Consumers are no longer willing to be passive recipients of care but are demanding quality health care at a reasonable cost, with an active role in health care decisions. There will be a growing public demand for accountable and responsive health care professionals (Pew Health Professions Commission, 1991). Therefore, the nursing profession must acquire verified knowledge of how its services are perceived by the public.
Physicians' and nurses' roles are shifting as health care economics are forcing changes in the traditional roles of the health care enterprise. Given the current and projected demands for elder health care and the changes in the roles of the health care providers, there is a need to study what elders expect from nursing. Findings from such studies would promote more effective care that addresses elders' expectations and thus contributes to their satisfaction with nursing care.
The purpose of this study was to describe elders' role expectations of nursing. Elders were defined as individuals who are 60 years of age and older. Descriptions referred to verbal accounts of feelings, thoughts, and experiences. Role expectations were defined as anticipated behaviors associated with a specific role. These expectations evolve over time and are influenced by experiences with individuals in the role (Biddle, 1979; Biddle & Thomas, 1979).
Rempusheski, Chamberlain, Picard, Ruzanski and Collier (1988) used the Grounded Theory approach to examine individuals' expectations about hospital care by examining unsolicited letters received from 63 patients and families following hospital discharge. One of the hypotheses generated from the analysis was that if expected service needs are met during the hospital stay, then the individuals will evaluate the care received positively.
Larson (1987) studied cancer patients' and nurses' perceptions of important nurse caring behaviors. The mean patient age for Larson's study was 42 years. Participants were asked to rank the perceived importance of 50 items on the CARE-Q instrument related to nurse caring behaviors. Larson reported a marked difference between nurses' and patients' rankings. Only one item, "puts patients first no matter what else happens," (p. 171) was given a high priority by both participant groups.
Scharf and Caley (1993) used the CARE-Q instrument with patients, nurses, and physicians in a coronary care setting and reported findings similar to those described by Larson (1987). The average patient age was reported to be 62 years. In both studies, the five most important nurse caring behaviors identified by patients were: a) knowing how to administer shots, intravenous infusions, and manage equipment; b) knowing when to call the doctor; c) giving medicines and treatments on time; d) giving good physical care; and e) responding quickly to patienf s call. It was interesting to note that the physicians and patients chose four of the same five nurse caring behaviors. The nurses chose only two of the same five nurse behaviors as the patients: knows when to call the doctor and gives good physical care to the patient.
Mayer (1987) replicated Larson's study with oncology patients, who had a mean age of 54, and, based on the findings, suggested that the behaviors that nurses believe convey caring may not be of similar importance to the patient. Patients ranked technical skills highest whereas nurses ranked expressive behaviors more highly.
The results of all three of these studies suggest that there are differences in how patients and nurses rank the importance of nurses' caring behaviors (Larson, 1987; Mayer, 1987; Scharf & Caley, 1993). These differences may result in decreased levels of patient satisfaction with nursing care if patients' expectations are not congruent with nursing care behaviors. Additionally the need for further research is supported by the fact that the CARE-Q instrument originated in the 1970s from a sample of oncology patients and nurses (Larson, 1987). Therefore, eliciting the elderly consumer's descriptions regarding their expectations of the nursing role is an appropriate and beneficial extension to the topic's current body of knowledge.
In conclusion, little research has been directed toward comprehensively examining nursing expectations and health care preferences from the elder's perspective. This is evidenced by the fact that minimal research was found which enunciated elderly consumers' specific expectations of nursing. Identifying elders' expectations of nursing can provide nurses with information that will guide professional practice, enhance patient satisfaction, and perhaps improve elderly consumers' clinical outcomes.
A qualitative interview method was chosen to obtain the data for this study where the researcher acted as the instrument for the study and elicited patient responses through a nurse/ patient interview which was audiotaped. The participants were asked to describe their experiences with nurses and their expectations of nursing. The purpose of the qualitative research method is to develop knowledge by generating categories, themes, and patterns that require careful, interpretative judgments about what is significant and meaningful in the descriptive data (Marshall & Rossman, 1989; Patton, 1980).
