What kind of nurses do patients want?

Public perception and the social and microbiological significance of uniforms in the prevention and control of healthcare-associated infections: an evidence review

Background: There is significant public concern in England about health carers wearing uniform in public places and that contaminated uniforms may contribute to the spread of healthcare-associated infections (HCAI). Evidence of a link between contaminated uniforms and HCAI, or that wearing uniforms in public spaces may contribute to the spread of infection from the healthcare environment to the wider community, has not previously been systematically assessed.

Methods: A comprehensive review was conducted that focused on patient perceptions of the significance and infection risks of uniforms and microbiological and clinical evidence of the infection risks to patients from contaminated uniforms.

Results: Uniforms play an important role in the public's perception of healthcare professionals. This is constructed from social and cultural images leading patients to judge the professionalism and trustworthiness of practitioners based on the clothes they wear. The colour and design of uniforms may reinforce socially constructed concepts of cleanliness that result in unachievable expectations. Evidence directly related to the laundering of uniforms is limited. Small scale studies show that uniforms and white coats become progressively contaminated during clinical care and most microbial contamination originates from the wearer of the uniform. Although some studies theorise that uniforms may transmit HCAI, no studies demonstrated this in practice. A small number of studies evaluated the phases of the wash cycle in hospital laundries for patient linen but not uniforms. They indicate that micro-organisms are removed and killed during laundering, and dilution during washing and rinsing is important. Significant reductions in micro-organisms occur at lower temperatures more commonly used in home laundering. A small number of studies show that home laundering provides effective decontamination. We found no recent studies that accounted for advances in domestic washing machine and detergent technology or that addressed the theoretical infection risk linked with wearing uniforms in public places.

Conclusion: Despite the limited amount and quality of the evidence, the general public's perception is that uniforms pose an infection risk when worn inside and outside clinical settings. This is reinforced by media comment and a lack of clear, accessible information and may have a damaging effect on the relationship between professionals and patients and the public image of healthcare workers. There is no good evidence to suggest uniforms are a significant risk, that home laundering is inferior to commercial processing of uniforms or that it presents a hazard in terms of cross-contamination of other items in the wash-load with hospital pathogens. It is essential that the evidence is considered in a balanced way and not over-emphasised in the development of uniform policy and that the general principles of infection control are stressed.

Pain: a quality of care issue during patients' admission to hospital

AIM

To determine the extent of clinically significant pain suffered by hospitalized patients during their stay and at discharge.

BACKGROUND

The management of pain in hospitals continues to be problematic, despite long-standing awareness of the problem and improvements, e.g. acute pain teams and patient-controlled analgesia, epidural analgesia. Poorly managed pain, especially acute pain, often leads to adverse physical and psychological outcomes including persistent pain and disability. A systems approach may improve the management of pain in hospitals.

DESIGN

A descriptive cross-sectional exploratory design.

METHOD

A large electronic pain score database of vital signs and pain scores was interrogated between 1st January 2010 and 31st December 2010 to establish the proportion of hospital inpatient stays with clinically significant pain during the hospital stay and at discharge.

FINDINGS

A total of 810,774 pain scores were analysed, representing 38,451 patient stays. Clinically significant pain was present in 38·4% of patient stays. Across surgical categories, 54·0% of emergency admissions experienced clinically significant pain, compared with 48·0% of elective admissions. Medical areas had a summary figure of 26·5%. For 30% patients, clinically significant pain was followed by a consecutive clinically significant pain score. Only 0·2% of pain assessments were made independently of vital signs.

CONCLUSION

Reducing the risk of long-term persistent pain should be seen as integral to improving patient safety and can be achieved by harnessing organizational pain management processes with quality improvement initiatives. The assessment of pain alongside vital signs should be reviewed. Setting quality targets for pain are essential for improving the patient's experience.

