F E AT U R E S
Critical Care Nurses’ Understanding of the Concept of Patient-Centered Care in Iran A Qualitative Study ■ ■
Maryam Esmaeili, MSN, BSN ■ Mohammad Ali Cheraghi, PhD, MSN, BSN Mahvash Salsali, PhD, MSN, BSN This study explores the perception of nurses working in critical care units about the patient-centered care, which is a crucial factor in attaining quality in nursing care. A qualitative exploratory study with conventional content analysis was used. Three main themes were extracted from the data: from accepting to understanding the patient; improved care as the result of skill and expertise; and adherence to patients’ rights charter. KEY WORDS: content analysis, critical care, nurses, patient-centered care Holist Nurs Pract 2014;28(1):31–37
Achieving quality in care is important because of the pivotal role of direct care in nursing as well as the growing emphasis on improving hospitals’ credibility and clinical status. Today’s health care has changed from provider-centered to patient-centered. In addition, patient satisfaction is considered an indicator of quality of health care services.1 According to the definition of the Institute of Medicine, quality in a health care system is defined as safe, timely, effective, efficient, equitable, and patient-centered care. Patient-centered care, which is 1 of the 6 specified facets, is a driver in improving the quality of care.2 Patient-centered care, originating with the work of Florence Nightingale, is a valuable and sobering concept in the nursing discipline. She was the first person to distinguish nursing from medicine by focusing on the patient instead of the disease.3 Different literature reviews show that patient-centered care has different characteristics in different cultures and settings.4,5 Patient interaction with health care Author Affiliations: Nursing and Midwifery Care Research Center (Dr Cheraghi), School of Nursing and Midwifery (Ms Esmaeili and Dr Salsali), Tehran University of Medical Sciences, Tehran, Iran. This study was one part of a PhD dissertation of the first author, financially supported by Tehran University of Medical Sciences. The authors thank the nurses for their sincere cooperation during the different stages of this study. No conflict of interest has been declared by the authors. Correspondence: Mohammad Ali Cheraghi, School of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St, Tohid Sq, Tehran 1419733171, Iran ([email protected]). DOI: 10.1097/HNP.0000000000000002
staff, the cooperation of the patient and family, consistency in caregiving, physical comfort, and liaison between different care services are some aspects of patient-centered care.5-8 Furthermore, the perception of health care workers and patients about patient-centered care varies across cultures, which causes difficulty in understanding and using this concept.7 Many case studies have recognized communication with the patient as the central element of patientcentered care.5,9 Furthermore, some studies mentioned the need of patients’ participation in the self-care, decision making, and independence. Also, in these studies, patients’ preferences were regarded.8,10,11 To define patient-centered care, different approaches have been used.4,12,13 Paying attention to the personal needs of patients, satisfaction, participation, and quality of care are common themes that have been used in the definition of patientcentered care, although there is no consensus on an acceptable definition thus far.8 A review of literature shows that although patient-centered care is one of the key elements in quality of care, there is little attention to nurses’ experience regarding this concept.14 Most surveys about patient-centered care have obvious shortcomings because of the weak analysis of patients’ perception and health care workers.6 A review on other studies in patient-centered care has shown that the critical care context is more closely associated with patient-centered care, which may be the result of higher care levels and greater observance 31
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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of standards in these units.5 Giving care in these areas is not a simple job. It is compulsory for caregivers to be highly skilled and prepared with the necessary knowledge of new care and treatment technologies to provide high-quality care.15 Emphasis on observing the patients’ rights charter, adherence to ethical considerations in nursing, and technological progress in clinical environments, especially in critical care units, affects care provision. Thus, nurses play an important role in giving care, which is focused on the patient, while working in advanced technological environments.16,17 Studies from Iran show that patients’ satisfaction with quality of care is of a higher level in critical care units than in other units.18,19 After a literature review, researchers highlighted the need for qualitative studies about patient-centered care in various settings.5 Therefore, considering existing evidence in Iran and lack of a comprehensive study on the patient-centered care, this study explores the understanding of nurses working in critical care units concerning patient-centered care in the cultural context of Iran.
METHODS Research design To evaluate the understanding of critical care nurses concerning patient-centered care while working in an Iranian context, a qualitative exploratory study was conducted using a conventional content analysis approach.
