Recognition of patients' worries by nurses and by other patients

An analysis of the ability of nurses to identify the anxiety levels of patients in general medical and surgical wards

The study investigated whether qualified nurses could distinguish between low and high anxiety in general medical and surgical wards. The sample comprised 94 patients and 62 nurses in two district general hospitals. The patients completed the Spielberger State-Trait Anxiety Inventory Version Y and were divided into high and low anxiety groups by reference to the published norms for the inventory. The nurses independently rated the patients into either high or low anxiety groups according to whether or not they believed individual patients needed more nursing time than was usual to help them to manage their anxiety. The joint ratings were signficant beyond the 0.01 level, supporting the hypothesis that the nurses could distinguish between high and low anxiety patients. However when data from the two hospitals were separated, the overall results were only significant in the hospital where patients had reported significantly lower average levels of anxiety. A tentative explanatory hypothesis is that assessment of patients may be easier where the general background level of patient anxiety in a ward is relatively low. In a subsidiary part of the study, feedback and group training failed to increase the correspondence between nurses' ratings and those obtained from the patients' questionnaires. The research method for comparing the views of patients with those of nurses proved practical for implementation in busy hospital wards and may therefore be useful for other investigations in similar settings.

Genetic Counselors' Judgments of Patient Concerns: Concordance and Consequences

The aims of this prospective study were to determine (a) the concordance between patient concerns and genetic counselors' judgments of these concerns, (b) the predictors of patient and counselor judgments, and (c) the relationship between concordance and patient outcomes. Patients' and counselors' views were sought before and after 131 routine genetic consultations. Before consultations, there was concordance about level of patient concern to within one point in 63% (82/131) of consultations and about type of patient concern in 60-84% of consultations. Lack of concordance in judging level and type of concern was associated with lower satisfaction with information and higher anxiety after the consultation. The biggest predictor of counselor judgment of concern was professional background: doctors judged patients to be more concerned than did nurses. Concordance of concern was predicted by counselors' experience in genetics: less experienced counselors overestimated patient concern. Future research needs to determine whether improving judgment of concern improves patient outcome.

What do patients and families want from a child neurology consultation?

Understanding what patients and their parents want is essential to plan appropriate patient-centered care. Questionnaires were distributed to 500 consecutive children and parents seen for their first pediatric neurology consultation. Both patients and their families answered questions about their expectations of the consultation, their level of worry, and the Penn State Worry Questionnaire. The 5 most important issues for the parents were to get information, to work with the doctor to manage the problem, to have questions answered, to find out what was wrong, and to discuss the impact on the child's life. The children had very similar priorities. The 5 least important concerns for parents were to get a prescription, blood tests, to talk to others with similar problems, to get a radiograph/computed tomography/magnetic resonance imaging (MRI) and to be told nothing is wrong. The pediatric neurologists did well in anticipating these priorities but had more difficulty appreciating parent and patient level of worry.

Validation of the surgical fear questionnaire in adult patients waiting for elective surgery

OBJECTIVES

Because existing instruments for assessing surgical fear seem either too general or too limited, the Surgical Fear Questionnaire (SFQ) was developed. The aim of this study is to assess the validity and reliability of the SFQ.

METHODS

Based on existing literature and expert consultation the ten-item SFQ was composed. Data on the SFQ were obtained from 5 prospective studies (N = 3233) in inpatient or day surgery patients. These data were used for exploratory factor analysis (EFA), confirmatory factor analysis (CFA), reliability analysis and validity analysis.

RESULTS

EFA in Study 1 and 2 revealed a two-factor structure with one factor associated with fear of the short-term consequences of surgery (SFQ-s, item 1-4) and the other factor with fear of the long-term consequences of surgery (SFQ-l, item 5-10). However, in both studies two items of the SFQ-l had low factor loadings. Therefore in Study 3 and 4 the 2-factor structure was tested and confirmed by CFA in an eight-item version of the SFQ. Across all studies significant correlations of the SFQ with pain catastrophizing, state anxiety, and preoperative pain intensity indicated good convergent validity. Internal consistency (Cronbach's alpha) was between 0.765-0.920 (SFQ-total), 0.766-0.877 (SFQ-s), and 0.628-0.899 (SFQ-l). The SFQ proved to be sensitive to detect differences based on age, sex, education level, employment status and preoperative pain intensity.

