Relationship-based care is fundamental to the practice of psychiatric–mental health nursing. Felgen (2004) described relationship-based care (RBC) as “the intentional caring relationship between the caregiver and patient” (p. 291) that promotes healing. Patients admitted to a psychiatric acute care setting are vulnerable and reliant on nursing staff to provide quality care grounded in caring and RBC to facilitate their recovery and discharge. Nursing staff's relationships and interactions with patients contribute to the psychiatric unit's therapeutic environment. Staff's behavior that communicates respect and understanding of the patient as a unique human being enhances the therapeutic milieu. In addition to medications, psychotherapy, and other therapeutic interventions, patients benefit from an environment characterized as a caring culture. Major contributors to the development of a therapeutic milieu are the relationships created with health care providers that value patients' dignity and autonomy. Lindwall, Boussaid, Kulzer, and Wigerblad's (2013) study affirmed nurses' caring actions of preserving a patient's dignity by being present and having the courage to respond to the patient's spoken and unspoken expressions of feelings.
A hospital in southeast Florida implemented a hospital-wide focus on RBC (Koloroutis & Abelson, 2017). The program's approach was consistent with the theoretical perspectives of Watson (2008). The hospital's initiative emphasized nursing staff's and other clinicians' need to reflect on their caring relationships with patients and families, themselves, and their colleagues.
Nurse caring behaviors are often linked with patient satisfaction with nursing care in acute care settings (Rafii, Hajinezhad, & Haghani, 2008). However, few studies have measured hospitalized psychiatric patients' perceptions of nurse caring. Moreover, patient satisfaction with nursing care is often used as an indicator of quality of care. Few studies were found that described the satisfaction of patients with psychiatric diagnoses with the care provided in acute care and other psychiatric facilities. Therefore, the purpose of the current study was to describe the relationship between psychiatric patients' perceptions of nurse caring and their satisfaction with care at a psychiatric health care institution.
In the current study, perception of nurse caring was measured using the Caring Behaviors Inventory-16 (CBI-16; Wolf, Dillon, Townsend, & Glasofer, 2017). According to Wolf, Giardino, Osborne, and Ambrose (1994), the conceptual definition of nurse caring is:
…an interactive and intersubjective process, occurring during moments of shared vulnerability between nurse and patient, which is self and other directed. Caring is directed toward the welfare of the patient and takes place when nurses respond to patients in a caring situation.
Satisfaction with care is defined as the extent to which patients approve of the care received from health care providers and was measured using the Client Satisfaction Survey, which was developed by the current study's institution. The hypothesis for the current study was: there is a relationship between patients' perceptions of nurse caring and satisfaction with care during hospitalization for a psychiatric disorder.
Review of the Literature
Patient Satisfaction with Care
Few studies were found related to patient satisfaction that specifically pertains to psychiatric nursing care. In 2004, Woodring et al. conducted a study to evaluate patient satisfaction by patients on an inpatient psychiatric unit. The purpose of their study was to identify patients' perceptions of quality care indicators and level of satisfaction with the interdisciplinary model of care and treatment plans. The researchers developed a 15-item instrument, the Penn State Inpatient Psychiatry Satisfaction Survey (PSIPSS), including two subscales, which was administered on day of discharge to 673 patients from 1999–2001 (Woodring et al., 2004). The PSIPSS showed internal consistency reliability and construct validity. Results of the study yielded high satisfaction scores with staff being pleasant and friendly and least satisfaction with the benefit of therapeutic groups. Patients ranked the three most helpful aspects of their hospitalization as staff friendliness, involvement with group activities, and staff attentiveness. The three least helpful items were efficiency of admission, unit appearance and cleanliness, and orientation to the unit. When comparing the results by age, the younger the patient, the least satisfied he/she was with overall care. Gender did not have any significant difference with the overall care, but male patients were statistically more satisfied with professional care and milieu than female patients.
Another inpatient study conducted by Huiting and Ziqiang (2013) examined patient satisfaction with patients in a psychiatric hospital in Singapore. Researchers compared patients' satisfaction with care between two units; one unit had implemented a program titled WOW, which emphasized the enhancement of nurse–patient relationships and the time nurses spend developing those relationships. The Newcastle Satisfaction with Nursing Scale (NSNS; Peterson, Charles, DiCenso, & Sword, 2005) was used with a purposive sample of racially diverse, male patients (N = 91). The WOW group's satisfaction scores were higher than the non-participating group; however, the difference was not statistically significant. Patients in the WOW group were more satisfied with nursing care (e.g., time spent with nurses; nurses' capability, availability, and knowledge; response time to their requests) than the comparison group. NSNS item scores were proportionately higher in the WOW group than the comparison group, except for one item with minimal difference (i.e., “patients were satisfied with being treated as an individual by nurses” [Huiting & Ziqiang, 2013, p. 270]).
