Nurse Caring and Perceived Caring Related to Patient Satisfaction: A Critical Literature Review

Running head: NURSE CARING AND PERCEIVED CARING

 NURSE CARING AND PERCEIVED CARING RELATED TO PATIENT SATISFACTION SATISFACTION A CRITICAL LITERATURE REVIEW SUBMITTED TO THE DEPARTMENT OF GRADUATE STUDIES IN NURSING EDUCATION IN PARTIAL FULFILLMENT OF THE REQUIREMENTS For the degree NURSE MASTER OF SCIENCE  by REBECCA L. DORTON

INDIANA WESLEYAN UNIVERSITY MARION, INDIANA JULY, 2014

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 NURSE CARING AND PERCEIVED CARING - Abstract In light of the current significance of the measurement of patient satisfaction for full reimbursement from the Centers for Medicare and Medicaid, the author critically reviewed current literature regarding regarding nurse caring and perceived caring related related to patient satisfaction. In recent years, due to government regulations, patient satisfaction has been an imp ortant factor in measuring the quality and financial well being of health care organizations. Also, patient satisfaction has been identified as a possible factor in promoting safety and other beneficial health outcomes. Caring was explored in the literature literature and related to patient satisfaction satisfaction through the theoretical framework of Jean Watson. Articles were accepted for review if they were peerreviewed studies published between 2008 and 2014; and were related to nurse caring, perceived caring, and patient satisfaction. satisfaction. There were 23 total articles selected that met the criteria. It was found that nurse caring factors affect perceived ca ring and patient satisfaction, and the idea that higher patient satisfaction is correlated with positive health outcomes was supported in this critical literature review.

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 Nurse Caring and Perceived Caring Related to Patient Satisfaction: A Critical Literature Literature Review Part I  –  Introduction  Introduction and Analysis of the Issue Introduction

Caring is a foundational concept in nursing. In the past 35 years it is a topic that has been a subject of study, research, research, and theory in nursing literature. literature. Many questions have been brought to the forefront of discussion related to the subject, such as: Is caring the essence of nursing, is is it the field‟s special knowledge area, is it equal to the discipline of nursing, is it a central concept in nursing, or is is it the core of its domain? Is it the goal or  the  the mission of nursing, or is it a goal and  a  a mission of nursing? (Meleis, 2012,  p. 91) The purpose for this critical literature review is to explore several facets of caring including caring theory, caring history, and perceived caring in the literature, and to relate them to the significant topic of patient satisfaction in today‟s health care health care environment. The aim of this  project is to analyze and synthesize current research on the topics described to confirm that  patient satisfaction is a result of nurse nurse caring and perceived caring and, that it is vital to the concern of nurses for financial as well as moral and ethical reasons. Patient satisfaction appears to bring about positive health outcomes in patients. If this could be established through current research, a clearer direction in additional research, theory, and practice could occur understanding that in promoting patient satisfaction, the nurse is promoting health. Caring Defined

Most individuals who have chosen nursing as their life‟s work have done so with an altruistic desire to care for others (Vance, (Vance, 2003). Humans have innate temperament traits which are acquired through environmental factors (Eley, Eley, Bertello, & Rogers-Clark, 2012). Caring

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is characterized by effective and skillful nursing, compassion, and understanding (FinfgeldConnett, 2008). For caring to occur the care recipient recipient needs to be open to receiving receiving and the care  provider needs to exhibit professional maturity with an underpinning of morality. morality. A conducive work environment for the implementation of caring is necessary (Finfgeld -Connett, 2008). “Caring has been defined by b y Jean Watson as a fundamental value that tha t guides nurses‟ ethical decision making and provides a basis for nurse caring actions” (as cited in Dingman, Williams, Fosbinder, & Warnick, 1999, p. 31). Jean Watson describes caring as preserving dignity dignity while addressing the person‟s needs. It is a commitment commitment to alleviate another‟s weaknesses by giving attention and concern for for the other (as cited cited in Vance, 2003). Caring is  both a construct and a concept. There is an emotional and subjective aspect of caring that cannot  be measured. There is also a behavioral, quantifiable dimension. Looking at the stated definitions definitions of Jean Watson, caring caring is a value and a commitment. In addition, she designed ten carative factors that are elements of caring (Watson, 2008). 200 8). These factors are interventions which require an intention to develop a relationship and actions that give substance to the plan. The commitment is a principle principle of ethics fixed fixed on preserving humanity and affirming the individual (Watson, 2008). Actions are presupposed by a foundation foundation of knowledge and proven competence. Watson‟s carative factors consist of: 

Values based on a humanistic-altruistic system

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Faith - hope

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Understanding of self and others

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Helping and trusting

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Expression of both positive and negative emotions

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Creative problem solving

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Transpersonal teaching and learning

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Providing an environment that supports and provides p rovides for spirituality, mental growth, and  physical wholeness

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Assistance with human needs

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Allowance for the phenomenological and spiritual (Watson, 2008)

The following is a description of caring by b y Jean Watson: The discipline of nursing, from my position, is/should be grounded in Caring Science; this, in turn, informs informs the profession. Caring Science informs and serves as the moral philosophical-theoretical-foundational starting starting point for nursing education, patient care, research, and even administrative practices (Watson, 2008, Chapter One, para. 5). When looking at caring through a humanistic worldview, one would say that caring is intrinsic to being human and nurses nurses demonstrate caring behaviors because they are are human. In contrast, Christian nursing is a ministry of holistic, compassionate care, responding to God‟s grace towards a sinful world, which aspires to promote optimal health and to bring comfort to the suffering, the needy, and the dying (Shelly & Miller, 2006). A Christian nurse operating und er a Christian worldview would view caring as a ministry of Jesus Christ. The motivation for caring would come from Christian principles of scripture to minister to those who are in distress. A view of caring based on the French philosopher Paul Ricoeur‟s work proposes that ethics, which is the goal of an accomplished accomplished person‟s life, is more desirable than morality, which is compulsory (Fredriksson & Eriksson, 2003). Caritas is Caritas is human love and charity in wanting what is good for the other. “Caritas, Caritas, as depicted in the narrative of the Good Samaritan, motivates the nurse nurse to take care of the other” (Fredriksson & Eriksson, 2003, p. 146). Solicitude

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is thoughtfulness and consideration. consideration. In French, it it means „tender care‟ (Fredriksson care‟ (Fredriksson & Eriksson, 2003). Expert nursing is the basic component of caring, c aring, but interpersonal sensitivity is key to the caring process and is empathetic insight into another person‟s suffering (Eriksson 1997; McNamara, 1995). Eriksson (1997) states, states, True caring is not a form of behavior, not n ot a feeling or state. It is an ontology, on tology, a way of living. living. It is not enough to “be there” - it is the way, the “spirit” in which it is done; and this spirit is caritative. (as cited by Eriksson, 1997, p. 9). Madeleine Leininger developed the Cultural Care Diversity and Universality Theory. She defines care as both an abstract and-or and-or a concrete phenomenon “as those assistive, supportive, and enabling experiences or ide as towards others with evident or anticipated need to ameliorate or improve a human condition or lifeway” (as cited in Leininger & McFarland, 2006, 2006,  p. 12). Leininger states that human caring has been learned and “Being human was to be caring, and caring was culturally based“ (as cited in Reynolds & Leininger, 1993, p. 24). Caring behaviors include a personal personal introduction; addressing the patient by his or her name; sitting at the patient‟s bedside for at least five minutes per shift and reviewing care; using touch; and verbalizing the mission statements in in planning care (Dingman et al., 1999). A concept analysis of caring conducted in 2004 determined that five attributes of caring a re evident in the literature. These attributes are: relationship, relationship, behavior, attitude, positive response, response, and flexibility (Brilowski & Wendler, 2005). History of Caring

