Challenges for hospital management in supporting nurses to deliver humanized care

Abstract

Hospitals are paying increasing attention to the delivery of humanized care. The purpose of this study was to explore from the nursing perspective what hospital managers might do to facilitate this. A secondary analysis from a primary ethnographic study regarding dignity in nursing practice was conducted. Twenty interviews of internal medicine nurses from four hospitals were analyzed, and three main themes were identified: Management of nursing teams, Management of ethical values, and Management of the context. It is important for institutional values to be closely aligned with those of the nursing profession, and nurse managers play a key role in ensuring that the latter are applied in practice. The proposed actions offer a cost‐effective framework through which nurses and managers may promote the delivery of humanized care.

1. INTRODUCTION

In the last two decades, hospitals have sought increasingly to deliver humanized care within the broader framework of effectiveness and efficiency (Dehghani et al., 2015; Olivares Bøgeskov et al., 2017). This has led to initiatives aimed at promoting more humanized care being implemented in various countries (Commissioning Board Chief Nursing Officer & DH Chief Nursing Adviser, 2012; Corrente, 2014; Ministério da Saúde, 2001), as well as within specific settings, including intensive care units (Heras La Calle et al., 2017), emergency departments (Lovato et al., 2013), pediatric units (Tripodi et al., 2017), and maternity services (Alvares et al., 2018), among others.

Humanization implies the creation of a healthcare culture that recognizes the subjective, historical, and sociocultural dimensions of both patients and professionals, the ultimate aim being to improve working conditions and care quality through the integration of human and scientific values (Backes et al., 2006). Although nursing as a profession has always been associated with the more human side of healthcare, the current predominance of medical technology and the need to keep up to date with the latest advances has led to an increasing biomedical emphasis in both the education and practice of nurses, to the detriment of their traditional role (Galvin & Todres, 2013; Poblete Troncoso & Valenzuela Suazo, 2007). In this regard, authors such as Beltrán Salazar (2016) have argued that the importance of humane patient care may be lost sight of within the biomedical approach. This situation has resulted in the re‐emergence of a number of theories or movements that emphasize the importance of the human aspects of caring and seek to place them once more at the heart of nursing (Kèrouac et al., 1996; Watson, 2012).

The need to promote a more humanized approach to healthcare has generated numerous studies that have sought to identify how professional values are put into practice (Martin‐Ferreres et al., 2019) and to locate them within a theoretical framework (Kèrouac et al., 1996). Research has also examined the relationship between the application of professional values and patient safety (Kangasniemi et al., 2013), the impact of ethical conflicts on professionals (Thorne, 2010), the implications that work values have for health institutions (Beltrán Salazar, 2016; Caricati et al., 2014), and patients’ perceptions of dignified care (Matiti & Trorey, 2008).

The purpose of the present study was to explore from the nursing perspective what hospital managers might do to facilitate nurses’ delivery of humanized care. Although professional nurses have a crucial role to play in the delivery of humanized care, health institutions must ensure that they have the necessary resources for doing so (Backes et al., 2006). Thus, awareness within the institution of those aspects that nurses see as facilitating their role will help to ensure that they are in a position to offer high‐quality humanized care. To date, several studies have explored the barriers that professional nurses perceive in relation to the performance of their role, with institutional policies and management being the main obstacle identified. More specifically, research has examined the impact of the institution on job satisfaction (Lu et al., 2005), the role of work climate and professional commitment (Caricati et al., 2014), and the effect of nurse supply and workload on professional development opportunities (Coventry et al., 2015). However, we are aware of no studies in which nurses were asked to identify institutional practices that might facilitate the delivery of humanized care. The present research aims to address this gap through an in‐depth exploration of nurses’ views in this regard.

2. METHOD

2.1. Design and data collection

In a previous ethnographic study aimed at exploring the delivery of dignified care by professional nurses, we concluded, based on the views expressed by nurses, that institutional policies play a key role in determining the extent to which humanized care is possible (Martin‐Ferreres et al., 2019). In order to gain deeper insight into this relationship between policy and practice, we carried out a new secondary analysis of the interviews conducted for the ethnographic study. The particular focus of interest was nurses’ views regarding what hospital managers might do to promote and enable them to deliver humanized patient care.

Participants in the primary study were nurses from the internal medicine units of four hospitals in the province of Barcelona (Spain) (Table 1). They were selected by means of purposeful sampling so as to ensure recruitment of good informants with experience of the study phenomenon.

TABLE 1.