In a comparative descriptive study, McCallum, Andrews, Gaughwin, Turnbull, and Mikocka-Walus (2016) investigated inpatient satisfaction with treatment for alcohol use disorder (AUD). They aimed to understand how treatment might be improved. Demographic and addiction severity were elicited by self-report. Scores on the Treatment Perception Questionnaire, a measure of satisfaction with standard AUD treatment, were compared for patients with and without severe mental health symptoms. Scores were stratified by responses on the Depression Anxiety Stress Scale. Patients were recruited from four government-funded services in South Australia. Of the 108 patients screened and invited to participate, 89 returned instruments. Patients with severe mental health symptoms were less satisfied with staff care compared to those with AUD only. Five treatment areas were identified: staff qualities, informed care, treatment access and continuity, issues related to inpatient stay, and mental health needs being addressed. Limitations of the study include a sample that may have comprised a high number of satisfied individuals and self-report was the data collection approach. Programs need to be developed based on patients' perspectives highlighting treatment improvements.
Gunasekara, Pentland, Rodgers, and Patterson (2014) noted inconsistent satisfaction levels with the experience of care by patients admitted for mental health services. Researchers analyzed submissions to suggestion boxes of adult psychiatric inpatient units of an Australian hospital. The research team comprised a consumer of mental health services and health care providers. The team initiated a quality improvement study and used a qualitative inquiry approach to understand patients' experiences. In addition to data from the suggestion boxes, researchers interviewed consumers (n = 2), consumer companions (n = 8), and mental health inpatients (n = 10) to understand patients' experiences. Unstructured interviews requested that participants describe “What makes a fantastic mental health nurse?” and “What can we do better?” (Gunasekara et al., 2014, p. 104). Initial findings were presented in themes; additional recommendations were sought. Mental health nursing care was described as a practice based on an empathetic approach, respect, friendly demeanor, and nurses' attention to self-care and reflective practice.
Patients wanted to be cared about with compassion (Gunasekara et al., 2014). Nurses needed to introduce themselves, communicate honestly and frequently about the processes of care, share treatment plans, and be attentive. The importance of establishing a relationship with patients and being a collaborative team was emphasized by nurses. Being self-reflective about care provided and acknowledging the importance of debriefing when challenged by incidents were highlighted. Researchers created a model describing elements of an environment that is recovery-oriented. Main concepts consisted of characteristics of excellent mental health nurses, personal qualities of nurses, consumer-focused needs, care of nurses, and the practice culture. Gunasekara et al. (2014) promoted the importance of developing a compassionate, patient-centered culture. Patient satisfaction might increase when information about what is important to patients is obtained, as a quality improvement agenda.
Staff and Patient Relationships and Caring
The purpose of Bye and Bernal's (1968) study was to evaluate the effect of patients' behavior on nurses' rating of patients' behavior. Researchers hypothesized a positive correlation: when a patient approached a nurse in a positive manner, the nurse would score the patient more positively than if the patient approached the nurse in a negative manner. A survey design used an investigator-created, 16-item instrument with paired adjectives and a 7-point semantic differential scale. The scale reversed positive and negative adjectives based on observed patient behavior. The instrument behaviors had face validity based on the literature and was piloted prior to the study. The sample comprised 11 psychiatric nurses who provided responses to patient approach. Two “patient accomplices” (Bye & Bernal, 1968, p. 252) were recruited for the study. They were instructed to approach nurses differently: either a friendly and warm approach or a cool and reserved-fashion approach. One patient's scores were used in the analysis on means of positive or negative behaviors. The findings from the Sign Test showed a statistically significant result (p ≤ 0.001), indicating that nurses' ratings of patients on the scale demonstrated a response to the patient approach/manner observed. Study limitations were: the instrument had no established reliability or construct validity and the sample size was small. The study by Bye and Bernal (1968) validates the need for accurate assessment instruments to measure nurse–patient relationships.
Using a comparative descriptive design, von Essen and Sjoden (1993) sought to determine the perceptions of most and least important nurse caring behaviors of psychiatric inpatients and staff on a psychiatric unit in comparison to findings of earlier studies conducted in somatic care settings (i.e., non-psychiatric general hospitals). The purposive sample comprised 63 nursing staff (18 nurses, 42 psychiatric nurses, and 3 nursing students) and 61 patients (majority diagnosed with depression) in four psychiatric inpatient units in Sweden. Caring behaviors were measured using a modified, Swedish language, psychiatric population version of the CARE-Q instrument. Nurse and patient versions differed. The instrument, originally created for somatic care, comprises six subscales: accessible, explains and facilitates, comforts, trusting relationship, anticipations, and monitors and follows through. The 50 items of the CARE-Q were ranked on a 7-point scale. Participants ranked items in order of importance; each item was followed by a ranking of “…one most and one least important item, 4 next most and 4 next to least important items, 10 rather and 10 not so important items, and 20 items that are neither important nor unimportant” (von Essen & Sjoden, 1993, p. 296). Content validity of the original English language CARE-Q was established. Sub-scale alpha coefficients in this study's version ranged from −0.086 to 0.464 (von Essen & Sjoden, 1993).