DISCUSSION

The SFQ is a valid and reliable eight-item index of surgical fear consisting of two subscales: fear of the short-term consequences of surgery and fear of the long-term consequences.

Advances in How Clinical Nurses Can Evaluate and Improve Quality of Life for Individuals With Cancer

PURPOSE/OBJECTIVES

To describe advances in the ways that clinical nurses understand, assess, and work to improve quality of life (QOL) for individuals with cancer since the 1995 Oncology Nursing Society's State-of-the-Knowledge Conference on QOL.

DATA SOURCES

Published research and clinical articles.

DATA SYNTHESIS

The number of QOL assessment tools and methods for understanding QOL results has increased. However, scant literature has focused on how clinical oncology nurses evaluate QOL and the methods they use to affect QOL for individuals with cancer.

CONCLUSIONS

Based on the nurse-patient relationship, clinical nurses are able to assess QOL in individuals with cancer and intervene appropriately to improve QOL.

IMPLICATIONS FOR NURSING

Clinical nurses can involve individuals with cancer in rating their QOL to assist in providing high-quality care that is directed at positively affecting QOL.

Patient–staff agreement in the perception of spinal cord lesioned patients' problems, emotional well-being, and coping pattern

STUDY DESIGN

Matched patient/staff study.

OBJECTIVES

To investigate spinal cord lesion (SCL) rehabilitation staff perceptions of SCL patient problems, coping efforts, and well-being, and to compare these evaluations with patient self-reports of the same aspects.

SETTINGS

Spinal Unit, Sahlgrenska University Hospital, Göteborg, Sweden.

METHODS

In all, 29 persons with SCL and 24 members of the caring staff participated. Each patient was matched to a staff person actually involved in his or her care. The participants completed a study-specific questionnaire containing 45 SCL-related problems covering six problem areas: somatic symptoms, functional limitations, role problems, family-related problems, psychosocial problems, and emotional problems. Coping activities were assessed by a self-report 47-item questionnaire covering eight aspects of coping: self-trust, problem focusing, acceptance, fatalism, resignation, protest, minimization, and social trust. The patients were instructed to respond to the items included in the questionnaires according to their situation during the last week, while staff members were instructed to reply as 'they thought that their matched patient would answer'.

RESULTS

Moderate but statistically significant correlations were demonstrated between patient and staff ratings of most investigated problem areas. However, the staff systematically overestimated patients' emotional as well as family problems, and tended to underestimate patients' reported coping ability and mental health. Staff were most accurate in assessing patients' physical symptoms, functional limitations, and role problems, but less accurate in their perception of less visible symptoms.

CONCLUSION

Relatively high agreement between patients and staff concerning patients' problems and states is possible to obtain in a caring setting. This may be more related to the quality of caring in the studied unit than to the study methodology used. Small units with high staff density and a long stay and/or prolonged contact with the patients probably facilitate communication with and knowledge about the patients. Interventions aimed at increasing staff awareness of patients' coping efforts may further improve staff ability to understand and support patients in their adaptation process.

"It's like an explosion in your life...": lay perspectives on stress and myocardial infarction

Psychological difficulties are common after myocardial infarction (MI). These difficulties are most often represented to patients through cardiac rehabilitation services and the literature offered to patients after MI as being related to "stress" and its management. However, no research has examined what MI patients understand by the term "stress" or how congruent lay views of stress are with those evident in the professional literature. The aim of the study reported here was to examine post-MI patients' views of stress, its functioning and relationship to their MI. As patients' views of stress were sought, qualitative interviews were used. A philosophical approach was taken (critical realism) that recognizes the legitimacy of both professional and lay perspectives. Data were generated in 44 semistructured interviews with 14 MI patients who were interviewed 48 hours, 1 week, 1 month and 3 months after hospital admission. While participants described their experiences after MI as being difficult, to convey this they used everyday terms such as fear, fright and worry. Rather than viewing stress as being a consequence of their MI, they perceived it to be a common cause of heart problems. Many considered stress as having a more influential role than other risk factors, such as smoking and diet. They expressed a wide variety of sophisticated and diverse views of stress and its functioning. Each of these views placed different weighting on the roles of social, personal and situational factors in contributing to the stressful reaction. Parallels were apparent between these lay accounts and theories of stress developed in the professional literature.