Participants In this study, 21 nurses (16 female and 5 males) working in critical care units in educational hospitals in Iranian urban areas were selected through purposive sampling. The inclusion criteria were at least 2 years of work experience and a willingness to participate. In this study, the head nurse was asked to nominate nurses who provided quality care. To reach the maximum variation, nurses of both genders with bachelor’s and master’s degrees were chosen.
Data collection Semistructured interviews were used individually and face-to-face. Each interview lasted 30 to 55 minutes and was performed in a quiet place in participants’ working units. The first author of this article
conducted and recorded the interviews, and all the recordings were transcribed verbatim immediately after the interview. The interview included the following main questions: What is your understanding of patient-centered care? In your opinion, what are the important reasons for patient-centered care? In addition, some probing questions were asked for additional clarification to answers given by participants.
Ethical consideration The Ethics and Research Committee of Tehran University of Medical Sciences approved this study (91D130168). Participants were informed about the objectives and method of the study. In addition, they were informed that they could withdraw at any time without penalty. Moreover, their permissions were secured for recording the interviews. All participants were assured of the confidentiality of the information.
Data analyses Data analyses were performed using a conventional content analysis approach. Qualitative content analysis simplifies data and provides structure and discipline, whereas content analysis explores the real meaning behind raw data.20 To analyze the data, the recorded interviews were transcribed verbatim and then read several times to gain a general impression. The resulting text from the interviews was divided into meaning units, which were then condensed, abstracted, coded, and labeled. These codes were then arranged into categories and subcategories according to their similarities and differences. In this study, the first author performed the data coding and all coauthors supervised the coding. If we disagreed over the coding, we discussed the codes until a consensus was achieved.
Rigor Similar to other qualitative approaches, content analysis entails discovering and evaluating processes to use the findings.21 To achieve credibility, member checking was used. The first author performed a member check for 8 participants. Data were coded by the authors after they were compared with one another. In cases of dissension, explanation and clarification were used to reach the final acceptance. Furthermore, a compendium of identified themes was given to participants for confirmation.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Patient-Centered Care
Findings The findings are the result of continuous interviews with 21 nurses until data saturation was reached. Nurses’ mean age was 33.61 years, and participants’ work experience ranged between 2 and 18 years, with a mean of 10.35 years. Data analysis resulted in identifying 3 main themes: from accepting to understanding the patient; improved care as the result of skill and expertise; and adherence to patients’ rights charter. The second theme of the study includes 2 subthemes: managerial skills in caring and the importance of getting to know the patient. The rest of the text discusses the meaning of each theme, with quotations from participants. From accepting to understanding the patient When nurses were asked about their experience of patient-centered care, they pointed to respecting patients’ dignity as human beings who have various biopsychosocial aspects. In fact, they believed that patients’ illnesses increased the importance of paying attention to and respecting them. They stated that accepting patients as human beings enhances communication, leads to respecting their customs and culture, considers patients’ preferences, and promotes punctual responses to patients’ requests. If we just see the patient, it is more like mechanical work. I mean that what happens when you do a series of tasks without any relation, but when you consider someone as a human being, you would not look down at him or her, and the patients’ opinion becomes important to you. It also becomes so important that what he/she thinks. (Nurse with 13 years of nursing experience)
To nurses, patient-centered care is preserving proper treatment according to patients’ preferences. Furthermore, considering patients’ preferences about their lifestyle and culture is central to quality patient care and is a way to provide comfort to patients. I put the patient in a proper position and then ask him or her whether or not he is ok, sometimes when the head of the bed is about 30 degrees, angled upward, they are uncomfortable, and when I explain them they do not accept. In a situation like this, I try to stay calm and tell them that’s all right, whatever you want.” (Nurse with 16 years of nursing experience) Sometimes we have some patients who do not eat the food that is served in the hospital. Well, they have special eating habits. I believe that the hospital is not a place for changing culture and lifestyles. I let their
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relatives bring them the food they like from home. (Nurse with 8 years of nursing experience)
Participants also mention the importance of punctual response to a patient’s demands. They believe that responding to a patient’s demands should be done in a timely manner. Nurses mentioned punctual response to a patient’s needs, especially to a patient’s first request, as an element in respecting the patient’s status; they believe that ignoring a patient’s requests is disruptive to the patient’s value and dignity. I believe when the patient calls you for the first time, you should see what he wants, if you don’t do this the first time it will be of no value if you sit beside him the next other times. The first time he calls is important. (Nurse with 16 years of nursing experience) The patient does not like it at all to call a nurse, then if she doesn’t answer and says I didn’t hear you and leaves, the patients would say “We called the nurse and she didn’t answer and she didn’t come.” (Nurse with 5 years of nursing experience)
The theme of “accepting the patient” was followed by the theme “understanding the patient and his or her condition.” By empathizing and through applying the patients’ condition to themselves, they try to meet what would be their own expectations about care as if they were ill. Using this thought process enhances the quality of care given and heightens the attention paid to patients. Most of the time, I consider myself in the situation in which the patient is. I mean that I really think if I was ill what I would expect from the caregiver? (Nurse with 3 years of nursing experience) I’ve always thought the patient could be me or a member of my family. Well then, what do I expect from the nurse? How would I like them to solve my problem? I notice if they pass me regardless or keep checking me. In this way, I tried to fulfill those expectations for them that I may have had myself in this kind of situation. (Nurse with 18 years of nursing experience).