The results of the study by von Essen and Sjoden (1993) yielded some discrepancies between patients and nursing staff. Psychiatric patients' (n = 61) and staff's (n = 63) responses differed on mean scores of the subscales; however, t test results showed that the subscales Explains and facilitates (p < 0.001) and Comforts (p < 0.05) differed at statistically significant levels. Patients indicated that the Explains and facilitates subscale was most important; nursing staff ranked the Comfort subscale as most important. Of the 10 highest mean items/rankings, patients and nursing staff ranked Listens to the patient when he/she is sad or upset the highest. Findings also revealed that patients identified the cognitive aspect of care as most important, whereas nursing staff identified the emotional component as most important. When comparing the results to prior studies in somatic settings, patients in psychiatric settings ranked the trusting relationship subscale higher than in settings caring for patients with somatic illnesses. Staff on psychiatric units ranked the Comfort subscale lower than staff in somatic care settings. Patients in psychiatric and somatic settings ranked the Explains and facilitates subscale as important, but patients in the somatic settings identified Monitors and follows through and anticipates scales more important than patients in psychiatric settings. Mann-Whitney U tests showed no significant pairwise difference on CARE-Q subscale ranking between patients or staff in psychiatric or somatic settings. The main limitations of the study were the lack of reliability and validity of the modified CARE-Q (von Essen & Sjoden, 1993). Understanding patients' perceptions of nurses' caring behaviors is important. Furthermore, patients' perceptions of nurse caring vary across institutional settings.
Gomez and Aillach (2013) examined dimensions that shaped the patient–physician relationship in a theoretical paper. They identified the need for physicians to communicate empathy to psychiatric patients. Verbal and nonverbal communication were key aspects of the communication episodes. The authors proposed that educational strategies that emphasized communication and empathic ability of physicians and other clinicians caring for patients were essential (Gomez & Aillach, 2013).
Delaney, Shattell, and Johnson (2017) proposed a model for nurse engagement with inpatients in psychiatric settings based on Peplau's theory of interpersonal relations and empirical and theoretical literature on therapeutic relationships. The model emphasizes the processes essential to validating patients' experiences and addresses compassionate care and understanding patients' narratives and needs.
Delaney et al. (2017) suggested that nurses' self-reflection assists them to understand how to comprehend the meaning of patients' behavior during interaction. They reviewed literature on nurse–patient relationships pertaining to interpersonal engagement training. The authors explored the Peplau framework as applied to inpatient nursing care and other work, such as Dziopa and Ahern's (2009) nine attributes of a therapeutic relationship and Gunasekara et al.'s (2014) attention to patients' perspectives, so that a caring environment is created to nurture recovery. Delaney et al. (2017) described how nurses learn interpersonal engagement by paying attention to presence, empathy, and self-awareness of their responses to patients as they interact with them. They suggested that nurses' responses to patients need to be based on an intersubjective sense of patients' experiences and meaning of their behavior.
The Model for Engagement (Delaney et al., 2017) was aimed at building nurses' ability to interact with patients as presented during planned learning experiences. Six core skills serve as engagement concepts. The authors described the empathic bridge that helps nurses understand patients' stories. The core skill set unfolds as a process for nurses that “…cultivates caring, nonjudgmental, and compassionate climate” (Delaney et al., 2017, p. 637). Skills include: center yourself; send intent/here to listen; establish empathic bridge; attunement; understand the story; and crafting a response. They presented essential elements of the core skills. The authors hoped that education on interpersonal engagement might clarify its elements, based on the model, and foster internalization of behavior that ultimately shapes nursing practice and through which nurses new to psychiatric nursing and seasoned nurses might explain their practice (Delaney et al., 2017).
Patients admitted to psychiatric hospitals and primary care agencies participate in studies that measure satisfaction with care. Their responses to various instruments can assist therapeutic teams and hospital administrators identify staff behaviors that need improvement and educational sessions so that the quality of services provided increases. Although different instruments have been used to measure caring behaviors and activities, additional studies need to be conducted and instruments compared to identify those with the best validity and reliability characteristics. Of interest are comparisons between nurse and patient perspectives.
Different models of care have been implemented in psychiatric facilities. They address the interpersonal aspects of care as central to patient care. Additional studies could implement programs of care based on patients' concerns with care provided and programs that emphasize enhancement of nurse–patient relationships based on evidence-based literature.
The RBC model (Koloroutis & Abelson, 2017) adopted by the hospital on a hospital-wide basis influenced the current study overall. Employees are introduced to the RBC model and Theory of Human Caring (Watson, 2008) at orientation. Continued focus in psychiatric services include further training on communication skills, patient- and family-centered care, and concepts of recovery.
Although the current study was not designed to evaluate the implementation of the model, it provided an opportunity to reflect on outcomes on patient satisfaction with care. This study addressed the constructs of perception of nurse caring and patient satisfaction with care. The constructs fit Mitchell, Ferketich, and Jennings' (1998) Quality Health Outcomes Model, which supplies the structure for the main study variables.