Understanding the paradox of patient pain and patient satisfaction

Pain, in all probability, is the most common symptom experienced by individuals who interact with health care providers. It is understood as a complex and highly individual experience. This complexity is reflected in the paradoxical relationship between patient satisfaction and patient reported pain scores. Using a holistic, caring approach, nurses can optimize the effect of analgesia and facilitate comfort for the person living in pain. Caring for the patient in pain begins with heartfelt compassion and intention to help the person who is suffering. The author describes how the complex relationship and interchange between the patient and the holistic nurse explains the paradox.

An investigation into the information received by patients undergoing a gastroscopy in a large teaching hospital in Ireland

The purpose of this article is to examine the information received by patients undergoing a gastroscopy. The growing number and complexity of day-case endoscopy increases the need for quality patient information. Provision of patient information reduces anxiety, increases knowledge, improves cooperation during endoscopy and increases compliance with discharge instructions. The study used a descriptive survey with convenience sampling (response rate 66%, N = 137). Patients received most of the standard procedural information (how and why the procedure is carried out), but they received considerably less sensory information (information regarding what they would hear, feel, smell, etc.). In addition, age and gender appeared to affect the amount of information received. Older patients received more procedural information than younger patients, and male patients received more information than female patients. The nurse was the main source of information. The majority of patients (>80%) received adequate information and were satisfied with the information received. Patients also received most of the information verbally on the day of the procedure rather than before admission. This study identified the need for patient information leaflets. The role of the nurse and the effect of age and gender on information provision are important considerations for healthcare professionals.

Caring in nursing: investigating the meaning of caring from the perspective of cancer patients in Beijing, China

AIMS

The aims of the study were to develop an understanding of caring in nursing from the perspective of cancer patients and attempt to identify the concept of caring in the Chinese cultural context.

BACKGROUND

Caring as a concept remains elusive, the acceptable definitions of the term care have not been reached. The expressions, processes and patterns of caring vary among cultures, but there is a lack of Chinese culture-based study about caring in nursing.

METHODS

A qualitative research design was used and 20 cancer patients were interviewed using a semi-structured interview guide. A qualitative content analysis was used to identify themes in the data.

RESULTS

Three themes emerged from the data, which suggested that caring is delivering care in an holistic way: nurses' caring attitudes and their professional responsibility for providing emotional support, nurses' professional knowledge and their professional responsibility for providing informational support and nurses' professional skills and their professional responsibility for providing practical support. The caring behaviour of nurses as perceived by cancer patients involved the provision of emotional, informational, and practical support and help based on patients' needs. A model of caring in nursing was formulated.

CONCLUSIONS

Caring in nursing as perceived by cancer patients involves nurses having qualified professional knowledge, attitudes and skills in oncology and providing the informational, emotional and practical supports and help required by cancer patients.

RELEVANCE TO CLINICAL PRACTICE

Caring is manifested in nursing actions through nurse-patient communication process. Patients have their inner expectation for nurses' caring behaviour and attitudes and nurses' performance of caring or uncaring behaviour has a direct influence on the feelings of patients. It is necessary for all nurses to continue improving their oncology professional knowledge, attitudes and skills as well as their abilities of offering informational, emotional and practical support and help for their cancer patients.

The experience of being listened to: a qualitative study of older adults in long-term care settings

The experience of being listened to for older adults living in long-term care facilities was explored using a qualitative descriptive method outlined in Parse (2001), with the human becoming theory as the theoretical framework. The themes that emerged from this study--Nurturing Contentment, Vital Genuine Connections, and Deference Triumphs Mediocrity--affirmed the experience of being listened to as fundamental to the participants' quality of life. The findings expand nursing theory, provide enhanced understanding of the experience of being listened to, and offer ideas for future research. Through the voices of older adults participating in this study, the authors learn how critical listening is to quality care, and thus to excellence in nursing practice.