Improved care as the result of skill and expertise In this study, nurses pointed to the unique nature of critical care settings. In fact, they refer to the continuing nature of a relationship with the patient. They believe that patients expect more from a nurse working in a critical care unit. Also, nurses believe in skill and expertise as key components in achieving patient-centered care. According to them, patient-centered care requires the expertise of the nurse.
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When I go over to a patient, I think that I should inject only a single needle, and there would not be a second one, this is important to me. I mean that I do my best not to harm the patient. This is my first thought when I go over to a patient. (Nurse with 4 years of nursing experience)
discharging the patient from the hospital sooner. For nurses, patient-centered care is making efforts to increase patients’ satisfaction. In this way, follow-up of the care and treatment are ways that make this satisfaction likely.
It is the art of a nurse to recognize the risk before the patient undergoes “myocardial infarction” once again. It means that before the patient has an ST elevation you heed the signs and not allow the patient to be in pain. (Nurse with 13 years of nursing experience).
Importance of getting to know the patient Attention to the patients’ awareness of their condition, medical history, and their problems are also considered important components of patient centered care, particularly in their first interactions with patients. Thorough assessment of a patient’s background and condition leads to a proper care plan that is specific to that patient’s condition.
Nurses who participated in the study considered that the nurse manager’s assessment of the performance of nurses working in critical care units through regular testing is important. They mention attending training classes and specialized courses for working in critical care units as ways to improve skills and expertise. Furthermore, they expressed that nurses’ up-to-date knowledge to provide appropriate care that considers specific circumstances of each patient is of great importance in patient-centered care. When my patient has Premature Ventricle Contractions (PVC), I should know what causes this problem and what I should do for the patient. When I have satisfactory scientific information, it would be much easier to recognize their problem and help the patients. (Nurse with 3 years of nursing experience)
Managerial skills in caring Managerial skills and follow-up care are other skills of nurses that contribute to patient-centered care. Nurses believe that outcomes of patient-centered care are as follows: punctual follow-up (carrying out paraclinical tests and follow-up counseling), highlighting preferences, and planning to provide care to avoid prolonged hospitalization and imposed added costs. After the doctors have visited patients, I prefer to do some tasks for the patient, based on what things have been done and what things will take priority. I mean that I do my best to help the patient not to stay here for a long time and wait for no reason. (Nurse with 16 years of nursing experience) I try to avoid wasting time as much as I can. I mean in a way that avoids keeping the patient in the hospital for extra days. By contrast, it had been seen that when coordination and follow-up are delayed, the patient has to wait in the hospital a few extra days. (Nurse with 17 years of nursing experience)
In fact, nurses believe that overseeing care and carrying out paraclinical tasks punctually would lead to acceleration of care and treatment and in
What I experienced most during these years was understanding and recognizing their mood and personality. It means that I tried to know the patient first, to know how they would be happy and how I should treat them. (Nurse with 18 years of nursing experience)
Another skill mentioned by nurses of critical care units was gaining comprehensive information about the patient’s condition to provide patient-centered care. In fact, nurses try to provide patient-centered care by checking the patient regularly, communicating with the patient, and considering the patient’s complaints. I must get to know the patient; I mean their first name, last name, diagnosis, their major problem, and the reason that has caused them to be admitted to this unit. How did they sleep last night? Did they have any problem? Do they have pain? I ask the patient all of these questions. (Nurse with 8 years of nursing experience)