Mitchell et al.'s (1998) Quality Health Outcomes Model includes systems characteristics, interventions, client characteristics, and outcomes. Within the model, interventions affect and are affected by system and client characteristics. System characteristics include the organized agency, including “…size, ownership, skill mix, client demographics, and technology” (Mitchell et al., 1998, p. 44). Direct and indirect interventions and activities represent clinical processes. Client (i.e., individual, family, or community) characteristics may consist of client demographics, health state, and disease risk factors. Outcomes of structures and processes address achievement of self-care, demonstration of health-promoting behaviors, health-related quality of life, perception of being well cared for, and symptom management (Mitchell et al., 1998).
The relationship between perception of nurse caring and satisfaction with care was tested in this study. Perception of nurse caring fits the intervention part of the model; satisfaction with care is consistent with an outcome of clinical processes or interventions, as patient satisfaction with services infers patient well-being.
The current study used a descriptive correlational design to explore the relationship between patients' perceptions of nurse caring and satisfaction with care. Patients hospitalized for psychiatric services completed the CBI-16, a measure of perceived nurse caring, and the Client Satisfaction Survey, a measure of patient satisfaction with care.
Sample and Setting
Patients hospitalized at one hospital in Florida that cares for individuals with psychiatric disorders constituted the convenience sample (N = 169). Adult patients admitted to a psychiatric unit in the hospital were recruited to participate by a staff nurse and researcher. Demographic characteristics were elicited and did not include admitting diagnosis. Reasons for participant attrition were a decision to stop participation and not completing the instruments.
The behavioral health hospital is an acute care community hospital in southeastern Florida that admits patients requiring psychiatric care. A wide variety of individual and group services are provided for patients with bipolar disorder, clinical depression, anxiety disorders, schizophrenia, and substance use. The investigators were experienced psychiatric nurses and academic faculty.
The institutional review board (IRB) of the hospital reviewed and approved the study, which received exempt approval, specified as minimal risk. One investigator (D.L.) described the study to staff nurses; she and a staff nurse invited patients to participate in the research. Patient consent was indicated by completion of the instruments.
Participant anonymity and confidentiality was maintained through use of identification numbers. No information was transferred or removed from patients' personal, protected, and private information. Data were aggregated. Completed instruments were stored in a locked office of the on-site researcher. Completed instruments were also scanned and e-mailed to a researcher who stored them in a secured file in an office. Data were entered into a password-protected computer. Paper copies of the instrument were destroyed 6 months after the study.
Two instruments were administered: CBI-16 and Client Satisfaction Survey. The CBI-16 comprises three parts. Section 1 includes an explanation of the study. Section 2 comprises 16 response items scored on a 6-point Likert scale, with 1 = never, 2 = almost never, 3 = occasionally, 4 = usually, 5 = almost always, and 6 = always. Item responses were summed to create a composite score. Section 3 includes patient demographic items. The average time to complete the instrument was estimated at 5 minutes. Initial internal consistency reliability and factorial, contrasted groups and discriminant validity were established for an acute care sample (Wolf et al., 2017).
The Client Satisfaction Survey was created by the hospital and comprises three parts. Part 1 contains 11 items and addresses satisfaction with care and services provided. Items are scored on a 4-point Likert scale, where 1 = never, 2 = sometimes, 3 = usually, and 4 = always. In Part 2, seven items elicited ratings on client satisfaction with overall services and those delivered by specific health care providers. Items are scored on a 4-point Likert scale, where 1 = very dissatisfied, 2 = mildly dissatisfied, 3 = mostly satisfied, and 4 = very satisfied. Part 3 elicited comments from patients. The average time to complete the instrument was approximately 5 minutes.
Procedures for Data Collection
Data collection followed approval by the hospital IRB. After a researcher or staff nurse explained the study and read the consent form, patients completed the CBI-16 (Wolf et al., 2017) and Client Satisfaction Survey. Approximately 40% to 50% of patients asked to participate in the study agreed to complete both instruments. Data were obtained at time of discharge when patients were asked to complete paper versions of the instruments. Patients completed the surveys in a common area (dining room) with privacy provided. All instruments had identification numbers. Data were collected over a 6-month period, which began in 2017 and ended in 2018.
SPSS version 24 was used for data entry and analysis. Descriptive statistics were calculated for patient demographics, item statistics, and composite scores. Cronbach's alpha coefficients were obtained for CBI-16 items and items on Parts 1 and 2 of the Client Satisfaction Survey. Pearson product moment correlation coefficients were calculated for the CBI-16 and two satisfaction with care composite scores.
Table 1 provides the demographic characteristics of participants. Participants' ages varied widely, with a mean age of 40.7 years. More men than women completed the instruments. More than 55% of participants were single. Approximately 60% of participants were White and 18% were Black. The most frequent educational level was grades 9 to 12 (45%). The highest frequency for employment category was unemployed (38.5%). Cronbach's alpha coefficients resulted in good reliability for the three instruments: CBI-16, α = 0.968; Part 1 Client Satisfaction with Care, α = 0.883; and Part 2 Client Satisfaction with Care (overall), α= 0.898.