Day surgery preoperative anxiety reduction and coping strategies

Hospitalization, even in patients who are not faced with the prospect of surgery, is known to cause anxiety. One may, therefore, expect some degree of anxiety in patients attending for day surgery. Anxiety provokes a physiological stress response, which impedes the healing process. Thus, the reduction of preoperative anxiety is widely accepted as part of nursing care. This article investigates the coping strategies that patients adopt and the suitability of current anxiety-reduction interventions. It argues that individual coping styles do not remain static but adapt according to need and proposes that, as a result of lack of awareness, the therapeutic potential of the nurse-patient relationship in anxiety-reduction is being overshadowed by uncertainty-reduction approaches which place a disproportionate emphasis on the provision of information.

Pain management 1: psychological and social aspects of pain

This two-part article presents psychological and social factors which affect pain perception and response and the implications of these for nursing practice. In this article, the complex interactions between neurophysiological and psychological factors are outlined and theories of pain perception and ways in which the pain experience can be modulated are presented. The role of psychological factors, attitudes, beliefs and expectations of both patient and practitioner, pain behaviours and ability to cope are discussed. In the second part, these are further elaborated with particular reference to the nurse-patient interaction. The use of psychological approaches to augment clinical practice, such as education, reduction of anxiety and improving coping ability, are suggested. Finally, the importance of communication skills in pain management is addressed.

Patient concerns in their first year with type 2 diabetes: patient and practice nurse views

One year after diagnosis, 250 patients with type 2 diabetes identified concerns related to having diabetes, in response to an open question and checklist. Their practice nurses independently reported what they believed were the patients' concerns. Nurses identified patients' main concerns in only 20% of cases. Patients' most frequent main concerns were 'fear of getting worse', 'following dietary advice' and 'damage caused by diabetes'. Nurses most frequently cited 'following dietary advice', 'illness or pain unrelated to diabetes' and 'overweight'. BMI over 25 was related to patient concerns about 'overweight' but not 'following dietary advice' nor 'taking exercise', mentioned also by people of lower weight. Only 19/106 patients with raised HbA1c levels reported concerns about high blood glucose levels. Nurse education in patient-centred care should build on the findings that patients focus more on current and future burden of symptoms and treatment than on blood glucose levels.

Patient and staff perceptions of cancer patients' psychological concerns and needs

This paper reviews patient and staff perceptions of cancer patients' psychological concerns and needs. An extensive literature search resulted in a total of 22 studies. Six of these concern staff ratings of hypothetical 'average' patients, and the main findings are that staff and patients are in relative agreement about the overall spectrum of concerns relevant to cancer patients, but less so regarding which concerns are of most importance to patients. Sixteen studies compare patient ratings with staff ratings of individual patients. The overall pattern of results indicates that staff tend to overestimate patient anxiety and emotional distress and show limited ability adequately to assess patient distress in terms of rank. Staff were able correctly to detect a majority of anxiety 'cases', while the identification of depression was less accurate. High detection rates for anxiety were obtained partly at the expense of staff also presuming anxiety in many non-distressed patients. Generally, there was better patient-staff agreement on the absence than the presence of patient anxiety and depression. Many studies were found to have serious methodological deficiencies and there is no clear evidence that patient-staff agreement is markedly better in studies fulfilling important methodological criteria. Several explanations of patient-staff discrepancies are discussed. Future research should be aimed at critically testing possible reasons for patient-staff disagreement and at investigating the consequences of such discrepancies.

