Caring Behaviors: Perceptions of Acute Care Nurses and Hospitalized Patients with Diabetes

Abstract

Caring behaviors

Perceptions of acute care nurses and hospitalized patients with diabetes

Purpose

The purpose of this study was to examine the perceptions of caring behaviors that influence the patient experience in acute care nurses and hospitalized patients with diabetes.

Background

Nurses are the caregivers who render most of the direct care patients receive while they are hospitalized. Understanding what patients perceive as caring behaviors is essential in tailoring nursing interventions to meet patient needs.

Data sources

Data collection occurred at a 1,200 bed, nonprofit academic medical center located in the Midwest.

Description

Sixty-four nurses and 54 patients with diabetes were queried about their experience with diabetes caring behaviors.

Conclusion

Nurses consistently reported providing caring behaviors more frequently than patients reported receiving them.

Implications

This study has implications for understanding the patient experience in the hospital setting specifically related to patient education. Providing patient education is an important caring intervention that directly affects the patient experience. However, none of the patients in this study identified this as a caring behavior used by nurses.

Introduction

Creating an optimal patient experience is a priority for healthcare executives. It is a worthy endeavor, yet it may be daunting given the lack of universal definition for patient experience. In the Patient Experience Leadership Survey conducted in 2009, 34.5 percent of respondents reported that patient experience equals patient-centered care, 29 percent agreed that providing care organized around the unique needs of each patient represented a positive patient experience and 23 percent identified excellent customer service as reflective of a memorable patient experience.¹ Cleveland Clinic defines the patient experience as “care that addresses every aspect of patients' encounters, including their physical comfort, as well as their educational, emotional and spiritual needs.”² Another definition, by the Beryl Institute, describes the patient experience as “the sum of all interactions shaped by an organization's culture that influence patient perceptions across the continuum of care.”³ According to Press Ganey CEO Patrick Ryan, the patient experience is “not about happiness. It's about patients being respected, being communicated with and having their care coordinated in such a way that they can get the best possible clinical outcome for whatever their circumstances are.”⁴ The common thread to these definitions is that each one encompasses an aspect of caring. A fundamental component of nursing caring is defined as “the work or practice of looking after those that cannot do it for themselves.”⁵

Behaviors associated with caring also serve the role of linking nursing interactions to the patient experience.

When patients are hospitalized, they have expectations about the care they will receive. Nurses are the caregivers who render the most direct care and have the most contact with patients while they are hospitalized.6 Understanding what patients perceive as caring behaviors is essential in tailoring nursing interventions that meet individual patient needs and impact the patient experience.

Background

Demands on bedside nurses have never been greater as they struggle with competing time demands and priorities to enhance the patient experience. The hectic pace of the bedside nurse may be perceived by the patient as lack of caring or may result in a nurse's inability to demonstrate behaviors discernible by the patient as caring. Without conscious attention to the development of the caring relationship, the patient experience can be negatively affected. Identifying the behaviors that patients perceive as caring can help nurses design interventions that are patient centric, predicated on evidence and contribute to the overall patient experience.

Patient perceptions of nurse caring behaviors

Previous research on patient perceptions of caring behaviors indicated that nurses' “professional knowledge and skills were rated the most caring behavior by patients.^7,8 In a grounded theory approach to understanding patient perceptions of nurse caring behaviors, Finch⁹ identified four themes: responding when needed and without being prompted, doing extra “little things,” following through and taking care of patient needs.

O'Connell and Landers¹⁰ compared the perceptions of nurses (n = 33) and family members (n = 19) of patients in three ICUs in Ireland. The top five caring behaviors reported by relatives, in descending order, were treat the patient as an individual, know what you are doing, know how to give injections, IVs, etc., know how to handle equipment and give the patient medications and treatments on time. The nurses in this study identified the most important caring behaviors as know what you are doing, treat the patient with respect, treat the patient as an individual and be kind and considerate. In another study, patients from six European countries were surveyed to determine whether caring behaviors affect satisfaction.¹¹ Study results from 1,565 patients revealed that “knowledge and skills” were rated the as the highest (most important caring behavior) and “positive connectedness” received the lowest rating.