Participant Demographics (N = 169)
Descriptive statistics for CBI-16 and satisfaction with care items are found in Table 2. The highest CBI-16 item means were: Treating your information confidentially, Giving your treatments and medications on time, and Demonstrating professional knowledge and skill. Spending time with you received the lowest item mean. Part 1 of the Client Satisfaction Survey revealed the following highest item means: I felt safe during my stay, The staff treated me with respect, My rights were explained to me, and My medications were explained to me. I discussed my discharge plans with my treatment team received the lowest item mean. For Part 2 of the Client Satisfaction Survey, patients' highest means were: overall satisfied with service received, nursing care, and the mental health counselor and their groups. Level of satisfaction with the physician received the lowest item mean. Part 3 comments described patients' appreciation of specific staff members; staff were polite, excellent, kind, helpful, and caring. Some participants wrote negative comments about the staff and hospitalization, such as rudeness and dissatisfaction with care.
Descriptive Statistics on the Caring Behaviors Inventory-16 (CBI-16) and Client Satisfaction Survey Subscales Satisfaction with Care and Overall Satisfaction (N = 169)
Table 3 provides the descriptive statistics for the CBI-16 and Parts 1 and 2 of the Client Satisfaction Survey's composite scores of satisfaction. Table 3 also depicts the correlation coefficients of perceived caring with client satisfaction with care, perceived caring with overall satisfaction with care, and client satisfaction with client overall satisfaction with care. Association hypotheses tested the relationship between perceived caring (CBI-16), client satisfaction with care (Part 1), and client overall satisfaction with care (Part 2). Another hypothesis tested the relationship between client satisfaction with care (Part 1) and overall satisfaction with care (Part 2). All correlations were positively, strongly correlated (r = 0.723, 0.717, and 0.747, respectively) and statistically significant (p < 0.01).
Descriptive Statistics on Composite Scores and Relationship Between Perceived Caring, Client Satisfaction with Care, and Client Overall Satisfaction with Care
The current study supports the link between perceived caring and patient satisfaction with care for patients hospitalized in a psychiatric institution. Findings showed that there was a positive, strong, statistically significant relationship between psychiatric patients' perceptions of nurse caring and their satisfaction with care. This finding is consistent with studies on patients hospitalized in acute care institutions (Palese et al., 2011) and with patients' satisfaction with a model of care and effective treatment plans in a psychiatric setting (Woodring et al., 2004).
It is gratifying that the highest item mean for CBI-16 responses was Treating your information confidentially. Of concern is the lowest item mean, Spending time with you. This result may be explained by staffing levels; however, it is unclear whether the staff mix influenced responses or if this is a concern for direct care and administrative staff. The current study did not examine staffing levels during data collection. Similarly, I felt safe during my stay and staff treated me with respect resulted in the highest item means on Part 1 of the Client Satisfaction Survey, which support the findings of Lindwall et al. (2013). Feeling safe is an important consideration of patients and health care providers; however, the item, I discussed my discharge plans with my treatment team, received the lowest item mean. As far as Part 2 results, patients were overall satisfied with services received, nursing care, and the mental health counselor care. The lowest item mean was satisfaction with the physician.
The current study adds to the literature on patient satisfaction with care and perceived nurse caring and provides an exploration of an important clinical topic—the inpatient psychiatric hospitalization experience. Few patients with psychiatric disorders complete the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (Press Ganey Associates, 2005). One explanation may be health care providers' reluctance to survey patients with psychiatric problems and possible negative survey responses when evaluating hospital care. In one study, psychiatric patients' survey results were eliminated in a large sample study (Elliott et al., 2010) across different hospitals' results. In another study, they were included but not distinguished from other respondents (Horton et al., 2017).
The results of the current study must be accepted with caution. The sample was one of convenience, restricting generalizability. In addition, many factors may affect perceptions of nurse caring and patient satisfaction with care, including involuntary commitment status, perceived intimidation due to possibility of restraint and/or seclusion, staff in power positions, limited access to personal belongings, expected attendance at scheduled activities, and limited control over daily schedule. Results could also be biased because data were collected when patients were hospitalized, and responses were most likely based on many types of health care providers. Patients might also have been anxious to leave and completed the instruments quickly.
Positive results could also be explained by the possibility that many patients who completed instruments were positive about caring and satisfied with care, and those with opposing views did not participate. The patient satisfaction instrument did not have previously established internal consistency reliability, or any type of validity, except perhaps face validity.
Psychiatric care from patients' perspectives deserves continuing attention. Patients admitted to acute care settings for psychiatric care are experiencing cognitive and/or emotional conditions that may impact their perceptions of care; therefore, tools that reflect their satisfaction with the care provided by nurses are important. Findings from the current study identify nurse caring behaviors from the patient's perspective, which could be incorporated into a model of care that enhances nurse–patient relationships, clinical practice, and patient outcomes. By addressing findings on caring in this study, nursing staff can develop stronger therapeutic relationships, with the goal of developing therapeutic alliances, increasing treatment adherence, and enhancing patients' engagement in their own care. Supporting the findings of this study is Delaney et al.'s (2017) Model of Engagement, which describes the need for communication skills, nurses' self-awareness and self-reflection, and attentiveness to patient's story.