Caring is a concept that that dates back to the beginning of human history. history. The need for caring is obvious for humanity to have survived. Historical documentation confirms confirms that ancient

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cultures and religions identified caring as an individual and collective responsibility of the  people (Stedman, 2013). The Book of Exodus mentions midwives assisting women in childbirth in ancient Egypt (Exodus 1:15-19). For centuries, caring was centered in the home and amongst family members. The responsibility of caring, has historically been dedicated to women women and those of lower social standing (Stedman, 2013). Madeleine Leininger discussed the differences between caring in a generic and  professional sense. Generic care was described as support for another to improve a human disorder. Professional caring was explained as being learned behaviors, procedures, or patterned patterned responses that help another to improve or sustain health (Reynolds & Leininger, 1993). Generic caring is an ancient expression of human h uman caring needed for the survival and health of Homo sapiens, including local home remedies and folk care (Reynolds & Leininger, 1993). For the purposes of this discussion on the history of caring, the profession of nursing and the activities of nurses will be focused on as b eing very closely connected with caring. Although, historically, there have been man y non-nurse caregivers who have fulfilled the role o f caring in the home and community. Anthropologically speaking, caring is one of the oldest and most universal expectations for human development and survival through our long history and in different places in the world. Caring for self and other human beings is a universal phenomenon that has endured beyond specific cultures, and has brought b rought forth important humanistic attributes of care-givers and care recipients. (Leininger, 1977/2012, p. 57). The discipline of nursing has its roots in the first century when Christians began to extend the teachings of Jesus Christ in exhorting believers to care for those in poverty, the sick, and those who were marginalized in the community. community. As churches grew larger, deacons were

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appointed to give care to the needy (Shelly & Miller, 2006). In Romans 16, a deacon named Phoebe is mentioned who is often credited with being the first visiting nurse (Shelly & Miller, 2006). By the third third century, groups of deaconesses who cared for the sick, were organized. In the fourth century, the church started hospitals staffed by nurses (She lly & Miller, 2006). Historical records of the fourth and fifth centuries chronicle the monastic movement when various religious orders cared for and protected the sick and wounded (Evans, 2004). The St. John of Jerusalem Order was a group of o f knights called Knight Hospitallers, who defended Jerusalem during the crusades. The group, later protected pilgrims by building hospitals and castles across Europe that provided lodging for travellers and places to care for the infirm (Evans, 2004). In 1475, a religious order of uneducated uneduc ated craftsmen was formed called the Alexian Brothers. They preached the Gospel and provided care to to the disenfranchised of society, including the poor, the disabled, and the the mentally ill (Evans, 2004). During the years of the  plague, in the fourteenth and fifteenth centuries, the Alexian Brothers were most widely known for burying the dead. After the plague abated, their hallmark ministry was to the mentally ill (Evans, 2004). From the sixteenth through the eighteenth centuries, many Catholic religious religious orders disbanded and monasteries were dissolved. Hospitals deteriorated and nursing moved  back into the home (Shelly & Miller, 2006). It is at that time recorded nursing activities fade, but resurface in the 18 00‟s when large charity hospitals were built, such as the Manchester Royal Infirmary in England (Evans, 2004) and the founding of missions and ministries such as the Widow‟s Society in New York, the Sisters of Mercy in Dublin, and the Society So ciety of Protestant sisters of Charity in London (Shelly & Miller, 2006). Theodor and Frederika Fleidner of Germany Germany saw the persistent needs of the

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impoverished and sick in their city and opened a garden house as a respite for orphaned and marginalized girls. Eventually, they established a group of deaconesses deaconesses to care for the sick in in their homes. This ministry developed into the Kaiserswerth Institute Institute for the Training Training of Deaconesses, consisting of a hospital and school for nurses (Shelly & Miller, 2006). Florence Nightingale studied at the Kaiserswerth Institute, and at Paris hospitals. She became a superintendent of a hospital in London, and then was asked by the British Government to serve as a nurse nurse in the Crimean War. War. It was during this time that she  began to develop her ideas around infection control, sanitation, and fundamental nursing care (Straughair, 2012). “Nightingale‟s philosophy and theory of nursing is stated clearly and concisely in Notes in Notes on Nursing (1859), Nursing (1859), Nightingale‟s most widely known work” (Tomey &. Alligood, 2006, p. 81). Florence Nightingale did not use the words transpersonal human caring, but her writings reveal the timelessness and manifestation of the concept and values for holistic nursing (Watson, 2010). Her writings were a foundation for the caring profession of nursing that it is today, setting the stage for it to develop into a separate and distinct profession. profession. History confirms that nursing has been viewed as an extension of the medical profession and under its jurisdiction (Stedman, 2013). Before 1880, it was a rare occurrence for illness to be treated in the hospital. Typically, the family doctor visited the sick person, gave instructions to the servants or female family members, and they tended to ill individuals in the home. The discovery of anesthetics and the advancement of medical and surgical techniques in the middle of the nineteenth century allowed all classes of society to seek treatment in hospitals hospitals (University of Glasgow, n. d.). Beginning in the 1860s, nursing schools produced educated women who were enthusiastically hired by

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hospital administrators, as by this time, doctors, patients, and the general public were insistent upon higher levels of skill in nurses (University of Glasgow, n. d.). In the early 1900s, issues related to sanitation and community health were the  pr imary imary concern of healthcare planners and and providers. Toward the mid 1900‟s, a shift shift in focus from community health to the health and well being of the individual occurred with th

scientific breakthroughs such such as antibiotics and vaccinations (Klainberg, (Klainberg, 2009). The 20

century brought many changes to the profession of nursing, with the addition of pro grams and professional organizations designed to address some of the problems in nursing and  promote nursing as a discipline. The American Nurses Association began publishing the  American Journal of Nursing  and  and nursing schools began allowing students to become licensed practical nurses and have additional training and testing to become registered nurses (Nursing Schools Path, 2014).  Nurses also began to gain further education and advanced degrees. The rise of nursing research and nursing theory has brought the profession of nursing into its own. While Florence Nightingale laid the foundation for nu rsing to become a distinct  profession, the realization came about later in history, though some nursing sociologists do not believe that nursing is a profession, but an emerging profession (Chitty, 2005). Whether or not this is the case, nursing is a very young profession, at best. Caring is a much much discussed topic in current nursing nursing literature. Caring became a topic of interest in the 1950‟s (Brilowski & Wendler, 2005). At that time, there was a deficiency of scholars to investigate investigate caring. In the late 1970s, research research on the subject was raised with the work of Jean Watson and an d the first National Caring Research Conference (Brilowski & Wendler, 2005). In 1979, Watson published Nursing: published Nursing: The Philosophy and

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Science of Caring. Her writing changed the face of nursing n ursing as it came onto the scene  before formal attention was being given to nursing theory as the foundation for the discipline of nursing and before much attention had been directed toward a philosophical foundation for nursing as a distinct discipline (Watson, 2008). Since then, many nurse nurse caring theories have been developed. Madeleine Leininger, Katie Erikson, Anne Boykin, and Savina Schoenhofer are a few examples of nurse theorists who have developed widely referenced caring theories. It was not until 1988 that The Cumulative Index to Nursing and Allied Health (CINAHL) identified caring as a separate keyword in the database. CINAHL then determined that caring caring was a nursing concept within the discipline discipline (Brilowski & Wendler, 2005). In preparation for this project, the search term “caring” was submitted in C INAHL, yielding 27,103 sources in the result list. Because of the many technological advances in the recent past, nurses can utilize technology to monitor their patients at a distance. Also, with the addition of the electronic health record, it could appear to patients and their families that nurses pay more attention to machines rather rather than to patients. Hence, there is a controversy over high-tech versus high-touch nursing care (Chitty, 2005). The argument has been made that technology and the attention a ttention on treating disorders in health care has been at the expense of caring, and that this is detrimental to nursing as a caring profession (Leininger, 1977/2012; Watson, 2008). The current state of caring in the U.S. is patientcentered, consumer driven, and technology-based. The professional care-giver care-giver in our society must be able to coordinate these factors, in addition to demonstrating sensitivity in the acts of car ing ing to be effective in toda y‟s health care environment.