Cancer patient and staff ratings of caring behaviors: relationship to level of pain intensity

This study explored differences in the perceived importance of nursing caring behaviors between patients with cancer pain and oncology nurses and to explore the relationship between level of pain intensity and the importance of various nursing caring behaviors. The study included 50 matched cancer patient-staff pairs from oncology inpatient units of 3 hospitals in northern Taiwan. The Brief Pain Inventory-Chinese version (BPI-C) and the Caring Assessment Report Evaluation Q-sort (CARE-Q) were used for data collection. Results revealed that cancer pain patients ranked "being accessible," "monitors and follows through," and "anticipates" as being the most important nursing caring behaviors; the nursing staff ranked "being accessible," "explains and facilitates," and "monitors and follows through" as being the most important behaviors. No correlations were found between cancer pain patients and staff rankings of the perceived importance of various caring behaviors. The self-reported level of pain intensity by patients was significantly positively correlated with the patient rating of the "anticipates" behavior. Patient self-reported level of pain interference was significantly positively correlated with the "monitors and follows through" behavior and significantly negatively correlated with the "explains and facilitates" behavior. Staff perception of both a patient's level of pain intensity and pain interference was significantly positively correlated with staff rating of the "being accessible" behavior. Results demonstrated that greater patient-staff communication is needed for staff to more accurately provide caring interventions to make patients with cancer pain feel cared for.

Caring Behaviors As Perceived by Nurse Practitioners

PURPOSE

To investigate nurse pratctitioners' (NPs') perceptions of their own caring behaviors and to examine NPs' demographics as a function of their caring behaviors.

DATA SOURCES

Responses to the Caring Behaviors Inventory(CBI) and a demographic inquiry from 348 NPs in Louisiana.

CONCLUSIONS

CBI mean scores and subscale scores were high for all 348 NPs. No statistically significant difference was found between male NPs' and female NPs' total mean CBI scores or between urban or rural total mean CBI scores. The interaction between nurse gender and area o practice was not statistically significant.

IMPLICATIONS FOR PRACTICE

NPs often work in clinic situations where productivity is the most valued characteristic and where little time is afforded for identifying caring behaviors of the NP and/or establishing a caring relationship with the patient. NPs must be extremely conscious of the need not to "throw out the baby with the bathwater" and sacrifice characteristics that are inherent in nursing for those emphasized in primary care practice. As their responsibilities in the health care setting continue to expand, NPs must continually evaluate and validate their roles to ensure quality care that satisfies patients.

Nurse-led intermediate care: patients' perceptions

Intermediate care currently forms one of the UK Government's main initiatives for improving the quality of post-acute care. This paper examines patients' and carers' experiences of a nurse-led unit, which aims to provide intermediate care for people no longer acutely ill. Drawing on findings from qualitative interview data, we demonstrate that patients viewed this model of care as acceptable but that they had markedly inconsistent experiences of care and reported considerable variation in their perceptions of the Unit's purpose. Some possible reasons for this are explored. Implications for the development of good quality nurse-led intermediate care are outlined.

Refusing analgesics: using continuous improvement to improve pain management on a surgical ward

Despite advances in pain control many patients experience moderate to severe pain whilst in hospital. Contributory factors include inadequate assessment and documentation of pain, as well as patient and professional misconceptions. A 28-bedded surgical ward in a District General Hospital in the South of England was the setting for the project. A small preliminary audit of pain on this ward indicated that some patients experienced postoperative pain, which was not effectively controlled. A 'continuous improvement' framework was used to increase understanding of the problem and identify an aim for the project, which was to reduce the number of patients refusing analgesics when offered by nurses. An audit to ascertain how many patients refused analgesia revealed that, of 133 patients offered, 93 (70%) refused. Using the 'Model for Improvement' (Langley et al., 1996) a number of changes were introduced, including a patient information sheet, regular documented pain assessment and an innovative staff education programme. To evaluate if the changes in practice had been successful, further audit data were collected from 167 patients. Sixty-three (44%) accepted analgesics, indicating a significant decrease in the number refusing (P = 0.005). This small project demonstrated that continuous improvement methodology can improve the management of pain and quality of care for patients. Such an approach brings practitioner and patient into meaningful understanding and offers solutions which are realistic, achievable and sustainable over time. Despite finite resources and increased pressure on staff it is possible to motivate people when they feel they have ownership and change is meaningful. Continuous improvement methods offer an exciting, feasible, patient-centred approach to improving care.