Description of the research context

Hospital	Type of management	No of beds	No of professionals	No of nurses
A	Private	272	900	272
B	Private	215	780	260
C	Private	100	145	57
D	Public	753	3239	983

The criteria for inclusion were as follows: (a) working on an internal medicine ward, (b) at least three years’ professional experience, (c) fluency in Spanish or Catalan, and (d) signing informed consent. With the aim of achieving maximum variation of responses within the sample, we selected participants of different age, gender, and years of experience.

Between September 2014 and May 2016, the main researcher conducted interviews with 20 nurses. All the interviews took place in a room made available by the participating hospital, and they were all recorded and subsequently transcribed. The mean duration of interviews was 68 minutes. Before starting each interview, the researcher explained the purpose of the study and obtained informed consent to proceed. Interviews began with questions about the general concept of humanized care, before asking more specifically about how its delivery may be influenced by the way in which health institutions are managed. Sociodemographic data were also obtained for all participants.

Alongside the interviews, the researcher kept a field diary in which she recorded her observations, including of the interviewee's nonverbal behavior. Throughout the process, the researcher maintained an attitude of constant reflexivity so as to monitor her subjectivity and minimize her influence on the collection and analysis of data.

2.2. Data analysis

We began by creating a primary document containing the interview transcriptions, which were then analyzed using an inductive method. In a first step the main researcher and another member of the team, working independently, read through the transcriptions several times in order to gain an overview of the study phenomenon and to identify units of meaning supported by selected quotations. They then shared their respective interpretations with the rest of the research team so as to reach a consensus. The units of meaning identified were then coded and grouped into 16 categories based on their similarity. Further analysis of these categories yielded six sub‐themes, from which three primary themes emerged. ATLAS.ti 7.2 for Windows was used to manage and organize the data.

2.3. Consideration of rigor

Rigor was ensured by applying the criteria proposed by Calderón (2002). Accordingly, during the analysis the findings were triangulated among all members of the research team in order to allow for discussion regarding the interpretation of data and the homogeneity of emergent categories.

2.4. Ethical considerations

The study was approved by the ethics committee of each of the participating hospitals, and all necessary institutional permissions were obtained. Prior to any data being collected, participants were informed about the aims of the study and it was made clear that they could withdraw their consent at any point. All participants signed informed consent, including for the interviews to be recorded. Only the principal investigator had access to the full recordings.

3. FINDINGS

All of the 20 nurses interviewed worked on a medical ward. They were aged between 26 and 57 years (mean: 39) and had a mean nursing experience of 15.6 years (range: 5–36 years). Eighteen were women and two were men. Seven of them (35%) reported that they had received continuing education on professional values.

Three themes emerged from the analysis, reflecting the three areas in which institutional factors and policies can influence nurses’ ability to deliver humanized care: Management of nursing teams, Management of ethical values, and Management of the context. Table 2 shows the three themes, along with their corresponding sub‐themes and categories.

TABLE 2.

Aspects of hospital management that influence the delivery of humanized care

Categories	Sub‐themes	Themes
Patient‐to‐nurse ratio Distribution of human resources Staff and shift rotation	Workload	Management of nursing teams
Administrative tasks
Recognition by hospital management Opportunities for promotion Support from line managers Work climate	Professional motivation
Nurses’ ethical values are shared by the institution Access to training in value‐based practice	Institutional values	Management of ethical values
Professional values Professional experience	Professional values
Use of care protocols Electronic medical records	Contextual facilitators	Management of the context
Speed of IT systems Interruptions	Contextual barriers

3.1. Management of nursing teams

3.1.1. Workload

All the nurses we interviewed saw workload as having a key influence on their ability to deliver humanized care. The aspect which most affected their workload was the patient‐to‐nurse ratio.

I think the hospital management allows me to apply my values and do my job properly because they’ve reduced the patient ratio, which is not usually what happens. (N19)

A lower ratio enables nurses to spend more time with patients and, therefore, develop better communication and provide unhurried care.

The only way that management can support us is by increasing the number of staff so that we have time to talk to patients if that’s what they need, to listen to them. (N9)

An appropriate distribution of human resources was seen as one way of reducing workload. For instance, the nurses suggested that staff could be distributed according to patients’ diagnosis and the complexity of their condition, instead of applying a predetermined staffing ratio across the board.

If there were closer monitoring of each unit, looking at workload and each patient’s needs and then assigning the number of nurses on that basis, I think the system would work better, we’d be able to offer better care to patients. (N4)

However, their actual working conditions involved a small number of nurses being responsible for large numbers of patients.