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Perceived Caring

Patient perceived care can be defined as patient assessments of nursing care (Teng et al., 2009). In 1994, Parasuraman, Zeithaml, and Berry developed a typology of service quality, which has been widely applied to nursing. They defined service quality as “reliability, responsiveness, assurance, empathy, and tangibles” (as cited in Teng et al., 2009, p. 302). Reliability is defined defined as the ability to dependably and correctly provide the  promised service. Responsiveness is willingness to assist assist customers and provide  promptness in fulfilling the needs of the customer. Assurance is described as the knowledge, courtesy, and ability of the employee to inspire trust and confidence (Teng et al., 2009). Empathy indicates “the care and individualized attention that the organization  provides its customers” (Teng et al., 2009, p. 303); and tangibles are the appearance of the facilities, equipment, and personnel. These parameters can be applied to the evaluation of nursing care from a patient‟s perspective (Ten g et al., 2009). A qualitative study by Larabee and Bolden (2001) utilized the application of Parasuraman‟s typology of service quality and identified and identified five themes regarding the quality of patient perceived care: 

Provision of needs

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Being pleasant

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Personal caring

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Competency

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Provision of prompt care (Larabee & Bolden, 2001)

Patient perception of care quality is a subjective, dynamic quality of the patient‟s discernment of the level to which the expectations of health care have been achieved.

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Since 1988, patient perception of care has been considered a health care outcome indicator and recent models of quality have included patient perception as a key component (Larabee & Bolden, 2001). In determining how do deliver care, the caregiver must determine the recipient‟s expectations (Corbin, 2007). How does a nurse make patients patients feel “cared about” as well as “care for”? How is the element of caring about another human being communicated (Corbin, 2007)? According to Mayeroff Mayeroff (1971), caring requires knowing. We sometimes speak as if caring did not require kn owledge, as if caring for someone, for example, were simply a matter of good intentions or warm regard. But in order to care I must understand und erstand the other‟s needs and I must be able to respond properly to them, and clearly good intentions do not guarantee this (Mayeroff, 1971, p. 9) Caring must be put into action through behaviors that relate to the particular needs of the  person being cared for. These needs are only understood by getting to know the “person”  behind the “patient” (Corbin, 2007). Patient Satisfaction

Patient satisfaction with nursing care has been described as the level of equality  between a patient‟s expectations of excellent nursing excellent nursing care and the perception of the actual care received (Liu & Wang, 2007). The identification of factors factors that influence healthcare consumers to see their care as quality care and be happy with the care received is a significant approach for drawing patients to a certain ho spital, thereby increasing profits (Otani & Kurz, 2004; Liu & Wang, 2007). Even more importantly, patient satisfaction satisfaction is viewed as a predictor of subsequent health related behavior (Mahon, 1996).

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Patient satisfaction may be considered to be one o f the desired outcomes of care, even an element in health status itself. An expression of satisfaction satisfaction or dissatisfaction is also the patient‟s judgment on the quality qu ality of care in all its aspects, but particularly as concerns the interpersonal process. process. By questioning  patients, one can obtain information about overall satisfaction and also about satisfaction with specific attributes of the interpersonal relationship, specific components of technical care, and outcomes of care (Donabedian, 1988/1997, p. 1746) Donabedian continues on to say that behaviors b ehaviors which indirectly suggest dissatisfaction are termination of care before release, noncompliance of treatment  prescriptions, ending affiliation with a health plan, and seeking treatment outside the plan (Donabedian, 1988/1997). These effects could deter needed health care interventions and ultimately hinder health outcomes. Satisfied patients are dependable and may be expected to return and provide pro vide referrals, leading to expanded profits for the institution and very likely, better clinical outcomes (Greeneich, 1993). Evidence suggests that caring behaviors greatly influence patient satisfaction (Burtson & Stichler, 2010; Dingman et al., 1999; Henderson et al., 2007; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004) and that nursing care is important in improving ove rall  patient satisfaction (Abramowitz, Cote`, & Berry, Berry, 1987; Larabee & Bolden, 2001; Otani & Kurz, 2004; Wagner & Bear, 2009). Patients reporting that their expectations have  been fulfilled through experiencing care, is the most significant predictor of overall overall  patient satisfaction (Bjertnaes, Sjetne, & Iversen, Iversen, 2011).

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In 1957, the first instrument to measure patient satisfaction was developed b y Abdellah and Levine (Wagner & Bear, 2009). Since that time, many tools have been designed to measure patient satisfaction, as the understanding of the factors that influence healthcare consumers is crucial for nurses, other health care workers, and administrators. Since 1986, the Joint Commission on Accreditation of Health Care Organizations has required measurement of patient outcomes and demonstration of continuous quality improvement (Mahon, 1996). In 1988, the Office of Technology Technolog y and Assessment identified patient satisfaction as a significant consideration in the provision of health care services and defined patient satisfaction as an important aspect in the measurement of health outcomes (Mahon, 1996). On March 23, 2010, President Obama signed signed the Patient Protection Protection and Affordable Care Act into law (U.S. Department of Health and Human Services, 2014). According to the law, full Medicare and Medicaid reimbursement is withheld from institutions that have not followed through with surveying patients with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (CMS, 2013). Patient satisfaction scores are determined by the HCAHPS survey, which is an instrument for collecting data pertaining to patients‟ satisfaction of satisfaction of their hospital experience (CMS, 2013). 201 3). HCAHPS is the first first standardized national survey of patients‟ perceptions of hospital care. It is  publicly reported; therefore consumers can compare hospital scores online (CMS, 2013). The goals of the HCAHPS initiative are: 

To produce and publish data of patients‟ perspectives of hospital care that  provides meaningful comparisons between institutions

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To establish incentives for hospitals to improve care quality

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To augment accountability of hospitals and health h ealth care organizations by

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increasing the transparency of the quality of care provided in return for public funds (CMS, 2013). It is imperative that hospitals receive the highest patient satisfaction scores possible for financial reimbursement and for public perception of the q uality of care that the hospital h ospital delivers. Hospital administrations are pushing for excellent HCAHPs scores and will continue to do so. In our current health care environment, patient satisfaction is a very important factor to measure, measure, collect the data upon, and report. Because of governmental regulations, competition between healthcare organizations and the connection with caring, perceived quality of care, and outcomes, this subject is important for nurses and other health care providers to grasp. In the balance of this critical literature review, review, the focus will be on caring theory, application o f theory to topics presented, synthesis of current literature related to these topics, recommendations, and interventions to improve outcomes. Part II  –  Theory,  Theory, Analysis, and Application Caring Theory