A summative evaluation of clinical competence: students' and nurses' perceptions of inpatients' individual physical and emotional needs

The ability to assess individual patients' physical and emotional needs was used as one foundation for evaluation of clinical competence for Swedish student nurses. Each of the randomly sampled 48 student nurses and their corresponding supervisors (48 nurses) assessed the perceived needs of a patient they both knew well by separately answering a questionnaire concerning basic physical and emotional needs. Simultaneously the selected patients (n = 48) were interviewed about their perceived needs. Student nurses' and nurses' assessments were compared with the individual patient's opinion. Both the students' and the nurses' assessments showed close similarities with the patients' own estimations, although certain under- and overestimations for both physical and emotional needs were found, with a predominance of overestimation of emotional needs. Student nurses and nurses also showed uncertainty in some of their assessments, mainly concerning emotional needs. Their assessments were closer than student nurses/patients or nurses/patients, and also closer for physical than for emotional needs. The conformity in student nurses' and their supervisors' assessments might be understood as the supervisors' influence as role models. Attention should be paid both in nursing education and in clinical practice to the need for individualization of patient care.

Psychological care in nursing education and practice: a search for definition and dimensions

Despite a wealth of literature from the medical and nursing arenas pointing to the significance of psychological care in illness, there appears to be little consensus on definition, description and dimensions of the concept. A literature review and analysis of textbook content was conducted to explore the nature of the concepts of psychological need and care which might inform nurse educationalists in the preparation of appropriate teaching and learning programmes. Preliminary findings indicate that there is little consensus upon definition or description and, with the exception of information-giving, upon the dimensions or components of psychological care, despite the fact that student nurses are prepared to meet the same nationally prescribed learning outcomes by pursuing broadly the same guidelines for educational content. It is suggested that this has particular implications for nursing lecturers with a responsibility for teaching the philosophy and practice of holistic care.

Thinking of the future and walking back to normal: an exploratory study of patients' experiences during recovery from lower limb fracture

Admission to hospital following a traumatic lower limb fracture is undoubtedly a stressful life event; however, few studies have detailed this from the patient's perspective. By exploring patients' experiences of hospitalization with lower limb trauma, this study aimed to explicate some of the factors impinging on the recovery trajectory. Patients' perceptions of the events influencing their strategies for coping with stress, hospitalization and temporary incapacity were investigated using a qualitative methodology. A convenience sample of nine patients was recruited from an orthopaedic ward in a district general hospital in Wales. The respondents used health diaries to document their recovery for up to 6 weeks after emergency surgery. These diaries were validated and supplemented by semi-structured interviews. Following their traumatic injuries, our respondents were subjected to a variety of stressors and uncertainties. They coped with this period of uncertainty by positive attempts to gain control over their situations, guided by an over-riding desire to 'return to normal' and assisted by the caring attributes of their nurses. From the experiences and events documented, this study was able to identify several stressors which could have been mitigated by optimization of the technical aspects of care, including the management of pain.

Nurses' ability to perceive patients' fears related to coronary arteriography

This study describes the congruence of the perceptions of 180 patient-nurse dyads concerning patients' fears related to coronary arteriography (CA). The perceptions were measured with a purpose-designed instrument which listed 26 objects of fear. t-Tests and chi-square tests were used to compare the responses and the associations with demographic data. The results pointed to inconsistencies between patients' and nurses' perceptions. Nurses and patients had congruent perceptions of the 10 most intense fears related to CA. Otherwise nurses tended to overestimate patients' fears. Nurses' perceptions of the intensity of individual patients' fears were incongruent so that before CA there was a tendency to overestimate the intensity of fears and after CA to underestimate it. The results suggest that nurses need to pay more attention to the assessment of individual patients' fears and to avoid stereotypical views of patient fears. The use of an assessment instrument is recommended as one way of enhancing the quality of care.