We’re each responsible for 13 patients. We need more nurses so as to have fewer patients and offer them better quality care. Ideally, it’d be no more than seven or eight patients. (N11)

Another factor with an important impact on workload concerned staff and shift rotations. In this regard, having a sufficient number of permanent staff was seen as positive. In general, permanent nurses on a unit where many of the staff were on rotation experienced a greater workload than was the case for those working in stable teams.

Constant staff changes get in the way of care. Changing unit or team every day… it creates anxiety, it’s unsettling, it holds you back because you’re not in your environment (…) I think increasing the number of permanent staff would help a lot. (…) When your colleagues know what to do it helps you to work better, in a more relaxed atmosphere. (N2)

As for nurses on rotation, some of them commented that because they were unable to get to know patients they got less involved and related to them on a more superficial level.

Not being able to follow things up undermined the value of my work. There were things I missed, it was impossible. If you don’t know you can’t act. (N17)

Reducing the amount of paperwork was also identified by nurses as something that would facilitate their delivery of care. They considered that they spent too long, especially on the afternoon shift, on tasks that could be performed by administrative staff.

If we didn’t have so much paperwork we’d have more time for patients. Time to check on IV lines, on their treatment, to show interest in them and give them time to talk about whatever it is they need. (N16)

3.1.2. Professional motivation

Over half of the nurses interviewed regarded professional motivation as another factor that facilitated the delivery of humanized care. Recognition by hospital management of nurses’ contribution, opportunities for promotion, feeling supported by line managers, and a positive work climate were identified as key elements contributing to their motivation as professionals. In this context, recognition of their work as individuals was also linked to job satisfaction.

I think they could recognize what I do by giving me a bit more responsibility, for example, making me a placement supervisor. If you feel recognized, then you’re more satisfied and you go to work happier. (N12)

In general, the nurses did not associate professional recognition with higher salaries. Rather, they considered that recognition could be shown by including them in new projects, enabling them to attend conferences, or even by reducing the number of rotations they had to do.

The possibility of going to that conference made a difference to me. Another way in which they make me feel valued is by considering me for a new project. (N17)

I feel valued when I’m able to work for three or more days on the same ward. (N16)

Those nurses who felt supported by their line manager reported being more satisfied at work as this helped them to fulfill their responsibilities.

I worked in a hospital where the nurse manager was always available. Any queries you had, she was there to help. The one here only comes if I phone her about something urgent. (N2)

3.2. Management of ethical values

3.2.1. Institutional values

All the nurses considered that the extent to which their own ethical values were shared and supported by the institution had a major impact on patient care and on themselves as individuals. Being unable to care for patients in line with their values generated considerable tension and anxiety and in some cases led to burnout.

A lot of nurses reach a point of burnout because they can’t work in a way that reflects what they believe in. So then there’s no meaning to what you’re doing, and without meaning your values are not the same. (N17)

In addition to the importance of shared values across professionals and the institution, some nurses also highlighted the need for the human and technical sides of care to be seen as equally important. However, their comments suggested that this was not the case.

I see the human side of patient care as being more important, but the hospital places more emphasis on the technical side. I try to combine the two. (N16)

The majority of participants also identified training in value‐based practice as something that would promote the delivery of humanized care. They considered that hospital management needed to do more to ensure that this was available to greater numbers of professionals.

I feel I lack knowledge about values, but the hospital is not always there to help me get the training I need. (N19)

3.2.2. Professional values

Alongside institutional values, some of the nurses considered that professionals should start from a set of personal values which enable them to integrate those of the institution into their daily practice.

I think we need to be aware of the institutional values, of how they want us to be with patients, but I don’t think that’s enough. We each need our own set of values and on that basis integrate those of the institution. (N1)

Some of the nurses highlighted the importance of professional experience as this enabled them to consolidate their values.

My professional values have got better and stronger because I’ve got many years of experience behind me. There ought to be some system that allowed you to reinforce or develop your values. (N17)

3.3. Management of the context

Another aspect that the majority of participants highlighted as having an impact on the delivery of humanized care was the way in which their work context was managed.

3.3.1. Contextual facilitators

Over half of the nurses thought that care protocols helped to ensure the quality of care in their unit. Others, however, considered that standardization of this kind meant that bureaucracy could come before patient care, thus reducing the time spent on the latter.

Everything is highly standardized, there are lots of protocols, a lot of paperwork and care plans, all of which is important, but the basic stuff, caring for patients, gets left behind. Caring for patients and meeting their needs should come first. (N3)

Almost all the participants saw the benefits of electronic medical records, allowing them access to all the information about a patient in real time, as this reduced the time spent on administrative tasks.