 Nursing theory emerged over a period of years when the discipline of nursing was  becoming autonomous, separating from the medical model and developing its distinct identity.  Nurses began obtaining higher education degrees with a new awareness of nursing as a  profession and an academic discipline in its own right (Tomey & Alligood, 2006). Research was recognized to be a path to new nursing nursing knowledge. However, it was soon realized realized that research

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alone produced only information, lacking a framework. framework. Nursing science was produced as a combination of research and theory (Tomey & Alligood, 2006). Caring theory gave nurses the language of caring that they needed to communicate the substance of their practice. Caring in the health c are environment was described as a wa y of  being (ontology) as opposed to just knowing what to do (epistemology) (Dyess, Boykin, & Bulfin, 2013). Caring theorists began developing their theories in the 1980s, being influenced by existential philosophy. The questions that guided the advancement of caring caring theories are: “What do nurses do?” (care for patients) and “How do nurses do what the y do?” (by caring for patients) (Meleis, 2012). Caring theories clarify the act of caring in interactive interactive situations based on values that honor and respect humanity: spirituality, worth as an individual, and hope. According to Meleis (2012) caring theory has added knowledge to nursing, which includes: 

The basic act of caring is central in ways that unite patients and nurses

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Caring is foundational to nursing as a discipline

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When nurses give care, relationships are transformed because caring for another human deeply affects the caregiver

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Meanings of health and illness are lived individually and adapted in community

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Choices, values, and interpretations, are privileges of being human . Nurses and  patients who understand each other‟s viewpoints are part are part of the act of caring

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Nurse-patient encounters involve communication as to expectations and how the relationship will progress

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Even if the nurse and patient have a historical background, it is the current moment that shapes their present relationship

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Madeleine Leininger. Madeleine Leininger practiced as a clinical specialist in child

 psychiatric nursing in the 1950s. She realized that culture differences between patients and nurses affected health outcomes. This discovery led her to study cultural differences in caring and later to pursue cultural anthropology as a complement to her nursing knowledge and practice (Reynolds & Leininger, 1993). Leininger believed that “care and culture culture were inextricably linked together and could not be separated in nursing care actions and decisions” (as cited in Reynolds & Leininger, 1993, p. 3). With a background in nursing and and anthropology, she was able to mesh the two disciplines disciplines each contributing to the other. other. She observed that medical  practice was oriented toward treating a disease, while nursing was focused on caring interventions that influence the health of individuals and communities (Reynolds & Leininger, 1993). Leininger developed the Culture Care Diversity and Un iversality Theory, through which she became known as the foremost supporter of the idea that nursing and caring were one and the same. She made statements such as “caring is the central, unique, dominant, and unifying focus of nursing” and “caring is nursing” nursing” (as cited in Reynolds & Leininger, 1993, p. 7). She developed the sunrise model, which is a theoretical model that portrays transcultural dimensions for nursing care utilizing utilizing the nursing process (Reynolds & Leininger, 1993). Leininger developed other models, including a taxonomy model used to help nurses understand categories of caring phenomenon (Reynolds & Leininger, 1993). Leininger states, states,  Nursing is the learned humanistic and scientific art of caring for  or with people who have varying care needs based upon diverse cultural life styles and human environments. Indeed, nursing is the profession which should be deeply concerned about and involved with caring behaviors, caring life styles, caring processes, and caring consequences. In

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fact, the linguistic derivation of nursing pertains to nurturance, or caring an d growth  processes. No construct could be more central, more essential and more promising for teaching, research, and practice, than ideas related to care and caring for the nursing  profession. (Leininger, 1977/2012, p. 1389) Leininger prefers qualitative methods in studying cultural characteristics. characteristics. Her ethnonursing method is based on emic views, which are beliefs of the person experiencing the phenomena, as opposed to etic views, which are beliefs b eliefs and practices of the researcher (Tomey & Alligood, 2006). Leininger has advanced the profession of nursing and contributed immensely to the academic and theoretical foundation of the discipline. Jean Watson. Jean Watson earned a master‟s degree in ps ychiatric nursing and a

doctorate in educational psychology at the University of Colorado (Tomey & Alligood, 2006 ). She joined the School of Nursing faculty of the University of Colorado where she served as a faculty faculty member (Tomey & Alligood, Alligood, 2006). Watson‟s first major work was published in 1979,  Nursing: The Philosophy and Science of Caring , which began as class notes for a course she was developing. The purpose of the book was to contribute new meaning and dignity to the discipline of nursing and nursing care, which se emed to be under achieving in its potential, lacking in identity and largely defined by medicine‟s theoretical framework and biomedical models (Tomey & Alligood, 2006). This book defined early stages of her theory development, which she explained in her second book   , Nursing: Human Science and Human Care (McCance, McKenna, & Boore, 1999). Watson‟s original work provided the basis for her Theory of Human Caring: Ten Carative Factors. She describes caring as being a science that incorporates human processes,  phenomena, and experiences. It comprises the arts and humanities and is based in an existential

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study between people and their world. Her theory is made up of carative factors that promote health and healing and contribute to humanity. These factors were designated as the foundation of caring in nursing, without which nurses ma y still be functioning as technicians within the  prevailing model of medicine (Watson, 2008). Her theory is based on humanism, with its origins in metaphysics (McCance et al., 1999). Watson‟s writings reflect the evolution of her theory of caring and hav e been geared toward educating nursing students and providing them with an ontological, ethical, and epistemological basis for their practice and research (Tomey (Tomey & Alligood, 2006). The goal of nursing within Watson‟s Watson‟s theory revolves around helping people gain a higher degree of harmony within the mind, body, and soul. She believes that caring transactions transactions are the avenue through which this is achieved (McCance et al., 1999). Theory Applied

Twenty-three articles have been selected for the co re investigative set for this critical literature review relating relating nurse caring and perceived caring to patient satisfaction. Five studies out of the 23 designated a nursing theory as the foundation for the research; four utilized Watson‟s Caring Theory of Transpersonal Nursing (1979); and one elected Boykin and Schoenhofer‟s Nursing as Caring theory (1990). For the application of a theoretical theoretical basis for this critical literature review, Jean Watson‟s theory of transpersonal caring will be highlighted. Watson developed the caring theory of transpersonal nursing in which she proposed that the development of a helping-trust relationship  between the nurse and patient is imperative for effective nursing. A trusting relationship  promotes and accepts the expression of feelings involving honesty, empathy, warmth, and effective communication (Tomey, & Alligood, Alligood, 2006). She states that by responding to others as

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unique individuals, the caring person recognizes the uniqueness of the other through the  perception of their feelings (Tomey & Alligood, 2006). According to a very large study of American patients, the highest priority in receiving care was to be treated with courtesy and respect (Otani, Herrmann, & Kurz, 2011). A study in five European countries found that individualized individu alized care is a predictor of patient satisfaction (Suhonen et al., 2011). A Colorado study concluded that the highest highest priorities for patients patients were listening to the patient and being sensitive to the patient, and that nurse behaviors beh aviors demonstrating  patience and attention to individual needs in an interpersonal environment were most highly valued (Merrill, Hayes, Clukey, & Curtis, 2012). Watson proposed that caring is moral rather than task oriented and is made up of transpersonal caring moments as an experience ex perience of a caring relationship between nurse and patient (Alligood & Tomey, 2006). Most of the recent studies studies on caring align align with Watson‟s ideas of transpersonal nurse caring. Process of Literature Selection