The relationship between patients' concerns and psychological distress in a hospice setting

A total of 87 patients admitted to two hospices during a 9 month period were assessed by trained nurses to determine their current concerns. These assessment interviews were tape recorded. A trained researcher then administered a semi structured concerns interview using the Concerns Checklist, the Hospital Anxiety and Depression Scale and the Spielberger State Anxiety Inventory. Patients reported an average of 6.5 concerns. Concerns about loss of independence and the family were most common. Although a third of the patient sample died within a short time after the interview, concerns about cancer, the future and dying were infrequent. Using a threshold score on the Hospital Anxiety and Depression Scale of > 19 to allow for the effect of disease, 17% of the sample were judged to be probable cases of clinical anxiety and/or depression. There was a strong association between the number of concerns patients experienced and psychological distress (p < 0.001). Concerns about pain and treatment were particularly associated with anxiety whereas concerns about disability were linked with depressed mood. Concerns about cancer were linked with both anxious and depressive changes in mood (p < 0.001). The study highlights the diverse nature of hospice patients' concerns and shows a clear link between psychological distress and number of concerns expressed by patients.

Staff and patient feedback in mental health services for older people

OBJECTIVES

To compare the views of patients and staff on the quality of care provided on a psychogeriatric assessment ward over a five year period. To describe the quality improvements which were made as a result of their respective comments.

DESIGN

Structured interviews were conducted with both patients and staff to obtain qualitative feedback and suggestions for improvement. An analysis of the percentage of positive and negative comments made by both patients and staff was used to compare the levels of satisfaction on a variety of aspects of the service provided.

SETTING

Psychogeriatric inpatient assessment ward.

SUBJECTS

75 patients and 85 staff interviews were conducted.

MAIN MEASURES

Structured interviews covering various aspects of service quality.

RESULTS

Staff and patients picked up on different aspects of service quality as important. Quality improvements which arose from the interviews were clearly different. Generally patients were more positive about the physical environment and standards of professional care than staff, but less positive about issues of privacy, social interaction, and empowerment.

CONCLUSIONS

The perspectives of patients and staff in this area are not interchangeable. Both series of interviews led to several positive changes in the quality of care. Interviews with staff seem to have been valuable in a low morale situation. A structured interview format provided patients with an opportunity to feedback openly and led to changes in service quality which would not otherwise have occurred.

Theoretical perspectives of nursing: a review of the literature

The discipline of nursing has slowly evolved from the traditional role of women having been influenced by a variety of factors such as apprenticeship, humanitarian aims, religious ideals, medicine, increasing technology, politics, war, feminism and more recently research. This variety of influences is reflected in the many and varied definitions and descriptions of nursing currently espoused in the literature. A review of the most widely cited definitions and descriptions of nursing from Nightingale to the present day resulted in the identification of eight theoretical perspectives of nursing. Each of these are discussed. The author concludes that nursing has yet to arrive at a consensus regarding the nature, components and process of nursing which is crucial for professional credibility and the viability of professional nursing as it enters the next millennium.

Patients' perceptions of pre-operative preparation for day surgery

While the quality of medical intervention associated with day surgery has greatly improved, the position of psychological preparation has remained virtually unchanged. Recent evidence, however, has suggested that anxiety levels can be significantly reduced if preparatory information can be matched with individual coping styles. As choice of coping style has been strongly linked with locus of control, two questionnaires were given to 150 subjects undergoing minor gynaecological day surgery in order to compare their health locus of control (HLC) with their preferred level of preparatory information. No correlation was established between the HLC measures and the selected level of preparatory information although information requirements were established. The results are discussed and recommendations made for future pre-operative psycho-educational programmes.

Toward a theory of social pharmacology: the actor-spectator paradox applied to the psychotropic prescribing process

Traditionally, drug prescribing was regarded as part of the physician's decision-making role. However, recently it has been recognized that such a perspective is insufficient to understand the psychotropic prescribing process. To understand this process, a drug communication perspective is necessary. This article describes the actor-spectator paradox and its influence on drug communication and psychotropic drug prescribing. The actor-spectator paradox postulates that the actor and the spectator have divergent perspectives about the cause of the actor's behavior. The spectator makes assumptions about the actor's cognitive system other than the actor herself is making. This difference is often the basis for misunderstandings between a health professional and a patient. If a health professional can learn to make more realistic assumptions about a patient's cognitive system, communication between the two will improve. In the same way a patient has to learn to make more realistic assumptions about the cognitive systems of health professionals. The actor-spectator paradox can be applied to different areas of Social Pharmacology such as the diagnosis of patients suffering from mental health problems, drug compliance, informed consent, and the prescribing of psychotropics.