Medical notes used to be written by hand and it was a lot of work. Now it’s all on computer. This is an improvement because I don’t waste time transcribing and trying to understand what has been written. (N13)

3.3.2. Contextual barriers

Although the introduction of electronic medical records was seen as a positive development, the speed of IT systems was highlighted as a problem.

The system should make things easier, but it's too slow. (N13)

Most of the nurses also referred to the large number of interruptions they experienced during their working day and how this made it difficult to attend to patients’ needs. The most common distractions were constant telephone calls and other professionals demanding their attention when they were with a patient.

You often have to cut them off mid‐sentence. They’re about to ask you something and you have to tell them, ‘hang on a minute, somebody’s calling’. There are a lot of interruptions, and you end up not doing half of what you intended. (N20)

4. DISCUSSION

Analysis of the interviews conducted in this qualitative study identified three areas in which institutional factors and policies can influence nurses’ ability to deliver humanized care. The first area, management of nursing teams, refers to those aspects directly related to institutional policy and, in particular, to the approach of nurse managers which may facilitate the delivery of humanized care. Key examples here are actions which help to reduce workload and increase staff motivation. More specifically, the nurses we interviewed considered that a reduced workload would, by allowing them to spend longer with patients, enable them to build closer relationships and provide better quality care.

Various authors (Aiken et al., 2014; Beltrán Salazar, 2016; Blomberg et al., 2019) have documented the negative effects of an excessive workload. Beltrán Salazar (2016) related increased workload, due primarily to staffing cuts, to a greater number of errors, poorer quality care, and lower satisfaction among professionals. Similarly, Blomberg et al. (2019) found that a high patient‐to‐nurse ratio reduced, among other things, the quality of care and patient safety. Importantly, Aiken et al. (2014) reported an association between an increase in nurses’ workload and an increased risk of patient mortality.

In terms of how these issues may be addressed, our participants suggested that workload could be reduced by establishing the patient‐to‐nurse ratio on a given ward on the basis of patients’ needs and the complexity of their diagnosis. Less staff rotation was also seen as something that would have a positive impact on workload. Another suggestion they made was to reduce the amount of paperwork they have to do by assigning these tasks, where possible, to a suitably qualified member of administrative staff. All of the above is consistent with the conclusions reached in the study by Beltrán Salazar (2016).

In line with one of the findings reported by Thorne (2010), our participants saw professional motivation as a positive element that could increase both job satisfaction and their commitment to the institution in which they worked. Although staff retention is still one of the most difficult and time‐consuming challenges in organizational management (Caricati et al., 2014; Lu et al., 2005), various studies have found that staff who feel recognized and valued by their organization are more likely to remain in their job, even without greater remuneration, and also that recognition of this kind encourages the application of professional ethics (Caricati et al., 2014; Dehghani et al., 2015). Consistent with a view expressed by the nurses we interviewed, research suggests that a supportive relationship with line managers (Dehghani et al., 2015) and opportunities within the organization for training and development (Slatyer et al., 2016) are key factors contributing to professional recognition.

The second area in which the delivery of humanized care may be affected concerns the management of ethical values, both those of professionals and those of the institution. With respect to institutional values, the nurses stressed how important it was for these to be aligned with the values of their profession, since feeling supported in the application of nursing values was crucial for avoiding unnecessary stress and burnout. This reflects a point made recently by Sonis et al. (2020), who argue that an emphasis on compassion and humanism is not burdensome for staff, and in fact, it can improve their job and personal satisfaction. This is consistent with studies showing that a good fit between the values of employees and those of the organization can have a number of benefits for the latter, since it is associated with less absenteeism and less staff turnover, thereby reducing organizational costs (Thorne, 2010). It should also be noted, as Corley (2002) argues, that a prolonged conflict of values can lead to moral distress among nurses as they struggle to respond to the needs of patients and families, thus undermining the delivery of humanized care.

Another value‐related issue that was raised by our participants concerned the need for hospital management to recognize the human and technical sides of patient care as being equally important. In their experience, however, the institution tended to prioritize the biomedical aspects of care over its more human side. This may be driven by the search for cost‐effectiveness, which, as Beltrán Salazar (2016) notes, may overlook the patient as person. However, cost‐effectiveness is not inherently incompatible with the delivery of humanized care. Indeed, the results of this study suggest not only that it is possible to achieve efficiency while simultaneously encouraging a more humanized approach to care but also that promoting humanized care can impact positively on hospital cost‐effectiveness. This is because management support for the practice of humanized care is likely to increase nurses’ job satisfaction and strengthen their commitment to the organization, thus helping to reduce staff turnover and, ultimately, to reduce organizational costs. Conversely, a management philosophy that emphasizes the biomedical and technical aspects of care and which leaves nurses little opportunity to relate to patients as individuals may result in job dissatisfaction and burnout, leading in turn to poorer quality care, absenteeism, and increased staff turnover, thus undermining the cost‐effectiveness of the institution as a whole (Caricati et al., 2014; Olivares Bøgeskov et al., 2017).