Based on the researcher's field notes and memos, there were a variety of the eliciting techniques and shifts in questioning which emerged throughout the data collection process. As the interviews progressed, the nature of participant questioning became more focused and specific so that the recurring categories as well as the properties of what elders expected from nursing became apparent. Following interview 6 the respondents' common expectations began to emerge and three labeled categories were established by interview 16 when no new themes emerged. In addition to the participants describing their expectations, 16 of the 28 respondents were asked to priority rank the labeled categories to indicate their importance with respect to the nursing role. These individuals were also asked to card-sort 10 of the most commonly stated nursing properties into the three established categories. The card-sort provided an additional assessment of the distinguishing properties as characteristics which depicted each category.
To insure a meaningful and realistic representation of the data, following interview 28, five participants were revisited, as a focus group, and asked to discuss the study's findings. The five participants were selected for these exercises because of their sustained daily nursing experiences, and their willingness to articulate their expectations as evidenced by their enthusiasm and thoughtful responses on the individual transcriptions.
Twenty-eight subjects were obtained from a community senior citizen center (CSCC) and two Veterans Affairs Medical Centers (VAMCs) in the southeastern United States. Each participant was at least 60 years of age, demonstrated coherent mental status, and reported having had an experience with a nurse within the past 2 years. Potential subjects were excluded if they were: a) retired nurses, b) diagnosed with post-traumatic stress disorder, and c) scheduled for psychiatric consultation or treatment. Agency consent, Institutional Review Board (IRB) approval, and consent of all potential participants were obtained prior to the interviews.
The investigator held a training session with all participating agency personnel to explain the study's purpose and sample selection criteria. Agency personnel then referred potential study participants to the researcher. The investigator contacted each potential participant, explained the study purpose and procedures, and verified that the potential participant met the established inclusion criteria. Once permission was obtained from the participant, the interview began. The investigator restated the study purpose, and confirmed that the individual could adequately hear the eliciting questions. To assist in data collection the researcher used an interview guide which was revised after a pilot study with three elders. The initial questions on the guide related to the location and frequency of the participant's prior encounters with a nurse. Subsequent sample questions prompted the subjects to describe their actual nursing encounters as well as what was anticipated and expected in ideal encounters with a nurse. A sample of the interview guide is presented in the Figure.
Nineteen of the subjects were interviewed at a VAMC clinic, hospital or nursing home. Five individuals were interviewed at the CSCC, while four individuals were interviewed in their homes. The taperecorded interviews varied in length but generally had a duration of at least 45 minutes. Each of the interviews was conducted with the subjects in a quiet and unhurried environment at a convenient time and location. Two of the interviews were completed with both a husband and wife present and their individual opinions were obtained by interviewing each spouse separately.
The study's participants ranged in age from 58 to 92 years with a mean age of 71 years and a median age of 70.5. The 58-year-old subject was initially reported by the RN to be 60 years of age. However, during the interview the researcher verified the subject's age and subsequently a decision was made to retain the interview based on the two following factors: the subject's daily nursing experiences during his 8-year tenure in a nursing home setting as well as the articulate and enthusiastic quality of his responses. Twenty-two of the participants were Caucasian and six were African-American. Twenty of the participants stated that they had completed no more than 12 years of education, two of these participants reported that they had no formal education. Eight of the subjects reported educational experience greater than high school, with one individual holding a master's degree. Twenty of the subjects reported incomes of $1,000 a month or more with eight individuals stating monthly incomes of $999 or less including two participants with monthly incomes of $500 or less. Twenty-five of the 28 respondents stated that their most recent encounter with nurses had been while in an acute or long-term health care facility. Only three of the 28 respondents had recently interacted with the nurse in the community.