A study of practising nurses' perceptions and experiences of intimacy within the nurse-patient relationship

AIM

This study investigated the perceptions and experiences of intimacy within the nurse-patient relationship.

BACKGROUND

Intimacy is an increasingly recognized nursing concept, which is intrinsically related to the therapeutic potential of nursing. However, the nature of intimacy as practised in nursing remains largely unexplored. A qualitative design was used and a purposive sample of 10 nurses was involved. Data were collected by means of semistructured interviews and diaries.

FINDINGS

Content analysis of the data yielded five categories relating to the nature of intimacy, involvement, resources, affinity for the patient and the rejection of intimacy. This paper focuses on the first of these categories. Intimacy emerged as a complex concept and included the subcategories of disclosure, levels of disclosure, sharing personal experiences, patient dependency and vulnerability, instrumental touch and intimacy and intimacy as an inappropriate term for the nurse-patient relationship. These findings are discussed in the light of existing theories and recommendations made for further research to expand and develop the issues highlighted.

CONCLUSIONS

The paper concludes by highlighting the complexity of the concept and identifies some of the constraints to intimacy in practice such as insufficient resources, the health care system and role changes.

A literature review on the concept of intimacy in nursing

AIM

This paper explores the concept of intimacy in nursing.

RATIONALE

Intimacy is an increasingly important concept in nursing and feature of the nurse-patient relationship, which is perceived to be intrinsic to the proposed therapeutic potential of nursing. The introduction to the paper highlights the theoretical enthusiasm and endorsement of intimacy, the apparent lack of conceptual clarity from a nursing perspective and little published research investigating intimacy in practice.

METHOD

Literature is reviewed from nursing and a variety of health-related disciplines.

FINDINGS

The paper traces the historical background of the nurse-patient relationship and intimacy and highlights the change in value from detachment and distancing to intimacy, commitment and involvement. The nature of intimacy is examined and a concept analysis based on literature from psychology and psychiatric medicine is critically analysed. Intimacy is suggested to have psychological, emotional and physical aspects, which are explored. An ethnographic research study on intimacy in nursing is reviewed, which also recognizes physical and emotional dimensions of the concept and the importance of sufficient resources to allow the close relationships advocated. Attention is drawn to the constraints on intimacy imposed by the current market-led health service. Literature and research on the implications and consequences of intimacy for the nurse are discussed. These report practical difficulties of maintaining close relationships with individual patients and the potential for over-involvement and emotional labour.

CONCLUSION

The paper concludes with the increasing importance attached to intimacy in nursing and its complex, ill-defined nature. This serves to highlight the importance of research aimed at exploring and clarifying intimacy and further illustrating the therapeutic potential of nursing.

Patients' and relatives' experiences and perspectives of 'Good' and 'Not so Good' quality care

AIMS

To explore patients' and relatives' perceptions of care and identify key criteria used to evaluate quality care, via descriptions of actual care experiences.

METHOD

A qualitative approach using Grounded Theory was adopted; data collected by semistructured interviews, from a purposive sample of 34 acute medical patients and 7 relatives, was subjected to question and thematic analysis.

FINDINGS

The nature of the care provided and interpersonal aspects of caring emerged as key quality issues for patients. Good Quality Care was characterized as individualized, patient focused and related to need; it was provided humanistically, through the presence of a caring relationship by staff who demonstrated involvement, commitment and concern. Care described as 'Not so Good' was routine, unrelated to need and delivered in an impersonal manner, by distant staff who did not know or involve patients.

CONCLUSIONS

Empirical evidence was found which support these findings, which are in opposition of the received view that patients place greater emphasis on the technical aspects of care tasks. The quality issues identified as important by patients and relatives in this study are not always evaluated in care audits. Those responsible for evaluating health care quality might consider combining traditional (professional/technical) audit criteria with those used by health care users to achieve a more comprehensive evaluation.