Adherence to patients’ rights charter According to nurses who participated in the study, observing patients’ rights during the care is important in achieving patient-centered care. In fact, nurses mentioned providing fair and humane care for all patients with different social conditions as patients’ right. Also, providing good quality care, the right of patients to choose their nurse, patient education, and paying attention to their complaints have been identified as respecting the rights of patients. Maybe the patient is not a good citizen or a good father, but for us, as a patient, he is to be respected. We just do the same that we do for a person of a sound societal level. It is not acceptable to check that one’s blood pressure two times and check this one’s only once. (Nurse with 18 years of nursing experience)
Some participants pointed to gaining acceptable information about care and treatment as rights of the
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Patient-Centered Care
patient. Also, they mentioned the importance of educating patients to empower them about self-care. To be precise, they believed that patient-centered care is an interactive human communication with a patient and is associated with offering enough and essential information to the patient and his or her family. I think the patient has the right to know that what we are doing for them is adhering to the charter of patients’ rights: the patient and family deserve to be aware of what should be done. When I go to a patient to give their medications, I tell the patient what those medications are and how they can help the patient. In this way, they are more satisfied and would interact more. (Nurse with 15 years of nursing experience)
Common understanding is an effective strategy in achieving patient-centered care. In fact, nurses believed that ignoring patients’ rights by some health care providers and doctors causes patient dissatisfaction and alienation during their time in the hospital. To nurses, coordination and cooperation of all health care workers to respect the rights and interests of patients is important to achieve patient-centered care. These days, each doctor expects their order to be done first, they do not even think about which one would be useful to the patient. Unfortunately, they think about themselves first, not to waste their time. But they do not consider what the right of the patient is. (Nurse with 14 years of nursing experience)
DISCUSSION Through examining the first theme of this study, nurses highlighted accepting patients as human and understanding their conditions. To nurses, patientcentered care means considering patients as more than just patients. However, they believed that in the process of patient-centered care, the first step is to accept patients as perfect human beings. The next step is to try to understand their conditions. Over time, having this attitude could increase nurses’ knowledge about patients’ life context, which would result in the increase of care quality.22,23 Eijk et al13 studied people with Parkinson disease in 2011. They conducted focus group interviews and mentioned psychoemotional support, respectful empathy, and accepting patients as human beings rather than as patients as their perception of patient-centered care.13 Patient-centered care focuses on understanding patients as persons with specific
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characteristics, needs, values, and preferences, in particular respecting morals and preferences in care decision making.24-26 The results of Aita et al27 study showed that respecting values, culture, and patients’ expectations would result in an effective relationship between patients and health care workers. In this study, the nurses considered patients’ preferences about their culture and customs as being important. Saha et al28 asserted that a focus on understanding patients’ cultures and knowledge about cultural differences can help achieve quality care in health care systems. Participants also mentioned the importance of a punctual response to patients’ needs as central to the delivery of patient-centered care and as a way to respect the dignity of patients. Furthermore, when nurses put themselves in the patients’ position, they believe that this leads to improved understanding of the patients’ conditions. Prompt access to services and health care workers are components of patientcentered care.3 With respect to the second theme of the study, nurses’ skill and expertise in performing tasks and actions prevent harming patients and help relieve their pain. Nurses’ expertise is an important theme found in studies conducted in the field of patient-centered care.3,26 Typically, experience is related to years of performance whereas the expertise of nurses in clinical decision making is based on knowledge gained for the reflective performance and the continuous care of patients in similar clinical conditions. Researchers found that nurses’ expertise and competencies positively correlated with patient satisfaction.26 Furthermore, the result of the