure nurse caring found for subscales 1, 3, 4, and 7. Subjects with low
behaviors were compared with perceived illness educational levels scored significantly higher on
and 4 demographic variables: gender, residence, these 4 subscales. No significant differences were
age, and education (Tables V and VI). The results of found for subscales 1 to 7 with respect to how sick
a Mann-Whitney U test on the subscales, in relation the patients perceived themselves to be.

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Baldursdottir and Jonsdottir Nurse caring behaviors

Table VI
Results of subscale comparison by age, education, and perceived illness

Age Education level Perceived illness


(df = 7) (df = 5) (df = 3)

Subscales χ2 P χ2 P χ2 P

1. Humanism/faith-hope/sensitivity 24.3 .001* 11.1 .049* 0.7 .881


2. Helping/trust 17.2 .016* 7.5 .189 2.2 .536
3. Expression of positive/negative feelings 23.0 .002* 12.0 .034* 1.3 .732
4. Teaching/learning 19.6 .007* 11.3 .046* 0.6 .891
5. Supportive/protective/corrective environment 21.8 .003* 7.0 .220 0.8 .852
6. Human needs assistance 20.6 .004* 5.9 .314 0.7 .875
7. Existential/phenomenological/spiritual forces 41.2 .000* 16.7 .005* 2.7 .445

Kruskall-Wallis one-way ANOVA.


df, Degrees of freedom.
*P <.05.

DISCUSSION tant because they also yield relatively high scores.


Results of this study show that the single most Despite this, behaviors related to physical care and
important item perceived by subjects is “Know what monitoring of patients are prioritized, whereas
they are doing,” which supports results from 4 of the aspects related to emotional and spiritual needs
5 previous studies that have used the CBA tool.10,13,14,16 were seen as less important, as has been discussed
These results also support several qualitative stud- earlier.
ies carried out in different settings.11,12,35-37 In all of Age correlated significantly with scores on all
these studies, patients prioritized the clinical com- subscales. The older the subjects, the more impor-
petence of the nurse. These results support Watson’s tant were the nurse caring behaviors. This finding
notion27,28 of caring as being manifested in actions may be explained by the fact that with increasing
for and on behalf of patients, in which the result is age, the need for health care increases. Elderly peo-
enrichment and protection of human dignity. In ple may generally feel vulnerable and thus may be
accordance with these results, the subscale “human particularly sensitive to receiving attentive assis-
needs assistance” ranked highest in this study, as in tance. For people who are at higher risk of getting
several others.10,13,14,16 The “human needs assis- diseases it may be of particular importance to know
tance” subscale contains 9 items, 5 of which belong that their health care providers are professionals
to the 10 most important nurse caring behaviors who are competent and ready to take care of them.
found in this study. The prominence of assistance Female participants scored significantly higher
with fulfilling human needs in the findings indicates than male participants in 5 of 7 subscales, which
that the nurse reveals the moral stance of caring accords with the notion that females have a better
through actions that are taken to respond to the conception of caring than males.39,40 Significant dif-
uniqueness of each individual, primarily the gratifi- ferences were also found on 4 subscales with
cation of unmet physical needs and the monitoring of regard to educational level, in which subjects with
patients.27,28 Caring is therefore not something the lower education scored higher on the importance
nurse reveals after finishing basic nursing care; rather, of nurse caring behaviors. This may be linked to the
in quality nursing practice, caring and competence fact that females scored higher and they might, on
necessarily coexist.25 average, have received less education than males.
Although substantial differences in means exist Results from this study, with regard to age, gender,
between the 10 most important nurse caring and educational level, differ from Cronin and Harri-
behaviors (4.77-4.94) and the 10 least important son’s study,10 in which no significant differences
ones (3.15-4.09), it is not appropriate to assume were found. This difference may be explained by
that the 10 least important items are unimportant the small sample size and relative homogeneity of
for the patients. These items certainly are impor- the sample in Cronin and Harrison’s study.

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Nurse caring behaviors Baldursdottir and Jonsdottir

No significant differences were found among cient caring for patients. These results do not sup-
subjects with regard to residence or the way in port the belief that more time is necessarily need-
which subjects perceived the seriousness of their ed in order to care. However, a caring moment can
illness. This finding is different from the findings of be created when the nurse is morally conscious
Huggins, Gandy, and Kohut,13 who demonstrated and authentically present with patients in fulfilling
that patients who were classified as “non-urgent” their unmet needs, utilizing his or her knowledge
had higher expectations than patients in the emer- base and clinical competence.27,28
gent group. The results of this study indicate that, Further studies that use the CBA tool are recom-
irrespective of the seriousness of their illness, mended to study how patients who stay for more
patients feel the same need to be cared for. Pro- than 24 hours at the hospital perceive nurse caring
fessionals should be aware of this need because behaviors. Patients’ perceptions of nurse caring
there is a tendency to minimize patients’ com- behaviors in settings outside the ED would also be
plaints if they are not considered to be seriously ill. useful, as would comparisons of the perceptions of
Patients are, however, entitled to high quality care, patients who have been in a hospital more than
regardless of the professional’s perception of the once with patients who are experiencing their first
seriousness of their illness. hospital stay.
Studying children as patients to find out which of
LIMITATIONS the nurse caring behaviors they and/or their par-
This study was limited to patients who received ents perceive as important could yield interesting
service at 1 department at 1 hospital. Furthermore, results and provide insight into whether children
the sample was a convenience sample; therefore have special needs with relation to caring. It could
results cannot easily be generalized to the ED pop- also be interesting to combine a study like this with
ulation at large. However, the results of this study a qualitative study in which interviews would give
are in many ways similar to and, to a large extent, insight into the various aspects of caring.
supportive of the results of comparable studies Nurses maintain that caring increases patients’
elsewhere. Participation is also limited to persons well-being.25,28 More general studies are needed to
who can read and write the Icelandic language and explain the ways that caring affects patient’s out-
are 18 years of age or older, thus excluding a con- comes and to demonstrate the effectiveness of car-
siderable portion of the patients (ie, children and ing on patient’s outcomes. Caring is an integral
their parents). The most seriously ill patients are component of nursing and studies on caring should
likely to have been transferred to other units of the be at the forefront of future nursing research.
hospital and were therefore excluded from the
study.
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