Caring was searched in the Cumulative Index to Nursing and Allied Health (CINAHL) resulting in 27,103 sources in in the result list. list. Combining caring with the terms or the phrases  patient satisfaction: perceived care; outcomes; patient perceived care; and patient safety reduced the number. Since the purpose of the review is to focus on current literature, the dates of January 2008 to June 2014 were set as parameters. Further limiting the articles articles to those written written in English, published in an academic journal, and identified by CINAHL as peer reviewed yielded a  practical amount of studies on which to focus. Characteristics for exclusion were as follows: 

Articles that consisted of personal narratives and stories that lacked data an alysis

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Articles having specific disease processes or conditions in the title

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Articles having to do with nursing education

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Editorial pieces, letters to the editor, book reviews, and other types of non-research oriented articles

There were 23 total articles relating nurse caring or perceived caring to patient satisfaction  published from 2008 to 2014, that met the criteria as explained. All of these articles were read and the information was categorized on a spreadsheet listing author; title; study type; journal; theoretical framework; hypothesis; sample size; analysis; and conclusions. Measurement Surveys. In measuring perceived caring and patient satisfaction, surveys are the most

commonly used methods utilized in quantitative quantitative research studies. They can provide information about a certain point in time (a cross-sectional study) or over a period of time (a longitudinal study). The formation of questionnaires is extremely complex, as they need to developed and tested for appropriateness in collecting the required data. The wording, construction, format, layout, and method of administration ad ministration of questionnaires are capable of producing bias (Hamer & Collinson, 2005). Most surveys are a form of Lickert scale, which is an ordinal scale scale that utilizes subjective data to assign a rating (Plichta & Kelvin, 2013). An advantage of conducting research based bas ed on surveys is that a great deal of information can be obtained from a large population fairly inexpensively, and the research tends to be accurate, utilizing a relatively small number of participants (LoBiondo-Wood & Hab er, 2006). A weakness of surveys is that the information tends tends to be superficial. Also, conducting a survey requires a great deal of expertise ex pertise in various research areas, including sampling techniques, questionnaire construction, interviewing, and data analysis (LoBiondo-Wood & Hab er, 2006). Sampling and design. In surveying a population, care and attention must be paid to the

sampling, which may be a simple random sample or convenience sample (Hamer & Collinson,

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2005). In a random sample, each individual in the population has an equal probability probability of being selected. In a convenience sample, the subjects are chosen based on their availability, availability, which is not as desirable (Creswell, 2009). Wolf‟s (2012) conducted a systematic review of the effect of nu rse caring of adults in a hospital setting. The purpose of the review was to find outcome research in which caring  protocols, interventions, or standards were related to patient satisfaction. satisfaction. He found that the studies represented a variation of designs but none were randomized randomized controlled trials. There were no precise descriptions of the intervention protocols. Therefore, no comparative effectiveness statements could be made. The samples were predominately convenience in nature (Wolf, 2012). He stated that there is is a need to create caring interventions interventions that can be tested and replicated so researchers can document the effectiveness of nurse caring in the context o f outcomes. He believes that patient satisfaction satisfaction is not a health outcome for an illness, nor is a caring intervention a treatment modality (Wolf, 2012). Wolf ‟s ‟s findings suggest findings suggest that caring research has not been performed rigorously, although, many studies have been done with the intent to measure caring and the effects it has on patient p atient satisfaction and health outcomes. These studies have indicated that there are measurable results of nurse caring, such as increased patient satisfaction and medical compliance, and decreased injurious falls, nosocomial infections, pain, and anxiety. It is the belief belief of this author that the emotive, non-tangible nature of a caring attitude, respect, and the communication of value to other human beings could be a factor in the illusiveness of caring measurement. Larabee and Bolden (2001) propose p ropose that nurse perceived caring and patient p atient satisfaction  be measured qualitatively. They contend that patients and nurses differ greatly on defining nursing care quality and ranking importance importance of quality factors. Also, they argue that validity of a

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 patient satisfaction survey is doubtful when it is not based on information information from a patient (Larabee & Bolden, 2001). Further, researchers need to use patient satisfaction instruments instruments that include measurement of patient-defined aspects of quality nursing care (Larabee & Bolden, 2001). Often the distinction between qualitative and quan titative research is described in terms of using words and open-ended questions (qualitative) rather than numbers or closed-ended questions (quantitative) (Creswell, (Creswell, 2009). Newman and Benz (1998) state that the qualitative and quantitative approaches should not be viewed as polar opposites but as different ends on a continuum (as cited in Creswell, Creswell, 2009). Creswell recommends that research research design methods be th

th

looked at based on philosophical assumptions. Until the late 19 century up until the mid 20 century, quantitative methodology was the gold standard in research.

In the 1960s, interest in qualitative research increased, followed b y the development of mixed methods (Creswell, 2009). Qualitative research is a way to explore and understand the meaning individuals or groups give to a social or human problem with the data d ata typically being collected in the participant‟s setting setting and analyzed by looking at themes. themes. Quantitative research tests measurable hypotheses by examining the relationship among variables. The variables can  be measured and the data analyzed using statistical procedures (Creswell, 2009). In the grouping of 23 research studies on nurse caring, perceived caring and patient satisfaction for this critical literature review, 18 of the studies were quantitative; two were q ualitative in nature; and three utilized mixed methods (see Table 1 in the Appendix). Instrumentation . Out of the quantitative studies, studies, five of them utilized the HCAHPS

survey instrument and three used the Wolf Caring Behaviors Inventory. Inventory. Two of the 23 core studies used the Patient Satisfaction Scale (PSS) developed by Kim (1991), which examines

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 patients‟ satisfaction with nursing care (Palese (Palese et al., 2011; Suhonen et al., 2012). It was designed to gather patient views about ab out nursing care, comparing patient satisfaction with care received (Palese et al., 2011). The PSS is an 11-item 11-item instrument based on patients‟ care needs and evaluation criteria. One Swiss study implemented the Basel Extent of Rationing of Nursing Care (BERNCA) survey to determine how rationing nursing care affected patient-reported outcomes. Nursing care rationing is defined as the withholding of or not following through on all needed nursing n ursing interventions due to lack of time, staffing, or adeq uate skill mix (Schubert, Clarke, Glass, Schaffert-Witvliet, & De Geest, 2009). The Service Quality Scale developed by Parasuraman, Zeithaml, and Berry (1994) was utilized in a Taiwanese study to measure patient perceived care quality (Teng et al., 2009). A survey conducted in a tertiary care Indiana hospital implemented the National Research Corporation Picker survey to examine an intervention developed to decrease patient uncertainty regarding nurse availability in response to immediate needs (Woodard, 2009). The Picker Patient Experience Experience Questionnaire (PPEQ-15) demonstrated a high correlation of selected items and a high transcultural validity (Al-Abri & Al-Balushi, 2014). One study implemented the Quality from the Patients Perspective (QPP) qu estionnaire which which evaluates patients‟ perceptions of care quality categorized in four dimensions: medicalmedicaltechnical competence; physical-technical conditions; identity-oriented approach; and sociocultural atmosphere (Frojd et al., 2011). The QPP has demonstrated acceptable reliability (Frojd, et al., 2011). The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey which is sent sent to patients within 48 hours after discharge from the hospital. It was developed by the Agency for Healthcare Research and Quality (AHRQ), part of the Department