Von Essen and Sjoden¹² studied the perceptions of 81 patients and 105 nurses in Sweden and found significant differences between patients and nurses. The patients rated knowing when to call the doctor, how to give injections, being honest with the patient, putting the patient first no matter what else happens and speaking to the patient in understandable terms as the highest mean items. Nurses rated the top five caring behaviors as listening to the patient, putting the patient first no matter what else happens, touches the patient when comfort is needed, talks to the patient and speaking to the patient in understandable terms.

These studies exploring perceptions of caring behaviors have revealed a lack of congruence between what nurses and patients perceive as caring. Identifying these behaviors can help nurses design interventions that are patient centric and evidence based and that contribute to the overall patient experience. Additional research is needed to examine perceptions of patients and nurses. The present study was designed as a pilot study to address the knowledge gap, specifically among patients with diabetes.

Method

Setting: The setting for the study was conducted on four medical inpatient units of a nonprofit, 1,220-bed teaching hospital in the Midwest.

Sample: A convenience sample of hospitalized patients with diabetes was invited to participate in the study. Inclusion criteria consisted of English-speaking adults 18 years and older with a diagnosis of diabetes who were alert, oriented, able to verbally respond to questions and who agreed to participate in the study. A total of 68 patients were approached to complete the survey; five patients refused, and seven patients were deemed too ill to be interviewed. The nurse sample included bedside registered nurses who had completed new nurse hospital orientation and were assigned to one of the four medical units. This nurse sample also was one of convenience. Nurses in managerial or advanced practice roles, or were in new nurse hospital orientation, were excluded.

Each patient participant was asked to respond to the following open-ended question: “What actions did your nurses use during this hospitalization that reflected ‘caring' in managing your diabetes?” Patients participated in an interview by the primary investigator, who was not involved in their care. Nurse participants were asked to respond to the following question via Survey Monkey: “What caring behaviors do you consistently use with patients who have diabetes to optimize their glucose control while in the hospital?”

Demographic information collected from patients included age, gender, race, marital status, education, employment status, reason for hospital admission, type of diabetes and length of time the patient had diabetes. Length of current hospitalization was abstracted from the participant's medical record. Nursing background data included age, gender, race, educational background, years of nursing experience and employment status (full or part time).

Results

Patient sample: The patient sample (n = 56) included 33 males (61 percent) and 21 females (37.5percent), ranging in age from 23 to 86 (M = 57.9 years; SD = 14.7). Ten patients had a diagnosis of diabetes mellitus (DM) Type 1, 45 patients had a diagnosis of DM Type 2 and one patient was diagnosed with latent autoimmune diabetes of adulthood, or Type 1.5. The duration of diabetes ranged from less than one year to more than 50 years. Tree patients used insulin pumps to manage their diabetes and were not dependent upon the nursing staff to administer insulin. Digestive disorders and infections were the two most prevalent diagnoses. Diabetes-related complications were the third most prevalent diagnosis. Patients' length of stay ranged from three to 25 days. (See Table 1).

Table 1.

Demographics of Patients (N = 54)

Variables	n	%
Gender
Female	21	39.0
Male	33	61.0
Race
African American	23	42.6
Asian	1	1.8
Asian Indian	2	3.7
Caucasian	25	46.3
Hispanic/Latino	3	5.6
Marital Status
Not Married	27	50.0
Married	19	35.2
Widowed	8	14.8
Education Completed
<High School	6	11.0
High School Graduate	19	35.2
Some College	14	26.0
College Graduate	8	15.0
Graduate School	6	11.0
Missing	1	1.8
Employment Status
Employed Full Time	11	20.3
Employed Part Time	1	1.3
Unemployed/Looking for work	5	11.0
Student	1	1.3
Retired	23	42.1
Disabled	13	24.0
Duration of diabetes diagnosis
<1 year	3	6.0
1–5 years	14	26.0
6–10 years	17	31.0
11–15 years	8	15.0
16–20 years	6	11.0
21–25 years	2	4.0
>25years	4	7.0
Type of Diabetes
Type 1	10	18.0
Type 2	43	80.0
Other	1	2.0
Admitting Diagnosis/System problem
Gastointestinal	12	22.2
Infection	10	18.6
Endocrine: DKA/Hypoglycemia	6	11.0
Cardiac	5	9.0
Renal	5	9.0
Respiratory	5	9.0
Cancer	4	7.1
Ortho/Neuro	3	6.2
Hematologic	3	6.2
Immunologic	1	1.7

Sixty-three registered nurses participated; 56 (89 percent) were female with an age range of 22 to 74 years (M = 36, SD = 13.9); 53 (83.4 percent) worked full time. On average, these nurses had worked 8.4 years as RNs and six years on the nursing unit. (See Table 2).