In addition, Chiovitti's (2008) model could be used to evaluate outcomes that affect perceived caring and patient satisfaction with hospital care. Use of a model of care delivery that addresses caring could be developed or adapted to tailor interventions to specific issues of patients hospitalized for psychiatric disorders. In a grounded theory study, Chiovitti (2008) developed a substantive theory of caring from the perspective of RNs working in Canadian acute psychiatric hospitals. The basic social psychological process, protective empowering, incorporated six categories: nurses (a) respected the patient, (b) did not take the patient's behavior personally, (c) kept the patient safe, (d) encouraged the patient's health, (e) related to the patient authentically, and (e) taught the patient interactively. Chiovitti (2008) noted that care provided in the context of the theory of protective empowering would help patients participate in activities, leading to positive outcomes in health and quality of life. Translation of the theory into a model of care and validation of the theory with patients might have positive effects on perceptions of caring and satisfaction with care.
The findings from the current study also indicate the need to enhance approaches to discharge planning and transitional care. Although not directly focused on discharge plans, von Essen and Sjoden's (1993) study identified patients' concerns with cognitive aspects of care, indicating the need for nurses to receive education and incorporate strategies related to motivating change and cognitive-behavioral approaches that may facilitate patients' discharge and be incorporated into transitional plans of care. A continued focus on patients' perspectives of nurse caring behaviors and satisfaction with care in psychiatric settings may lead to refinement of measurement tools and implementation of models of care, which enhance patient engagement and promote patient outcomes.
Future Projects and Plans
Gaps exist in the literature on the relationships between perceived nurse caring and patient satisfaction in patients admitted for psychiatric care. More research is needed on the patient experience with care during hospitalization. Future research might address the association and use HCAHPS surveys rather than a hospital-created instrument. However, HCAHPS surveys are typically mailed to a randomly selected patient group after discharge. The possibility of low response rates by patients in a psychiatric hospital must be considered. A modification of the CBI-16 could be tested in which Chiovitti's (2008) findings and von Essen and Sjoden's (1993) instrument are considered in instrument development. In addition, a qualitative study could explore patients' perspectives of aspects of care that might improve their hospitalization experience.
Future research could explore the association of perceived caring using the CBI-16 with perceptions of the unit atmosphere with the Moos (1989) Ward Atmosphere Scale. Tuvesson, Wann-Hansson, and Eklund (2011) studied nursing staff's perceptions of unit atmosphere and the psychosocial work environment. Although staff's perceptions are crucial to the unit environment, patients' perceptions of the unit environment also need to be investigated based on the study by Rossberg and Friis (2004). Studies related to patient recommendations for changes in clinical practice are also needed. In addition, the impact of staffing patterns could be considered a contributor to perception of perceived caring and patient satisfaction in a psychiatric setting.
RBC can facilitate patients' perceptions of nurse caring and satisfaction with care, and the current study validates the ethical behavior of maintaining patient confidentiality by nurses who are knowledgeable and skilled caregivers. Recommendations for future studies, based on gaps in the literature, include: psychiatric nurses' knowledge of caring behaviors, caring behaviors unique to psychiatric nursing, and psychiatric nurses' perception of patient satisfaction and related behaviors.
- Bye, W.G. & Bernal, M.E. (1968). The effects of two patient behaviors upon psychiatric nurses' ratings of the patient. Nursing Research, 17, 251–255.
- Chiovitti, R.F. (2008). Nurses' meaning of caring with patients in acute psychiatric hospital settings: A grounded theory study. International Journal of Nursing Studies, 45, 203–223. doi:10.1016/j.ijnurstu.2006.08.018 [CrossRef]
- Delaney, K.R., Shattell, M. & Johnson, M.E. (2017). Capturing the interpersonal process of psychiatric nurses: A model for engagement. Archives of Psychiatric Nursing, 31, 634–640. doi:10.1016/j.apnu.2017.08.003 [CrossRef]
- Dziopa, F. & Ahern, K.J. (2009). What makes a quality therapeutic relationship in psychiatric/mental health nursing. A review of the research literature. Internet Journal of Advanced Nursing Practice, 10, 7 Retrieved from http://ispub.com/IJANP/10/1/7218
- Elliott, M.N., Lehrman, W.G., Goldstein, E., Hambarsoomian, K., Beckett, M.K. & Giordano, L.A. (2010). Do hospitals rank differently on HCAHPS for different patient subgroups?Medical Care Research and Review, 67, 56–73. doi:10.1177/1077558709339066 [CrossRef]
- Felgen, J. (2004). A caring and healing environment. Nursing Administration Quarterly, 28, 288–301. doi:10.1097/00006216-200410000-00012 [CrossRef]
- Gomez, G. & Aillach, E. (2013) Ways to improve the patient-physician relationship. Current Opinion in Psychiatry, 26, 453–457. doi:10.1097/YCO.0b013e328363be50 [CrossRef]
- Gunasekara, I., Pentland, T., Rodgers, T. & Patterson, S. (2014). What makes an excellent mental health nurse? A pragmatic inquiry initiated and conducted by people with lived experience of service use. International Journal of Mental Health Nursing, 23, 101–109. doi:10.1111/inm.12027 [CrossRef]
- Horton, D.J., Yarbrough, P.M., Wanner, N., Murphy, R.D., Kukhareva, P.V. & Kawamoto, K. (2017). Improving physician communication with patients as measured by HCAHPS using a standardized communication model. American Journal of Medical Quality, 32, 617–624. doi:10.1177/1062860616689592 [CrossRef]
- Huiting, S. & Ziqiang, L. (2013). An evaluative study of the WOW program on patients' satisfaction in acute psychiatric units. International Journal of Caring Science, 6, 267–277.