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of Health and Human Services (Otani (Otani et al., 2011). The Harvard Medical School, the RAND Corporation, and the American Institutes for Research have rigorously and scientifically tested HCAHPS for validity, reliability, credibility, and usefulness for research (Otani et al., 2 011). The utilization of HCAHPS is an initiative by the government to standardize and publicl y report  patient satisfaction with hospitals, thereby thereby enhancing accountability of health care organizations and creating incentives for hospitals to improve their quality of care (CMS, 2013). The possible answers for the HCAHPS survey are never, sometimes, usually, and always (two of the questions relating to nursing are are yes/no). There are 32 questions in the the survey, with 11 of the questions having to do d o with demographics: three questions directly relating to care from physicians; two questions relating to hospital environment; and two questions pertaining to the hospital in general (CMS, (CMS, 2013). The remaining 14 questions are directly related to nursing care. They pertain to nurses:

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Treating patients with respect

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Listening carefully to patients

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Explaining things to patients in a way they can understand

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Giving prompt help after call button activation

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Helping patients to the bathroom in a timely manner

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Implementing pain control measures

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Giving medication instructions regarding the purpose of the medication and possible side effects

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Finding out if the patient would need help after discharge from the hospital

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Giving thorough discharge instructions to patients as to what symptoms or health  problems to look for after going home

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Including family members/caregivers in discharge planning (CMS, 2013). The Caring Behaviors Inventory, developed by Zane Wolf, is based on a conceptual

definition of caring by Jean Watson (1988), and describes nurse caring as an interactive process that occurs during shared openness between nurses and patients (as cited in Palese et al., 2011). The instrument includes four factors: 

 Nurses dealing with patients‟ needs and insecurities

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 Nurses demonstrating skill and knowledge

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 Nurses demonstrating respect and showing interest

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 Nurses helping patients through positive connectedness (Palese et al., 2011).

The original Wolf Caring Behaviors Inventory (1981) was a 75-item instrument, and was reduced to a 42-item tool, and then then shortened to a 24-item version (Merrill (Merrill et al., 2012). All versions have been tested as to their completeness, reliability, and validity (Coulombe, Yeakel, Maljanian, & Bohannon, 2002). The Caring Behaviors Inventory for for Elders was implemented in evaluating community-dwelling community-dwelling elders‟ perception of staff caring (Wolf & Goldberg, 2011). The researchers of the remaining quantitative studies developed their own measurement instruments in the form form of various Lickert scales. Patient surveys were designed to measure satisfaction in meeting the particular characteristics of their studies (DeJesus, Howell, Williams, Hathaway, & Vickers, 2014; Liu et al., 2010; Maxson, Derby, Wrobleski, & Foss, 2012). The qualitative studies used ethnographic qualitative methods (Coughlin, 2012); observation of caring behaviors (Liu et al., 2010); and the nurse-patient bonding instrument instrument (Tojero, 2012). The mixed method studies implemented Lickert scale surveys in combination with interviews and observation (DeJesus et al., 2014; Liu et al., 2 010; Merrill et al., 2012).

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Summary

Part II of this critical literature review discusses a few caring theories with Jean Watson‟s Watson‟s Theory of Transpersonal Nurse Caring being the most applicable to the present study of nurse caring and perceived caring related to patient satisfaction. Sampling, research methods, methods, instrumentation, and specific attributes of the research studies of interest related to the topics, were examine as well. Research findings and applications will will be presented in Part III. III. Part III - Research Findings and Applications Overview and Synthesis of Findings Demographics. The core articles for this critical literature review exhibit an

international scope in research application. application. A total of fourteen different countries are represented represented in eleven studies out of the set of 23 (See Table 1). The studies performed in foreign foreign countries explored the: 

Relationship between individualized nursing care and patient satisfaction (Suhonen et al., 2011)

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Identification of the most important caring behaviors as perceived by patients (Suliman, Welmann, Omer, & Thomas, 2009).

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Relationship of nurse professional commitment to patient safety and care quality (Teng et al., 2009)

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Association of higher levels of patient safety culture and rationing of nu rsing care with frequency of adverse events (Ausserhofer et al., 2013 )

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Identification of areas in need of quality improvement and differences related gender, age, and type of admission (Frojd, et al., 2011)

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Identification of incidents and nurses‟ behaviors that influence patients‟ participation participation in care (Larsson, Sahlsten, Segesten, & Plos, 2011)

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Correlation between caring as perceived by b y patients and patient satisfaction and differences between the six European countries (Palese et al., 2011)

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Description of levels of nursing care rationing and identification of levels of rationing related to patient safety and satisfaction (Schubert et al., 20 08)

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Relationship of proactive nursing care to patient safety (falls), patient experience, and staff satisfaction (Ciccu-Moore et al., 2014)

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Direct and indirect relationships between nurse characteristics, patient characteristics, and  patient satisfaction (Tojero, 2012)

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Relationship between nurse staffing, patient outcomes, and patient satisfaction (Zhu et al., 2012) All of the European, Asian, and Middle Eastern studies were performed on either medical

or surgical inpatients, except the Taiwanese study, which took into account all inpatient units in the hospitals except pediatric, intensive intensive care (ICU), and psychiatric. psychiatric. Private patients (self pay) were excluded in the Taiwanese study as well well (Teng et al., 2009). The study performed in the the Philippines included medical, surgical, obstetrical, and ICU patients (Tojero, 201 2). Research studies based in the United States occurred in different areas of the country:  Nebraska (Snide & Nailon, 2013); a Midwestern state (DeJesus et al., 2014; Maxson et al., 2012; Woodard, 2009); New York, California, and Florida (Tzeng, Hu, Yin, & Johnson, 2011); Pennsylvania (Wolf & Goldberg, 2011); a Northeastern No rtheastern State (Coughlin, 2012; Radwin, Cabral, & Wilkes, 2009); Colorado (Merrill et al., 2012); Indiana, Michigan, Al abama, and Washington

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D.C. (Liu et al., 2010); and 32 hospitals in the Midwest, Southeast, and Northeast (Otani et al., 2011), were represented in the research articles. The U.S. studies showed a variety variety in areas of nursing care as well. Some studies utilized HCAHPS to determine certain dimensions dimensions of patient reported care quality. quality. These studies typically had very large samples and data were gathered from inpatients who had been in a variety of care settings (Otani et al., 2011; Tzeng et al., 2011). Variations in care practice areas include emergency department (Liu et al, 2010); elder outpatient care (Wolf & Goldberg, 2 011); hematology/oncology inpatient (Radwin et al., 20 09); rehabilitation nursing (Seeber, 2012); mental health outpatient (DeJesus, et al., 2014); ICU trauma nursing (Merrill et al., 2012); surgical cardiac (Coughlin, 2012); and medical/surgical inpatient (Maxson et al., 2012; Snide &  Nailon, 2013; Woodard, 2009). These studies researched the: 

Perceptions of care of nurses and patients during main events of hospitalization (Coughlin, 2012)

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Effectiveness of care managers in promoting patient self-care and improvement in depressed individuals (DeJesus, et al., 2014)

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Effect of caring behaviors of emergency department nurses and other personnel that lead to patient loyalty (Liu et al., 2010)

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Relationship of bedside report of nurses to patient satisfaction with plan of care and  perception of teamwork (Maxson et al., 2012)

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Difference gender and ethnicity makes in relationship to the interpretation of nurse caring  behaviors (Merrill et al., 2012)

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Relationship between staff care, nursing care, physician care, an d environment with  perception of overall hospital care (Otani et al., 2011)