The data were analyzed using a constant comparative approach to depict how elders described their expectations of nursing (Glaser & Strauss, 1967; Strauss & Corbin, 1990). Data collection and analysis were conducted concurrently as a single, ongoing process so that the data were analyzed after each interview to uncover the common patterns that depicted a category. While coding the data, methodological memos recorded ideas about how the researcher could, with future participants, use questions or clarifications to elicit richer responses. Data collection and analysis continued until theoretical saturation of the categories occurred.
To assess reliability of the coded data, a content analysis expert audited four randomly selected interviews at different phases throughout the data collection and analysis process. The expert reanalyzed the transcripts of the four interviews independent of the researcher's coding notations and the results of the audit were compared for methodological congruence and analytical precision Additionally, the researcher reinterviewed eight participants throughout data collection to clarify informational gaps and verify the participants' agreement with the coded categories, properties and rankings.
An ongoing analysis of the data revealed that there were three categories, or recurring patterns, which emerged from how the elders described their expectations of the nursing role. Each of the three categories is described and selected examples are provided to illustrate the category as well as indicate the features from which the operational definitions were derived. Information related to how the elders priority-ranked the categories and the selected common properties for each category is also provided. The findings culminate with a description of the focus group exercise.
Category I: Attentive
When asked what the elders expected from nurses, approximately 21 of the 28 participants described examples that were categorized as attentive. Many of the respondents stated that they expected nurses to be responsive to a patient's need for help. Several respondents emphasized that they expected the nurse to be "prompt," "alert," "available," and "attentive" to a patient's need. They expected the nurse to be efficient, in a timely manner, when providing patient services. Selected descriptions that were categorized as attentive expectations follow:
*"I appreciate the nurse popping in and checking on me without me having to page them for help. When I need anything and I ask for it and get it, that's good nursing care.. .when it doesn't take half the night to get something."
*"The patient wants to have confidence that they [the nurses] will come to your rescue. It is very important that the nurse check on you, be alert, and take quick action if something goes wrong."
*"I would have died if it hadn't been for a nurse. I don't really think I would have made it to morning if she hadn't been making rounds, because when I woke up she was giving me updraft treatments and oxygen.. .She really saved me, that day, because she found me. Instead of sitting up there at a desk, she was available, spotted trouble, and started treatment."
Based on the respondents' descriptions, the expectation of attentive care was operationally defined as nursing actions that were responsive, in a timely manner, to expressed or unexpressed patient needs.
Category II: Caring
All 28 participants described caring nurse attributes when asked what they expected from nursing. Descriptions that were categorized as caring included:
*"You take one person that wants to do something and they can do more than 10 that don't want to do anything! I expect the nurse to be kind and nice, to show concern and give me personalized attention."
*"The most important thing to me is her friendly attitude and that she shows that there's a little feeling in there [pointing to heart] for you, as the patient."
*"I think a patient decides when a nurse is a good nurse or a bad nurse in the first couple days dealing with her, really... if they really care and if they're interested in what they're doing. You want the nurse to be somebody... who's really sincere, interested and cares."
*"The nurse needs to be encouraging and loving to the patient, and to be sensitive to your needs...Nursing is caring which is the substratum of everything, caring is having compassion and is a lot like loving which I believe relieves a lot of stress and is part of the healing process."
*"The nurse is sensitive to my needs and goes to the pharmacy to get my meds, here at the clinic, because I am so short of breath...she saves me steps and has even delivered my medicines to my home."
*"I was talking to the nurse one day about my hips hurting, so she said, I got a real sheepskin that I bought for my daddy. Would you like to try it? Well, I really appreciate that! You see, if they care about you, they'll come nearer to doing more than anybody that doesn't care. Well, if I ever got real sick, I'd want that person to nurse me because she'll do all she can to help you."
Based on the respondents' descriptions the expectation of caring nurse behaviors was defined operationally as demonstrating an attitude of loving concern, kindness, and compassion which extends into personalized nursing actions.