study of Rauta et al29 demonstrated that nurses’ expertise in technical performance as well as their scientific knowledge are crucial to achieving positive outcomes in patient care. In fact, nurses’ expertise is effective in preventing complications and increasing patient satisfaction. The Hobbs5 review of published studies on patient-centered care found that positive outcomes occur when the actions and processes engaged by nurses reduce or eliminate harm to patients. With respect to this study’s third theme, adherence to patients’ rights, nurses believed that patientcentered care enhanced the rights of patients in receiving high-quality care. However, nurses also referred to the importance of other health care workers respecting patients’ rights to achieve patient-centered care. Further studies should be conducted to further explicate this aspect of patient-centered care. Patients’ rights are directly associated with patients’
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satisfaction of care in a way that following the rights of the patient is an indicator for achieving quality in care and patient satisfaction.30 The result of the study by Fotaki31 shows that health care providers must consider the rights of patients, although patients may not be familiar with their own rights. In Iran, the charter of patients’ rights includes receiving suitable services, receiving acceptable and correct information, the right to choose, free decision making, respecting patients’ privacy, and listening to patients’ complaints. Providing good-quality services to patients by expert nurses, getting clear information about the treatment, and receiving fair and satisfactory care are examples mentioned by nurses who participated in the study. One of the challenges to protecting the rights of patients to be fully aware of health care policies is lack of patients’ access to information resources and shortcomings in patients’ gaining essential information about the disease and treatment.32 The results of a study by Malinger et al33 revealed that identifying information needs of patients and educating them play important roles both in patient-centered care and in increasing satisfaction among cancer patients.
CONCLUSION On the basis of the findings of this study, accepting patients as human beings and not only as patients, putting oneself in patients’ position to further understand their condition, relieving their pain, avoiding harm to patients, and adhering to the rights of patients could be effective in achieving patient-centered care. Achieving patient-centered care entails team work and managers’ attention to providing thorough and holistic attention to the patient. This study explored only critical care nurses’ understanding of patient-centered care, a limitation of the study. Furthermore, other studies are suggested to understand patients’ attitudes concerning the concept of patient-centered care.
REFERENCES 1. Marshall A, Kitson A, Zeitz K. Patients views of patient-centered care: a phenomenological case study in one surgical unit. J Adv Nurs. 2012;68(12):2664-2673. 2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. www. iom.edu/Reports/2001/ crossing the quality chasm. A New Health System for 21st-century.aspx. Accessed September 2011.
3. Lauver DR, Ward SE, Heidrich SM. Patient-centred interventions. Res Nurs Health. 2002;25(4):246-255. 4. Boer D, Delnoij D, Rademakers J. The importance of patient-centered care for various patient groups. Patient Educ Couns. 2011;85(2): 46-52. 5. Hobbs JL. A dimensional analysis of patient-centered care. Nurs Res. 2009;58(1):52-62. 6. Small DC, Small RM. Patients first. Engaging the hearts and minds of nurses with a patient-centered practice model. Online J Issues Nurs. 2011;16(2):1-13. 7. Robinson JH, Callister LC, Berry JA, et al. Patient-centered care and adherence: definitions and applications to improve outcomes. Acad Nurse Pract. 2008;20(12):600-607. 8. Wolf D, Lehman L, Quinlin R, et al. Can nurses impact patient outcomes using patient-centered care model? J Nurs Adm. 2008;38(12): 532-540. 9. Gillespie R, Floring D, Gillam S. How is patient-centered care understood by the clinical, managerial and lay stakeholders responsible for promoting this agenda? Health Expect. 2004;7(2):142-148. 10. Kitson A, Marshall A, Bassett K, et al. What are the core elements of patient-centered care? A narrative review and synthesis of the literature from health policy, medicine and nursing. J Adm Nurs. 2012;69(1): 4-15. 11. Luxford K, Safran DG, Delbanco T. Promoting patient-centered care: a qualitative study of vacillators and barriers in health care organizations with a reputation for improving the patient experience. Int J Qual Health Care. 2011;23(5):510-515. 