- Koloroutis, M. & Abelson, D (Eds.). (2017). Advancing relationship-based cultures. Minneapolis, MN: Creative Health Care Management, Inc.
- Lindwall, L., Boussaid, L., Kulzer, S. & Wigerblad, Å. (2013). Patient dignity in psychiatric nursing practice. Journal of Psychiatric and Mental Health Nursing, 19, 569–576. doi:10.1111/j.1365-2850.2011.01837.x [CrossRef]
- McCallum, S.L., Andrews, J.M., Gaughwin, M.D., Turnbull, D.A. & Mikocka-Walus, A.A. (2016). Patient satisfaction with treatment for alcohol use disorders: Comparing patients with and without severe mental health symptoms. Patient Preference and Adherence, 10, 1498–1500. doi:10.2147/PPA.S92902 [CrossRef]
- Mitchell, P.H., Ferketich, S. & Jennings, B.M. (1998). Quality health outcomes model. Image: The Journal of Nursing Scholarship, 30, 43–46.
- Moos, R.H. (1989). Ward Atmosphere Scale manual: Social climate scale. Washington, DC: Consulting Psychologists Press.
- Palese, A., Tomietto, M., Suhonen, R., Efstathiou, G., Tsangari, H., Merkouris, A. & Papastavrou, E. (2011). Surgical patient satisfaction as an outcome of nurses' caring behaviors: A descriptive and correlational study in six European countries. Journal of Nursing Scholarship, 43, 341–350. doi:10.1111/j.1547-5069.2011.01413.x [CrossRef]
- Peterson, W.E., Charles, C., DiCenso, A. & Sword, W. (2005). The Newcastle Satisfaction with Nursing Scales: A valid measure of maternal satisfaction with inpatient postpartum nursing care. Journal of Advanced Nursing, 52, 672–681. doi:10.1111/j.1365-2648.2005.03634.x [CrossRef]
- Press Ganey Associates. (2005). Hospital CAHPS Integrated Survey–IZ Expanded Survey Customization Form (Inpatient). South Bend, IN: Author.
- Rafii, F., Hajinezhad, M.E. & Haghani, H. (2008). Nurse caring in Iran and its relationship with patient satisfaction. Australian Journal of Advanced Nursing, 26, 75–84.
- Rossberg, J.I. & Friis, S. (2004). Patients' and staff's perceptions of the psychiatric ward environment. Psychiatric Services, 55, 798–803. doi:10.1176/appi.ps.55.7.798 [CrossRef]
- Tuvesson, H., Wann-Hansson, C. & Eklund, M. (2011). The ward atmosphere important for the psychosocial work environment of nursing staff in psychiatric in-patient care. BMC Nursing, 10, 12. doi:10.1186/1472-6955-10-12 [CrossRef]
- von Essen, L. & Sjoden, P. (1993). Perceived importance of caring behaviors to Swedish psychiatric inpatients and staff, with comparisons to somatically-ill samples. Research in Nursing & Health, 16, 293–303. doi:10.1002/nur.4770160408 [CrossRef]
- Watson, J. (2008). Nursing: The philosophy and science of caring (rev. ed.). Boulder, CO: University of Colorado Press.
- Wolf, Z.R., Dillon, P.M., Townsend, A.B. & Glasofer, A. (2017). Caring Behaviors Inventory-24 Revised: CBI-16 validation and psychometric properties. International Journal for Human Caring, 21, 185–192. doi:10.20467/1091-5710.21.4.185 [CrossRef]
- Wolf, Z.R., Giardino, E.R., Osborne, P.A. & Ambrose, M.S. (1994). Dimensions of nurse caring. Image: Journal of Nursing Scholarship, 26, 107–111.