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Correlations between patient-centered nursing care, patient attributes, and health outcomes (Radwin et al., 2009)

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Effect of the Kind Peace of Mind hourly rounding model on patient patien t satisfaction (Seeber, 2012)

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Relationship of nursing staff creative care implementation to overall patient satisfaction (Snide & Nailon, 2013)

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Correlations between HCAHPS scores related to overall hospital satisfaction and hospital fall rates according to age groups (Tzeng et al., 2011)



Perceived care in relation to elderly enrolled in a n outpatient day program (Wolf & Goldberg, 2011)

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Difference between fall rates, patient satisfaction, and frequency of call light use among  patients who received standard care related to patients who received hourly rounding (Woodard, 2009) Some researchers measured data in their studies pertaining to demo graphic aspects of

 patient populations in relation to perceived caring and satisfaction. These factors included age, ethnicity, gender, and education. In a Saudi Arabian study of 393 patients, it was found that men and women viewed the importance of caring behaviors differently. Women ranked five caring  behaviors as more important than did men (Suliman et al., 2009). In a study done in Sweden, Sweden , older patients scored higher in 18 out of 23 items pertaining to patient satisfaction than did younger patients; women‟s reports of ca re quality perception in the area of having the chance to make decisions related to their care was higher than men‟s; and men gave higher scores than women in questions concerning food, comfort of beds, and the overall mood on the unit (Frojd (Frojd et al., 2011). In the same study, patients patients who had planned

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admissions expressed higher satisfaction in care quality in the manner in which treatments and examinations took place; useful information provided; relief for pain; respect of doctors towards them; and opportunity to speak with doctors in private, than patients who had been admitted to the hospital through the emergency department (Frojd et al., 2011). Radwin et al. (2009) did not find a difference between male and female cancer patients‟ conceptions of quality care, or a difference related to age, race, ethnicity ethnicity or educational level. In a Pennsylvania study of a group of diverse elderly patients in an outpatient program, no difference was found between perceptions of care by distinction of gender or ethnicity (Wolf & Goldberg, 2011). Safety. When individuals come to a hospital to receive surgery, testing, and/or treatment,

they expect that they will be protected and unharmed while they are there. there. A very large Swiss study related the organizational variables of nurse practice en vironment quality; implicit nurse care rationing; and levels of skill mix with the patient outcomes of medication errors, urinary tract infection, falls, pressure ulcers, sepsis, sepsis, pneumonia, and patient satisfaction. It was found that higher levels of implicit nursing care rationing resulted in a substantial decrease in the odds of patient perceived quality of care and a significant increase in the projected likelihood of medication errors, sepsis, and pneumonia (Ausserhofer et al., 2013). Tzeng and associates (2011) studied HCAHPS results of 478 U.S. hospitals from three states and found that patient satisfaction and injurious fall fall rates were negatively correlated. correlated. It is suggested from this study that consistently, across hospitals and in all three states, the h igher the  patient satisfaction scores with the cleanliness and quietness of the the environment and nursing staff responsiveness, lower fall rates were reported (Tzeng (Tzeng et al., 2011). In Florida, the higher patient patient  perceived quality care in relation to all factors measured in the study (quietness and cleanliness

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of environment; communication with nurses; responsiveness of staff; and medication teachin g), the lower were injurious fall rates (Tzeng et al., 2 011). A Swiss study demonstrated that the factors of nosocomial infections, pressure ulcers, and patient satisfaction were sensitive to low levels of nurse c are rationing with negative effects. In this study, the fall rate was not affected; neither were nurse reported medication errors or critical incidents (Schubert et al., 2009). In an Indiana hospital, a clinical nurse specialist implemented a program of charge nurse rounding every two hours with the intention of decreasing patient uncertainty in a hospital environment. The results indicated a significant significant increase in patient satisfaction, decrease in call-light use, and a decrease in patient falls (Woodard, 2009). Research in Scotland revealed that the initiation o f a care and comfort rounding program over a period of one year improved patient satisfaction ratings and decreased patient fall rates (Ciccu-Moore et al., 2014). A study in Taiwan showed showed that professional commitment on the part of nurses improved patient safety by decreasing falls and medication errors, and also improved documentation and responsiveness. Patient perceived care quality was also also enhanced (Teng et al., 2009). In China, it was found that higher nurse to patient patient ratios had significant positive effects on the outcomes of nurse-reported quality of care, patient-reported quality of care,  patients‟ confidence and ability for self -care -care upon discharge, and adverse events during hospitalization (Zhu et al., 2012). Health outcomes. A mixed study in the Midwestern United States found that

implementing a care manager program in outpatient care of depressed patients improved  perceived care satisfaction, increased their understanding of depression, and promoted depression self-management abilities. abilities. These outcomes increased the probability of treatment

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response and remission of depression (DeJesus et al., 2014). The skill of motivating motivating patients to  participate in their own care is an integral part of nursing practice. Self-care participation decreases anxiety and stress, yields better treatment results, and increases medical compliance (Larsson et al., 2011). A qualitative Swedish study demonstrated that positive incidents of nursing care stimulated patient participation and increased patient satisfaction, while negative occurrences with care inhibited patient participation and decreased patient satisfaction. satisfaction. In this study, it was found that nurses communicating information that is consistent and relevant to  patients‟ care and valuing their patients through meaningful interactions are the most significant significant interventions for promoting patient participation (Larsson et al., 2011). In a study of a rehabilitation unit, a model of hourly rounding, increased touches, and a  program to increase socialization and decrease boredom was implemented with resultant improved patient satisfaction, lower call-light usage, and increased pain control (Seeber, 2012). According to Wagner and Bear (2009), patient satisfaction influences whether patients utilize health services at a later date, affecting follow-up care and impacting compliance to prescriptive treatments and recommendations. This very likely would have consequences as to the health status and severity of the condition (Wagner & Bear, 2009). A New England study indicated that that individualized nursing interventions were positively related to the desired health outcomes of a sense of well-being, positive attitude, and authentic self-representation (Radwin et al., 2009). Discussion

In this critical literature review regarding nurse caring and patient perceived care related to patient satisfaction, some factors have been analyzed. This continuum of logical correlations correlations are based on the previous discussion: 

 Nurses provide care

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35

 Nurses care by demonstrating certain behaviors and attitudes called caritative factors factors



Patients perceive the care and have a certain level of satisfaction with the care



Patient satisfaction can be measured



Higher satisfaction promotes results such as financial gain for institutions and increased safety and positive health outcomes for patients



It is the duty of those in the nursing n ursing profession to continue measuring patient satisfaction and applying the data to nursing practice, thereby promoting health Otani and associates analyzed data from 31,471 31,471 patients‟ HCAHPS results. The results

revealed that nursing care is the most influential factor on overall rating of patient satisfaction and intention to recommend (Otani et al., 2011). In addition, this study demonstrated that the highest priority for patients is to be respected and treated with courtesy by nurses and physicians. ph ysicians. It was reported that patients want information regarding their health concerns including their medications and treatments, and that they desire to be listened listened to. Patients expect that their surroundings to be clean and quiet qu iet and that their pain be controlled and comfort increased (Otani et al., 2011). The result of this massive study is notably interesting interesting since these issues are the very ones that Florence Nightingale discussed in her “Notes on Nursing” in the 1850s 1850s (Tomey &. Alligood, 2006). Recommendations