Patients' perceptions of hospice day care: a phenomenological study

This study explored the perceptions of 12 patients attending a day care unit in June/July 1996, with the purpose of finding out what was important to these people about their day care experiences. It used a phenomenological methodology derived from Paterson and Zderad's Humanistic Nursing Theory. The patients described numerous aspects of the day care service that were important to them. All 12 people interviewed considered the service satisfactory, and a number considered it to be more than anyone could or should expect. Day care was found to help them feel comfortable, to feel of value and to feel less isolated. In addition, the participants were found to be living with cancer in two different ways. All 12 knew they had cancer and might be terminally ill. Yet some seemed to "tolerate" their life with cancer, whereas others saw it as requiring "adaptation". The day care service was supporting both these styles of managing life with cancer. The interpretation of the findings suggests that the reason patients expressed such satisfaction with the service offered was because the care was humanistic. It responded to individual opinions, feelings and understandings of health and well-being, by giving people time and responding to their individual concerns. In this way, it was flexible enough to support people in managing their illness using their own preferred style.

Management of pain through autogenic training

Physical and emotional pain are an inevitable part of human existence and are without natural antidotes. In view of this, and in the light of increasing professional reluctance to depend on analgesics, this paper proposes the widespread application of autogenic training, a relaxation technique which has been seen to confront pain very effectively, and also to reduce substantially drugs dependency. It analyses autogenic training in respect of some of the more common pain-allied disorders such as childbirth, headaches and migraines, back pain, cancer and palliative care, and cardiology.

Infection control: reducing the psychological effects of isolation

Although previous studies have shown that some patients, when nursed in isolation for infection control purposes, experience negative emotional effects, little research has been published which suggests what healthcare professionals can do to prevent or reduce these effects. A study was therefore carried out involving 21 patients being nursed in isolation who completed questionnaires. Five patients with negative experiences of isolation were then interviewed about the reasons for feeling the way they did and what they felt could be done to reduce or prevent negative emotions. Recommendations made from the research include the provision of written and individualized information, improved communication from medical staff, provision of a common room and better facilities to relieve boredom. Further large scale research is needed to investigate strategies to improve the isolation experience.

Perceptions of caring among patients with cancer and their staff. Differences and disagreements

The current dyadic study investigated (a) patient and staff perceptions of the importance of caring behaviors, patient health, quality of life, and greatest health-related concern; (b) patient anxiety and depression (Hospital Anxiety and Depression Scale); and (c) staff views of patient perceptions of the importance of caring behaviors. The study included 21 matched patient-staff dyads. Three questionnaire versions of the Caring Assessment Instrument were used to tap patient (CARE-P) and staff (CARE-S) perceptions, and staff views of patient perceptions (CARE-SP). There were no correlations between patient and staff perceptions of the importance of caring behaviors, patient health, quality of life, or greatest health-related concern. However, staff views of patient perceptions about the importance of caring behaviors were strongly correlated with their own perceptions. Staff ratings of the importance of caring behaviors were not related to patient anxiety, depression, health, and/or quality of life. Patient depression was negatively correlated with three CARE-Q subscales. The results indicate that staff are not successful in judging the importance of caring behaviors, health, quality of life, and greatest health-related concern for individual patients. The major implication is that staff must be open to patient perceptions of what caring behaviors are important, and must validate their own perceptions of patient needs and concerns.

Chinese elderly patients' perceptions of their rehabilitation needs following a stroke

Stroke is the third leading cause of death and disability among Chinese elderly patients in Hong Kong and yet the rehabilitation needs of these patients are rarely explored. The aim of this study was to identify the rehabilitation needs of Chinese elderly patients following a stroke. The study adopted an ethnographic approach, information being gathered by the researcher through interviews with 15 key informants selected by purposive sampling. The perceptions of patients as to their own needs were sought at three stages of recovery - in the acute and rehabilitation settings and at 1 month following discharge. Ethical approval was gained from the Chinese University Faculty of Medicine ethical committee and access agreed by the hospital authorities. Verbal approval was gained from the patients before each interview, following confirmation of the voluntary nature of participation and assurance of confidentiality and anonymity. The researcher's role was also clearly stated. Analysis of the interview data produced five categories of patient need at the three stages of recovery, namely informational, physical, psychological, social and spiritual. The most frequently stated, but largely unmet, need in all settings was the need for information, particularly information about the reasons for stroke and about the activities that promote recovery. In the acute and rehabilitation settings patients' responses indicated a need to be respected as individuals, to be addressed by name and to be provided with privacy. Although the Barthel Index administered during interviews charted recovery at different rates, nurses did not always make links between the level of functional ability and the help needed with physical tasks. They also failed to recognize the relationship between physical and psychological needs and the equal importance of both in recovery from stroke. As Chinese elderly patients tend to take a passive role in seeking help and information, nurses play a significant role in the identification of individual rehabilitation needs. Implications for nursing practice are discussed.