Category III: Knowledgeable
When asked what they expected from nursing, approximately 21 of the 28 participants described expectations related to the nurse being knowledgeable. Examples of responses that were coded into this category include statements such as expecting the nurse to be a professional, recognizes a patient need, and knows what to do. Several participants stated they wanted the nurse to know how to get blood, work equipgive medications correctly, and IVs. Selected descriptions that categorized as knowledgeable are now provided.
*"...I want her to act like she what she's doing, she knows stuff....I mean nurses may not it but when, when she first a patient and she talks to him, she talks to him is...is what has a to do with how the patient feels the nurse...thafs when he then which one of the nurses he wants something or somewhich one he'll...call...he may her or have more confidence in or her because they...give the that feeling of trust, confiand that they know what doing and that they...feel they know more than the others."
*"A good nurse makes a statement what is happening to me before can tell. If you're sick they will it before you can tell them. I the nurse to explain stuff to whaf s wrong with you, your know the patient's condition as well as who he is as a person."
*"I expect that the nurses use their knowledge to get information to the doctor that would be helpful to the patient."
*"I know if a nurse is knowledgeable because if s like knowing if someone can drive a car. ..you can tell real quick through their actions..Mke can they explain things to you, in layman's terms, answer questions and not leave you hanging...They know what to do and then confidently do it."
Based on the participants' descriptions, the expectation of knowledgeable nursing was defined operationally as those actions in which the nurse recognizes patients' needs, relays information, and demonstrates competent professional performance.
Sixteen of 28 subjects were asked to rank the relative importance of the three categories of expectations. The most important category was given 1 point, the second most important received 2 points, the least important category receiving a value of 3 points. Therefore, the lowest score reflected the highest priority ranking, and the half point is an indication of a tie. The knowledgeable category received the highest priority ranking with a score of 27.5. The caring category received the middle score of 29.5, with the attentive category receiving the lowest priority ranking with a score of 39. Based on the subjects' rankings, the knowledgeable and caring categories received very close priority scores and therefore, are assumed to be closely ranked expectations compared with the lower priority placed on the attentive category.
Common Properties of the Categories
The same 16 subjects were also asked to card-sort 10 of the most commonly stated nursing properties or attributes into the three established categories. One individual, however, did not wish to complete the card sort. Spradle/s (1980) card-sort technique assisted with verifying the properties for each category as the 15 participants were instructed to choose a category for each of the attributes. For each category, a frequency count of the selected properties was conducted to establish the most commonly chosen examples. The attributes the participants most frequently chose as distinguishing properties of the knowledgeable category were: a) recognizes what the patient needs; b) is competent with skills, and c) explains and provides information. The nurse attributes most frequently chosen to distinguish the caring category were: a) demonstrates interest; b) is patient; c) is pleasant, and d) is kind and nice. The nurse attributes chosen for the attentive category were: a) being responsive; b) providing prompt service, and c) talcing action.
Focus Group Discussion
The five focus group participants enthusiastically endorsed the credibility of the three labeled categories, their common properties as well as the relative importance of the categories' rankings. The group also described how they thought the categories were connected or linked. Examples of supportive statements that emerged in the discussion follow.
*"I want a knowledgeable person to be attentive to my needs and then you will be caring."
*"Knowledge drives the whole process. I don't think you can do anything in a professional way and do it well unless you are fully knowledgeable of what you are doing."
*"The nurse must be caring to be attentive and if you are attentive then you are caring. What matters to me is that the nurse is knowledgeable, knows what to do, responds and gets on it!"
The focus group concluded that if the nurse is knowledgeable and caring then the nurse would be attentive. The nurse should therefore demonstrate professional competence when recognizing a patient need as well as demonstrating concern for the patient in the delivery of responsive services to the public.
All of the study respondents were asked if they could describe the role of the registered nurse (RN) and distinguish the RN from other health team members. Most of the subjects could not distinguish the RN from other health team members. However, if they stated that they were able to identify the RN, it was accomplished most frequently by name badge or tasks performed. The subjects unanimously stated that this was important and that they wanted to be able to identify the RN. The majority of the subjects had difficulty describing the RN role and their descriptions focused on hospital skills and tasks performed by the nurse. Additionally, the majority of the subjects viewed the nurse as a dependent service caregiver who is "directed by the physician." The subjects also stated the following preferences. They did not want the nurse to "be in a hurry, act domineering, ignore the patient or behave like they were there just for the pay."