Disclosure of concerns by hospice patients and their identification by nurses

As part of an evaluation of the training of hospice nurses in communication skills, the selectivity of patients in disclosing their concerns and the ability of nurses to register all the concerns disclosed were studied. Forty-two nurses were recruited from two hospices in the north of England. They were asked to determine and write down patients' current concerns before and after training, and nine months later. Their interviews were tape recorded to permit rating of the concerns disclosed. After each interview a research nurse used a semistructured interview and the Concerns Checklist to elicit patients' concerns. The Spielberger State Anxiety Scale and Hospital Anxiety and Depression Scale were then administered to assess patients' mood. In total, 87 patients were thus assessed. Patients were highly selective in what they disclosed and showed a strong bias towards disclosing physical symptoms. Overall, 60% of concerns remained hidden and concerns about the future, appearance and loss of independence were withheld more than 80% of the time. Patients who were more anxious or depressed were less likely to disclose concerns. The nurses registered only 40% of the concerns disclosed to them at interview, and less than 20% of patients' concerns were identified appropriately. The nurses were selective in the categories of concerns that they registered. Pain, family worries, appetite and weight loss, nausea and vomiting were noted most frequently, while concerns about cancer, bowel function, treatment and emotional worries were not registered. The patients' main concern was identified and recorded in only 45% of cases. Overall, it was found that hospice patients selectively disclosed physical symptoms while nurses did not elicit or register patients' concerns accurately. Nurses therefore need to improve their ability to elicit and register all of their patients' concerns and to pay particular attention to those who are anxious and depressed.

Good patients cope with their pain: postoperative analgesia and nurses' perceptions of their patients' pain

Patients routinely receive less analgesia postoperatively than they need. Previous attempts to understand this have examined the nurses' attitudes to analgesia and their ability to assess accurately the intensity of their patients' pain. The present study examined three hypotheses derived from an alternative view that undermedication results from patients failing to disclose their difficulty in coping with pain because this would lead to disapproval by nurses: (i) that analgesic intake is related, not to pain intensity but to patients' feelings of being unable to cope with pain and to nurses' assessment of their inability to cope; (ii) that nurses specifically underestimate patients' ability to cope with their pain; and (iii) that poor coping with pain is seen by nurses as indicative of a 'bad' patient. Pain ratings were completed by 56 patients undergoing minor abdominal surgery; nurses completed similar scales to show their perception of patients' pain, as well as a specially devised scale which measured how negatively or positively they felt about their patients. Nurses were sensitive to the intensity of their patients' pain, but underestimated how well patients felt they coped with pain and how much they wanted analgesia. Patients who experienced the worst pain, or whom the nurses perceived as coping least well with their pain, were evaluated by the nurses as unpopular and demanding.

Patient advocacy: a role for nurses?

There is much controversy surrounding the issue of nurses in the role of patient advocate. Cancer patients are vulnerable due to their diagnoses, the anxiety that it generates, the nature of the disease and subsequent treatment and may diminished autonomy as a result. It is questionable whether the nurse is able to promote the best interest of the patient in this situation. Models of advocacy and the nurse-patient relationship are discussed. The main arguments for taking on the role of patient advocate include: reference to long periods of time spent with patient and the chance to build a relationship; on duty to care and the duty to do no harm. Criticisms of the appropriateness of advocacy role for nurses include: inability for the patient to choose his or her nurse; promotion of self interests; charges of paternalism; challenges from other health care professionals and multiple and/or conflicting obligations. It is concluded that perhaps the most ethical way of caring is by empowering patients and promoting self-advocacy. This concept needs to be further explored.