Talking on the telephone with people who have experienced pain in hospital: clinical audit or research?

The adequacy of postoperative pain management in British hospitals appears insufficient to improve patient care, and much of the research and clinical audit in postoperative pain has failed to seek the patient's perspective. This paper reports on the findings from a semi-structured telephone interview survey which formed part of a hospital-wide audit on postoperative pain at a district general hospital in the south of England. Of a total of 360 completed audit questionnaires, 114 patients left their telephone number and 29 were interviewed. Content analysis revealed five main themes: inadequate information, pain at home, staff attitudes, expectations of pain, and ward atmosphere. Several patients identified insightful strategies that potentially could improve pain management. The telephone interview generated a richness of data that had not been reported before in this important area. Some authors view clinical audit and research as having different characteristics but this work raises important questions for both approaches when using the semi-structured telephone interview. The ethical issues pertaining to collection of audit data using the telephone interview are discussed.

Stoma care: exploring the value of effective listening

This article discusses how nurses can effectively utilize listening skills during interactions with patients. Listening is a core skill for all healthcare professionals with studies demonstrating that nurses perceive themselves to be much less skillful in the use of facilitative interpersonal skills which involve listening than practitioner centred authoritative ones. Listening effectively allows nurses to respond more completely to patients' needs but there are many obstacles which unfortunately can interfere with this process. Stoma care nurses utilize listening skills to ensure that both the physical and psychological needs of their patients are met. The author suggests that listening skills can enhance intuitive nursing practice.

Noncompliance by patients: a response to professor Dimond

A recent article published in Nursing Ethics, written by Professor Bridgit Dimond, highlighted the topic of noncompliance by patients and attention was drawn to a number of issues relevant to health care professionals. In this response, some specific challenges facing nurses are considered in the light of Professor Dimond's arguments. In doing so, the notion of compliance as an appropriate concept in modern nursing practice is questioned. The recommendations to emerge include strategies to consider patient response to treatment regimens in the form of adherence to health care advice through negotiated therapy. The claimed benefits of health care recommendations are considered and caution about iatrogenesis is advised.

Evaluating the use of a pain assessment tool and care plan: a pilot study

Pain control in hospital has long been documented as ineffective and problematic. A multi-professional group of clinicians formed to consider how they might continue to improve pain management at a district general hospital. Following a pain audit, in general wards, it became apparent that pain assessment tools were not being used. The group devised a draft pilot assessment tool and care plan which was piloted over a 2-week period on a rehabilitation ward for elderly people. A review of these documents revealed that pain assessment using the body map ascertained considerable detail about the pain location, and the pain ruler elicited pain intensity and associated descriptors. None of the documented goals for pain were measurable, and interventions focused on analgesia and actions to relieve the physical cause of the pain. No psychosocial interventions were mentioned. All care plans were evaluated at least once but 44% of evaluations did not refer to the pain. On this ward, these outcomes suggest the pain assessment tool has the potential to improve communication of pain between the patient and the nurse but there is an urgent need for education to enable this information to be used effectively and develop pain management strategies which reflect the multidimensional nature of pain.

Assessing patient satisfaction. Part 2. Findings: nursing, the hospital and patients' concerns

Part 1 of this article discussed the process of evaluating patient satisfaction by means of unstructured, in-depth interviews. In this part, the content of interviews will be presented and the analytic domains derived from the research will be described. These are 'nursing', 'the hospital' and 'patients' concerns', and the categories which make up these domains will be discussed.