A related issue that emerged in the interviews with nurses concerned the need for more training in value‐based practice, since many of them acknowledged that this was an area where they lacked knowledge. In addition to training, however, they also emphasized the key role played by nurse managers when it came to dealing with ethical dilemmas and applying their professional values in clinical practice. This is consistent with the findings of previous studies (Aitamaa et al., 2021; Olivares Bøgeskov et al., 2017). A final point of note here is that the nurses also considered it important for professionals to have their own set of personal values which enabled them to integrate those of their profession and those of the institution into their daily practice.

The third and final area that, in the view of the nurses we interviewed, may influence the delivery of humanized care involves factors related to management of the work context. In this respect, and consistent with the findings of Kangasniemi et al., (2013), the nurses considered that the use of care protocols and electronic medical records facilitated a more humanized approach. However, they also felt that the performance of IT systems needed to be improved, as slow speeds and technical problems took up time that would be better spent with patients. The amount of time they could dedicate to patients was also undermined by the frequent interruptions they experienced (telephone calls, doctors, or other professionals demanding their attention when they were with a patient), which forced them to work faster. We referred earlier to this aspect in relation to patient safety, but such interruptions may also imply a loss of privacy and/or confidentiality for patients (Walsh & Kowanko, 2002), both of which are key components of dignified care (Martin‐Ferreres et al., 2019).

It is important to note that the three areas described above are not independent of one another, and it is the interplay between them that ultimately affects the way in which nurse's care for patients. Figure 1 provides an overview of these inter‐relationships.

FIGURE 1.

Actions and benefits of promoting humanized nursing care

It can be seen in the figure that nurses identified actions in each of the three areas that would help to promote (or already contribute to) the delivery of humanized care. Furthermore, these actions lead to a series of benefits that cut across the specific area in which action is taken. A management strategy that encourages and enables nurses to adopt a more humanized approach to patient care will increase their job satisfaction, thus helping to reduce staff turnover, stress, burnout, and absenteeism (Busch et al., 2019). This, in turn, has benefits for patients, insofar as nurses who feel recognized and satisfied as professionals will be more likely to deliver safe and high‐quality care (Dreiher et al., 2020). Our findings in this respect are consistent with previous studies (Busch et al., 2019; Caricati et al., 2014) and highlight the mutual relationship between the practice of humanized care and job satisfaction. In addition, and importantly, our results suggest that hospital managers can achieve the goal of cost‐effectiveness while also implementing strategies to promote humanized care.

A final point to note is that the views of the nurses we interviewed reflect areas of interest and concerns identified in studies conducted in other countries, and in this respect, we believe that our results add to the international body of knowledge on this topic.

4.1. Limitations

This study has a number of limitations. The first is that our results offer a partial view based on nurses’ perceptions, and as such, they may not capture the efforts that hospital managers are already making in an attempt to facilitate the delivery of humanized care. Although the fact that only two of the 20 nurses interviewed were men might be considered a limitation, it also means that the gender distribution of our sample broadly reflects that of the nursing profession as a whole in several countries, where 15%–20% of nurses are male (Boniol et al., 2019). However, we cannot rule out the possibility that our findings may be subject to a gender bias. In addition, the fact that the sample was comprised solely of nurses working in internal medicine units implies that their perceptions may differ from those of professionals employed in other specialist areas.

5. CONCLUSIONS

The results of this study highlight the key role that hospital management can play in enabling the delivery of humanized care, as well as the challenges facing institutions in this respect. As this was a qualitative study based on the views of nurses, the aspects identified as facilitators of a more humanized approach to care are likely to be acceptable to professionals, rather than being seen as examples of top‐down management.

Although a commercial emphasis is increasingly common within healthcare, the results of this study suggest that the goal of cost‐effectiveness is not incompatible with the delivery of humanized care, provided that strategies are put in place to improve job satisfaction and staff retention, both of which are central to high‐quality care and patient safety. Nurse managers have a key role in this regard, especially in terms of ensuring that institutional values are aligned with those of the nursing profession. As for healthcare institutions as a whole, they should not only encourage training in value‐based practice but also seek to recruit professionals whose personal ethics are consistent with the delivery of humanized care and who are able to integrate them with those of the organization.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.