How nurses in a stroke rehabilitation unit attempt to meet the psychological needs of patients who become depressed following a stroke

Fourteen qualified nurses working in a stroke rehabilitation unit were interviewed in order to ascertain their understanding of post-stroke depression, what they do to help a patient who becomes depressed and what they feel unable to do. They were also asked what would improve the situation. The nurses were able to describe the characteristics of depression following a stroke and recognize its effect on the subject's rehabilitation. They were able to identify patients who were becoming depressed and tried to help them to the best of their abilities. They felt constrained, however; mainly by lack of time, limited skills and lack of appropriate training. They themselves wanted to be able to meet the needs of depressed patients and thought that this could be achieved through better staff education and access to other health professionals experienced in providing psychological care. It is recommended that nurses have access to expert personnel both as a source of referral for patients and as a resource for support and guidance to staff. In addition, an education programme combining theoretical and practical aspects of psychological care would be useful.

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.

What kind of nurses do patients want?

This article discusses whether certain aspects of 'New Nursing' which involve changes in nurse-patient relationships and the emphasis of the nurse's role fit with patients' preferences for their care. It reports on a study investigating these issues, and concludes that patients in general want a warm and friendly style of nursing, but a substantial minority do not agree with the use of patients' first names. Patients' evaluations of the most important nursing activities focus on listening to patients' worries, teaching them about their conditions, and relieving pain.

The role of the patient in standard setting and audit

This article examines some of the problems and issues involved in quality assurance of nursing care and the measurement of patients' views of health care. It argues that these two endeavours can and indeed should be related.

The reduction of anxiety in surgical patients: an important nursing task or the medicalization of preparatory worry?

The reduction of pre-operative anxiety in surgical patients is a routine part of nursing care, but much of the evidence which supports the view that high anxiety is related to worse recovery is based on ambiguous or unreliable indices of recovery. Instead, it has been argued that moderate levels of preoperative anxiety can help patients to prepare for surgery and reduce its stressfulness. On this basis, attempts to reduce anxiety would amount to the "medicalization" of a normal and useful state. Until recently little evidence supported this view, but research which has used hormonal changes to index surgical stress has provided evidence consistent with it. Alternative strategies for psychological preparation can be designed, which are not based on an attempt to reduce anxiety. However, attempts at psychological preparation of surgical patients pre-operatively should be regarded as experimental until more evidence is available about their effects on recovery.

How accurately do nurses perceive patients' needs? A comparison of general and psychiatric settings

This paper examines to what extent nurses' perceptions of patients' needs correspond to the patients' views of their own needs. A questionnaire was designed to assess patients' emotional and physical needs in general medical wards and in acute psychiatric wards. Sixty patients, 30 psychiatric and 30 general, together with their 'key' nurses, took part in the study. Results indicate that, despite there being no evidence of appreciable disagreement between the 'average' psychiatric nurse and the 'average' psychiatric patient, there is little evidence that individual nurses and their patients, whether psychiatric or general, agree. The nurses' inability to perceive patients' needs on an individual basis is consistent with other studies which suggest that nurses use stereotypes when perceiving patients' needs. Implications for nursing care are discussed.

Mothers', midwives' and obstetricians' views on the features of obstetric care which influence satisfaction with childbirth

A sample of 15 women was interviewed 18-96 h postnatally to identify objective features of labour and postnatal care about which they expressed preferences. The importance of each item to a mother's satisfaction was then rated by a sample of 224 similar women. The same questionnaire was also completed by 28 midwives and 52 obstetricians. The items rated most important concerned the explanation of procedures and the involvement of mothers in administering or choosing them. Second was support from the presence of a partner and qualified hospital staff, third the physical comfort of the postnatal ward. The avoidance of obstetric interventions, such as episiotomy or use of forceps, was less important than the presence of these other features. The mean ranking given to each item by the midwives and obstetricians correlated very highly with that given by the mothers; those caring for obstetric patients are much more sensitive to their preferences than is popularly believed. There was no evidence that midwives perceived patients' needs more accurately than did the obstetricians. Discrepancies between the three groups' ranking of specific items may reflect the defence of their respective roles by each profession.