Table 2.

Demographics of Nurses (N = 64)

Variables	n	%
Gender
Female	57	89.0
Male	7	11.0
Race
African American	8	12.5
Asian	9	14.0
Asian Indian	1	1.5
Caucasian	44	69.0
Hispanic	2	3.0
Highest Nursing Degree
Associate Degree	19	30.0
Diploma	2	3.0
Bachelor's Degree	40	62.0
Master's Degree	2	3.5
Other	1	1.5
Work Status
Full Time	53	83.0
Part Time	11	17.0

Patients verbalized positive caring examples, offered observations of when nurses tried to be caring and described situations when the interaction with the nurse was not perceived as caring. After the primary investigator reviewed the responses via content analysis, three categories were identified; these were confirmed by the other investigators. These categories included providing information, surveillance/monitoring and listening to patient concerns. Thirty-four patients (62 percent) described the caring behavior of providing information stating that they were informed of their blood sugar results and informed of upcoming tests and procedures. Regarding surveillance/monitoring, 13 patients indicated that nurses paid attention to and monitored them. Evidence of this category was the remark that six patients (11 percent) described experiencing a hypoglycemic event while in the hospital, stating that the nurses responded quickly. In terms of listening, one patient eloquently described his experience of nurse caring this way: “Since I am blind, I get a sense of how caring a nurse is going to be by the tone of her voice. … I know they are busy, but you never hear it in their voice or in their footsteps as they walk away.”

The themes that emerged from the nurses' responses included teaching, listening and supporting. Teaching was the most prevalent caring behavior described by the participants and was identified by 41 (76 percent) of nurses. One nurse wrote, “I find out what patients know about their diabetes and I learn from those that know themselves well. I teach those that need further instruction.” Another nurse said, “I assessed my patient's level of knowledge regarding her diabetes, determining what she does at home and how well it works for her.”

Listening was a topic identified by 39 (67 percent) of nurses. In an illustration of listening, one nurse conveyed her practices in this way: “I strive to include patients in their care by listening when they are uncomfortable with a dosage or a medication that is prescribed.” Another nurse summed up listening this way: “Listening is the ultimate caring strategy. It conveys respect, acceptance and trust. It says to the patient, ‘I am with you, and I am here for you.’ It says to the family, ‘I think your loved one is important too.’”

The third most common intervention, supporting, was described by nurse participants as including praising behaviors, as described by one respondent: “I praise them when they are engaging in their care and asking questions, and I encourage them to ask me questions.” In describing her supporting role, one nurse wrote: “I always implement education in patients' plan of care. I learn about the patients' lifestyle and their strengths and weaknesses and develop a plan based on those observations.”

Discussion

Similar to the findings of previous research, the nurses and patients in our study perceived listening as reflective of caring. However, the promotion of teaching-learning that nurses in the present study identified as indicative of caring behaviors was not identified in previous studies examining caring^7,8,12–16 or by the patients in this study. Patients did identify “keeping them informed” of their response to treatment or procedures for the day as reflective of nurse caring.

It was interesting to note that none of the patients identified formal teaching as a caring behavior used by nurses. Perhaps the disparity between nurses describing the teaching they provided and the patients identifying keeping them informed is the language and conversational tone used by nurses when providing teaching. It may be advantageous for nurses teaching patients about diabetes management to precede their instruction by stating that they are teaching the patient about preventing low blood sugars, or how to monitor their blood sugars because they care about them.

There are several limitations to this study. Specifically, data were collected from both patients and nurses at a single site, during one interview per participant. There is also a selection bias in the patients included for interviewing. It is recommended that future research focus on more extensive interviews over a period of the patients' hospitalizations, in order to capture a more complete view of the patients' experience with hospitalization and care.

The study results have implications for care of patients hospitalized with diabetes, such as disseminating specific behaviors patients think are caring in managing their diabetes and, conversely, behaviors nurses believe are caring. This information can be shared with nurses to refine the way they provide care to patients, or encourage nurses to ask patients about their expectations of care while in the hospital. This may result in more patient-centric care and improvement in the overall patient experience. Educational programs may be developed that highlight the caring expectations of patients. Further, this study may help nurses become aware of the importance of their caring interventions with patients.