The elders in this study described knowledgeable nurse attributes as their most important nursing role expectation. The participants expected the nurse to be knowledgeable and recognize patient needs, to explain and provide information and to be competent with skills. Previous researchers have reported that patients appear to highly value nurses' technical and professional competence behaviors (Allanach & Golden, 1988; Bader, 1988, Hinshaw & Oakes, 1977; Larson, 1987; MacStravic, 1988; Mayer, 1987; Risser, 1975; Scharf & Caley, 1993). Competent and knowledgeable nurse attributes were priority items chosen by subjects in three studies that identified important nurse caring behaviors (Larson, 1987; Mayer, 1987; Scharf & Caley, 1993). In these studies, the patients ranked knowing how to give shots, intravenous infusions, and how to manage equipment as the number one priority of the subjects. In two of these studies, the second priority was knowing when to call the doctor (Larson, 1987; Scharf & Caley, 1993).
Mayer (1987) reported that patients ranked three caring behaviors as the most important nurse behaviors. The caring behaviors were: that the nurse "is cheerful, puts the patient first no matter what else happens, and encourages the patient to call if he/she has problems" (Mayer, 1987, p. 50). These findings are consistent with the findings from the present study in which participants ranked the caring attribute as the second most important nursing role expectation. The study's respondents expected the nurse to demonstrate interest in them and to be patient, kind and pleasant.
Responsiveness has been identified as an important nursing behavior in previous studies. It was reported in two prior studies that nurses should give medications and treatments on time and quickly respond to patients' calls (Larson, 1987; Scharf & Caley, 1993). These responsive nurse attributes were also reported as being important by Boyle, Modderman and Mann (1989), Elbeck (1986), Gardner and Wheeler (1987), and Micalizzi (1991). The study's elders corroborated this finding by ranking that their third most important expectation was that the nurse should be attentive in providing efficient services that are responsive to patients' needs. Thus, the expectations of nursing reported by the 28 elderly participants of this study are congruent with descriptions of valued nursing behaviors that have been identified in previous studies.
Limitations identified for this study are:
1. The results are not transferable to other nursing settings due to the use of a convenience sample.
2. The respondents' descriptions may not reflect their role expectations of registered nurses but could relate to any individual who assumed the position of nurse to the respondents.
This study describes 28 older adults' opinions, expectations and health care preferences which influence their judgments about nursing. Congruent with prior findings, the study's elders expect the nurse to be knowledgeable, caring, and attentive. Prior research has also reported that there may be disparity between nurse and patient perceptions of their health care service. The subjects in this study generally could not identify or distinguish the role of the RN from other health care workers. The subjects also had difficulty describing nursing's unique contributions to health care. Based on these findings, it is speculated that nursing may be experiencing product ambiguity with a public who is unsure of who nurses are and what nurses do. The most significant implication, which was also suggested by Larson (1987), therefore, is that nurses should not assume that their intentions and actions are similarly perceived and understood by the patient. Nurses in practice as well as in educational settings need to be encouraged to elicit consumer expectations, listen closely to the patient, and validate the effectiveness of their actions with the patient It is important that RNs introduce and identify themselves and explain their role as well as their preparation, licensure and credentialing. Nursing service departments in all health care organizations should establish a mechanism for eliciting judgments regarding the quality of nursing care. Staff education should then highlight the valued consumer expectations of nursing.
Providing nursing care that is congruent with expectations should enhance elderly consumers' satisfaction with their nursing care, as well as improve the public's image of nursing. However, further research is needed to validate these expectations with other samples of elders and to determine the relationship between fulfillment of expectations and satisfaction with and outcomes of nursing care.
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