Nurses' perception of stress in preoperative surgical patients

It is generally recognized that the stress of hospitalization and hospital treatment can impede the recovery of patients and in some cases cause potentially life-threatening physiological changes. Previous studies have indicated that nurses do not accurately perceive worry, anxiety and stress in patients. In order to assess how accurately nurses perceive worry, anxiety and stress in their patients, questionnaires were designed and distributed to a group of preoperative patients and nursing staff from general surgical wards, in order to discover how closely these two groups considered various situations and events as causing worry in preoperative patients. The results showed that whilst there was a considerable level of agreement between the two groups for the rank order of the 26 items in the questionnaire, nursing staff consistently assessed patients as worrying considerably more than the patients actually reported themselves. The nurses in the study were therefore over-estimating the degree of worry, anxiety and stress in their patients.

The social bases of discrepancies in health/illness perceptions

Health care professionals generally assume that their perceptions and assessments of their patients' health status are accurate and are congruent with those of the patient and other health care providers. However, despite the patient education process, there is evidence that discrepancies in perceptions persist. These discrepancies are of particular concern to nurses because they may interfere with the provision of quality patient care. Poor communication, non-compliance with the treatment regimen, inadequate or unnecessary treatment, and ethical problems could be outcomes of discrepancies in perceptions. In this paper, the literature pertaining to discrepancies in health/illness perceptions is reviewed. As well, several social factors that may affect perceptions are described. These include cultural background, gender, socioeconomic status, experience and role. The effect of occupational role on health/illness perceptions has not been examined systematically. Regarding differences in perceptions of physicians, nurses and patients, further research is required to clarify and explain the nature of discrepancies in health/illness perceptions.

Development of a self-administered questionnaire to measure women's knowledge of prenatal screening and diagnostic tests

A prerequisite to an informed decision to undergo any screening or diagnostic test is knowledge about such a test. This study describes the development of a self-administered questionnaire to measure knowledge of prenatal tests, for use in studies concerning the uptake of these tests. Both the reliability (internal and test-retest) and predictive validity are evaluated. Validity is assessed in two studies: first, comparison is made between three criterion groups (two with experience of pregnancy, one without); and second, scores on the questionnaire are compared before and after women have been provided with information about possible tests. The results show this to be both a reliable and valid measure of knowledge about prenatal tests. The results also highlight aspects of knowledge that are lacking. For example, a sizeable minority of women were uncertain or incorrect in identifying which tests they had undergone in a recent pregnancy.

Concern about cancer in women undergoing elective gynaecological surgery

Interviews were conducted with 63 women aged 18-75 shortly after their admission to hospital for routine non-cancer gynaecological surgery. Three groups were studied: major surgery, chiefly hysterectomy, carried out for benign conditions (n = 25); minor surgery such as dilatation and curettage (n = 29); fertility investigations and sterilisations (n = 9). Women were asked whether they worried if they were suffering from seven serious illnesses including heart disease, breast cancer and gynaecological cancer (cancer of the cervix, womb or ovaries). Significantly more women were concerned that they suffered from gynaecological cancer than any other illness. When asked why they were worried, over 85% of those expressing concern believed that their current gynaecological problem stemmed from cancer. Worry about gynaecological cancer was positively associated with psychiatric status and gynaecological knowledge, and negatively with satisfaction with treatment. A link with presenting clinical symptoms was also identified. This study revealed high levels of unwarranted distress in women undergoing routine surgery. Such fears may not be allayed, since surgeons and staff may not consider cancer to be relevant to the patient's clinical condition.

Perceptions of labour: discrepancies between midwives' and patients' ratings

Women's ratings of their experience of childbirth were compared with midwives' ratings of the women's experience. The midwives' ratings were significantly different from those of their patients. Midwives presented a more positive picture of the woman's experience than did the woman herself. Furthermore, the women reported using psychoprophylactic techniques for controlling discomfort for significantly more of the time than the midwives reported that the women used such techniques. The results are discussed in the context of similar findings reported in the literature.