- Woodring, S., Polomano, R.C., Haagen, B.F., Haack, M.M., Nunn, R.R., Miller, G.L. & Tan, T.L. (2004). Development and testing of patient satisfaction measure for inpatient psychiatry care. Journal of Nursing Care Quality, 19, 137–148. doi:10.1097/00001786-200404000-00011 [CrossRef]
Participant Demographics (N = 169)
|Characteristic||Mean (SD) (Range)|
|Age (years)||40.72 (16.60) (18 to 91)|
|Length of stay (days)||6.18 (2.65) (1 to 21)|
| Male||89 (52.7)|
| Female||72 (42.6)|
| Missing||8 (4.7)|
| Single||94 (55.6)|
| Married||23 (13.6)|
| Divorced||17 (10.1)|
| Separated||11 (6.5)|
| Partner||9 (5.3)|
| Widowed||3 (1.8)|
| Missing||12 (7.1)|
| White||101 (59.8)|
| Black||30 (17.8)|
| Hispanic||19 (11.2)|
| Multiracial||6 (3.6)|
| Asian||4 (2.4)|
| Native American Indian||3 (1.8)|
| Missing||5 (3)|
| Grades 1 to 8||8 (4.7)|
| Grades 9 to 12||76 (45)|
| 1 to 2 years||39 (23.1)|
| 3 to 4 years||24 (14.2)|
| ≥5 years||19 (11.2)|
| Missing||3 (1.8)|
| Unemployed||65 (38.5)|
| Employed||53 (31.4)|
| Disabled||30 (17.8)|
| Retired||12 (7.1)|
| Work at home||4 (2.4)|
| Missing||5 (3)|
Descriptive Statistics on the Caring Behaviors Inventory-16 (CBI-16) and Client Satisfaction Survey Subscales Satisfaction with Care and Overall Satisfaction (N = 169)
|Item||Mean Score (SD)||Responses (n)|
| 1. Attentively listening to you.||4.52 (1.25)||168|
| 2. Giving instructions or teaching you.||4.51 (1.27)||168|
| 3. Treating you as an individual.||4.62 (1.28)||169|
| 4. Spending time with you.||4.03 (1.43)||168|
| 5. Supporting you.||4.50 (1.30)||169|
| 6. Being empathetic or identifying with you.||4.43 (1.32)||169|
| 7. Being confident with you.||4.65 (1.30)||169|
| 8. Demonstrating professional knowledge and skill.||4.76 (1.14)||169|
| 9. Including you in planning your care.||4.67 (1.41)||161|
| 10. Treating your information confidentially.||5.11 (1.14)||169|
| 11. Returning to you voluntarily.||4.58 (1.31)||165|
| 12. Talking with you.||4.45 (1.33)||167|
| 13. Meeting your stated and unstated needs.||4.40 (1.32)||165|
| 14. Responding quickly when you call.||4.34 (1.34)||166|
| 15. Giving your treatments and medications on time.||5.01 (1.10)||166|
| 16. Relieving your symptoms.||4.49 (1.32)||162|
|Client Satisfaction with Careb|
| 1. The staff treated me with respect.||3.32 (0.80)||169|
| 2. My rights were explained to me.||3.17 (1.04)||167|
| 3. My medications were explained to me.||3.17 (0.99)||167|
| 4. I had enough time with my doctor.||3.16 (2.52)||1.11|
| 5. I took part in interesting activities.||3.04 (0.93)||167|
| 6. The food tastes good.||2.98 (0.91)||165|
| 7. The unit was clean and comfortable.||3.16 (0.92)||167|
| 8. I participated in the development of my treatment plan.||3.07 (0.97)||168|
| 9. I discussed my discharge plans with my treatment team.||2.97 (1.04)||167|
| 10. The therapeutic groups helped me understand my problems.||3.00 (0.97)||167|
| 11. I felt safe during my stay.||3.34 (0.71)||168|
|Client Overall Satisfaction with Careb|
| 1. Overall, how satisfied were you with the services you have received?||3.10 (0.87)||164|
| 2. If a friend were to ever need similar help, would you recommend our program?||2.95 (1.09)||162|
| 3. Please rate your level of satisfaction with your physician.||2.90 (1.02)||159|
| 4. Please rate your level of satisfaction with your social worker service.||3.12 (0.94)||159|
| 5. Please rate your level of satisfaction with your nursing care.||3.33 (0.82)||160|
| 6. Please rate your level of satisfaction with your recreational therapist and their groups.||3.29 (0.89)||162|
| 7. Please rate your level of satisfaction with your mental health counselor and their groups.||3.32 (0.83)||155|
Descriptive Statistics on Composite Scores and Relationship Between Perceived Caring, Client Satisfaction with Care, and Client Overall Satisfaction with Care
|Outcome||Mean (SD) (Range)|
|Perceived caring (n = 151)||73.56 (17.01) (26 to 96)|
|Client satisfaction with care (n = 160)||34.10 (7.28) (16 to 53)|
|Client overall satisfaction with care (n = 149)||22.26 (5.07) (7 to 28)|
|Perceived caring with client satisfaction with care||0.723*|
|Perceived caring with overall satisfaction with care||0.717*|
|Client satisfaction with client overall satisfaction with care||0.747*|