One need for additional research related to the topics of this critical literature review is a continued search for an operational definition definition of caring. As of 1977, Madeleine Leininger had not found a universal definition of caring (Leininger, 1977/2012), and other caring theo rists have concurred (Meleis, 2012). In searching for such a definition, it is the belief of this author that additional knowledge will be discovered and an d the discipline, profession, and practice o f nursing

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will be promoted. Besides defining the concept of caring, caring, practicing nurses need to be able to understand the significance of the the quality of care. The grasping of this concept and construct has the potential to further refine nursing as a discipline (Burhans & Alligood, 2010), thereby adding to the nursing paradigm. Many surveys have been designed to measure measure patient satisfaction and more reliable and valid tools need to be further developed through additional research and understanding of the significance of patient satisfaction. Since nurses‟ perception of care given and patients‟ perception patients‟ perception of care received are often very different (Coughlin, 2012; Palese et al., 2011), it would be prudent for nursing researchers to continue searching for the factors that conceptu alize patients‟ perceptions of care in all settings, including various cultural contexts. Even though there was a representation representation of many countries and ethnicities in this study, there is still much to learn about different cultural  perceptions of nursing care quality. Other recommendations for further research would be 

To explore interventions to improve emotional support and health education to  patients (Wagner & Bear, 2009)



To identify organizational factors related to patient outcomes to foster incentives for safety improvements (Ausserhofer et al., 2013)



To study ethnic differences utilizing large sample sizes (Merrill et al., 2012)

Interventions that Could Improve Outcomes Education of patients. Several of the studies identified a need for patients to receive

relative, consistent information regarding their health (Coughlin, 2012; DeJ esus et al., 2014; Frojd et al., 2011; Larsson et al., 2011; Otani et al., 2011). It is the belief of this author that that nurses need to have more information on how to educate patients and institutions need to foster  patient education to a greater degree. Nurses have a wealth of knowledge to share. Encouraging

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questions from patients, anticipating needs related to specific conditions, and utilizing certain teaching methods are skills that can be encouraged to help nurses educate patients, thereby improving patient satisfaction. Education of nursing students. Education planning for promoting caring behaviors and

nursing students’ relationship with patients is of utmost importance (Palese et al., 2011). A study at the University of Wisconsin-Madison found that compassion may be taught through meditative activities (Weng, (Weng, Fox, Shackman, Stoldola, Caldwell, & Olson Olson et al, 2013). Increased altruistic behaviors after compassion training were associated with altered activation in brain areas related to social, cognition, and emotion regulation. Results were validated with a functional brain MRI. The compassion training utilized guided audio instructions with practice practice of feeling compassion for different targets (a loved one, self, a stranger, and a difficult person). The findings supported the possibility that compassion and altruism can be viewed as trainable skills rather than stable traits (Weng et al., 2013). Reflective education can help an individual develop self-awareness, motivation, empathy, purpose, and social responsibility, teaching students to identify their intentions and motivations (Horton-Deutsch & Sherwood, 2008). Education of practicing nurses. In a study of six European countries in which the

sample was 1,565 surgical patients, it was reported that the most frequent nursing behavior exhibited was “knowledge and skills.” However, this feature of the Caring Behaviors Inventory had no effect on patient satisfaction satisfaction (Palese et al., 2011). “Positive connectedness” was the factor factor that most served patients‟ requests regarding satisfaction satisfaction in this study. This factor entails teaching, spending time with and including the patient in planning care, and suggests understanding and relationship (Palese et al., 2011).

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This data identifies a disconnect between nursing kn owledge and nursing practice. It is necessary for nurses to be educated on the importance of patient satisfaction, not onl y for financial justification, but for ethical reasons, as well. It is the observation and experience of this author that most nurses have no idea of o f the connection of patient satisfaction with positive health outcomes. Administrators continually talk about financial responsibilities regarding patient satisfaction, while ignoring the health ramifications. Recommendations for administrators . Nurses need to have support in their their efforts to

interact with patients appropriately so they can be effective in delivering care (Palese et al., 2011). Ways to enhance professional commitment of nurses need to be adopted to a greater degree, with incentives for obtaining specialty certifications and advan ced degrees (Teng et al., 2009).  Nursing and other administrators would be wise to invest highly in two areas: high quality, caring, and competent nurses, and staff who ensure that the hospital is clean and quiet (Otani et al., 2011; Tzeng et al., 2011). Conclusion

In this critical literature review regarding nurse caring and patient perceived care related to patient satisfaction, very current literature referring to these topics were anal yzed. In 2001, Larabee and Bolden concluded that nursing care should be based on patient-centered interventions, as it is the most significant significant predictor of patient satisfaction. This was also confirmed in later research (Larabee & Bolden, 2001; Palese et al., 2011; Wagner & Bear, 2009). It has been demonstrated in some of the research studies for this review that nurse caring,  patient perceived caring, and patient satisfaction are related, and are important dimensions in the current health care environment. The literature supports the ideas that improved patient patient

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satisfaction can benefit the health care system through moneta ry means and through improved health outcomes of patients.

39

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Appendix A Table 1  Authors/Year Ausserhofer, Schubert et al. 2012 Ciccu-Moore, Grant et al 2014 Coughlin 2012 DeJesus, Howell, Williams et al. 2014 Frojd, Swenne, Rubertsson et al. 2011 Larsson, Sahlsten, Segesten, & Plos 2011 Liu, Franz, Allen, Chang et al. 2010 Maxson, Derby, Wrobleski, & Foss 2012 Merrill, Hayes, Clukey, & Curtis 2012 Otani, Herrmann, & Kurz 2011 Palese, Tomietto, et al. 2011 Radwin, Cabral, & Wilkes 2009 Schubert, Clarke, et al. 2008 Seeber 2012

Core Articles Country Switzerland

Method Quantitative

Sample 1630 nurses working in 35 acute care hospitals

United Kingdom

Quantitative

604 patients in 12 months

United States

Qualitative

238 older persons

United States

Mixed

125 patients

Sweden

Quantitative

2734 patients

Sweden

Qualitative

17 patients 105 critical incidents

United States

Mixed

United States

Quantitative

728 observed patients 619 unobserved  patients 60 patients

United States

Mixed

103 trauma patients

United States

Quantitative

31,471 patients

Cyprus, Czech Republic, Greece, Finland, Hungary & Italy United States

Quantitative

1,565 surgical patients

Quantitative

173 hematology/ oncology patients

Switzerland

Quantitative

1338 nurses 779 patients

United States

Quantitative

24 patients

 NURSE CARING AND PERCEIVED CARING

Snide & Nailon 2013 Suhonen, Papastavrou, Efstathiou et al. 2011 Suliman, Welman, Omer et al. 2009 Teng, Dai, Shyu, Wong, Chu, & Tsai 2009 Tojero 2012 Tzeng, Hu, Yin & Johnson 2011 Wolf & Goldberg 2011 Woodard 2009 Zhu, You Zheng, Liu, Fang et al 2012

51

United States

Quantitative

Czech Republic, Cyprus, Finland, Greece, and Hungary Saudi Arabia

Quantitative

21 quarters top-decile ratings 1315 surgical patients

Quantitative

393 patients

Taiwan

Quantitative

248 nurse/inpatient dyads

Philippines

Qualitative

United States

Quantitative

210 nurse/patient dyadic interactions 478 hospitals HCAHPS results

United States

Quantitative

238 older persons

United States

Quantitative

9 charge nurses

China

Quantitative

181 hospitals 5,430 patients 7,802 nurses

 Note.  Note. Description of core research studies regarding countries in which they were performed, methodology, and sample characteristics.