12. Bolster D, Manias E. Person-centered interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observation and interview study. Int J Nurs Stud. 2010;47(2):154165. 13. Eijk M, Faber M, Shamma S, et al. Moving towards patient-centered healthcare for patients with Parkinson’s disease. Parkinsonism Relat Disord. 2011;17(5):360-364. 14. Williams B. The way to patient-centered care. J Nurs Manag. 2010;41(10):10-12. 15. West E, Mays N, Rafferty A, et al. Nursing resources and patient outcomes in intensive care: a systematic review of the literature. Int J Nurs Stud. 2009;46(7):993-1011. 16. Epstein RM, Fiscella K, Lesser CS, Stang KC. Why the nation needs a policy push on patient-centered health care. Health Aff. 2010;8:14891495. 17. Joolaee S, Hajibabaee F. An Iranian perspective on patients rights. Nurs Ethics. 2006;13(5):488-502. 18. Ghamari Zareh Z, Anoosheh M, Vanaki Z, et al. Quality of nurses performance and patients satisfaction in cardiac care units. Zahedan J Res Med Sci. 2008;10(1):27-36. 19. Madani G, Farzan A. Patients satisfaction from medical and nursing services. J Nurs Mid. 2010;24(3):15-22. 20. Streubert HJ, Carpenter DR. Qualitative Research in Nursing: Advancing the Humanistic Imperative. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. 21. Silverman D. Doing Qualitative Research. London, England: Sage; 2013. 22. Flick U. An Introduction to Qualitative Research. London, England: Sage; 2009. 23. Moran J, Bekker H, Latchford G. Everyday use of patient-centred, motivational techniques in routine consultations between doctors and patients with diabetes. Patient Educ Couns. 2008;73(2):224-231. 24. Epstein RM, Street RL. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-103. 25. Mead N, Bower P. Patient-centeredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2002;51(7):1087-1110. 26. Radwin LE, Cabral HJ, Wilkes G. Relationship between patient-centred cancer nursing intervention and desired health outcomes in the context of the health care system. Res Nurs Health. 2009;32(1):4-17.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Patient-Centered Care 27. Aita V, McIlvain H, Backer E. Patient-centred care and communication in primary care practice: what is involved? Patient Educ Couns. 2005;58(3):296-304. 28. Saha S, Mary CB, Cooper LA. Patient centeredness, cultural competence and health care quality. J Natl Med Assoc. 2008;100(11):12751285. 29. Rauta S, Salantera S, Nivalainen J, et al. Validation of the core elements of preoperative nursing. J Clin Nurs. 2012;21(21/22):1-9. 30. Mpinga EK, Chastonay P. Satisfaction of patients: a right to health indicator? Health Policy. 2011;100(36):144-150.
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31. Fotaki M. Users perceptions of health care reforms: quality of care and patient rights in four regions in the Russian federation. Soc Sci Med. 2006;63(7):1637-1647. 32. McCormack LA, Treiman K, Rupert D, et al. Measuring patientcentered communication in cancer care: a literature review and development of a systematic approach. Soc Sci Med. 2011;72: 1085-1095. 33. Malinger JB, Griggs JJ, Shields CG. Patient-centred care and breast cancer survivors satisfaction with information. Patient Educ Couns. 2005;57(3):342-349.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Critical Care Nurses’ Understanding of the Concept of Patient-Centered Care in Iran A Qualitative Study ■ ■
Maryam Esmaeili, MSN, BSN ■ Mohammad Ali Cheraghi, PhD, MSN, BSN Mahvash Salsali, PhD, MSN, BSN This study explores the perception of nurses working in critical care units about the patient-centered care, which is a crucial factor in attaining quality in nursing care. A qualitative exploratory study with conventional content analysis was used. Three main themes were extracted from the data: from accepting to understanding the patient; improved care as the result of skill and expertise; and adherence to patients’ rights charter. KEY WORDS: content analysis, critical care, nurses, patient-centered care Holist Nurs Pract 2014;28(1):31–37
Achieving quality in care is important because of the pivotal role of direct care in nursing as well as the growing emphasis on improving hospitals’ credibility and clinical status. Today’s health care has changed from provider-centered to patient-centered. In addition, patient satisfaction is considered an indicator of quality of health care services.1 According to the definition of the Institute of Medicine, quality in a health care system is defined as safe, timely, effective, efficient, equitable, and patient-centered care. Patient-centered care, which is 1 of the 6 specified facets, is a driver in improving the quality of care.2 Patient-centered care, originating with the work of Florence Nightingale, is a valuable and sobering concept in the nursing discipline. She was the first person to distinguish nursing from medicine by focusing on the patient instead of the disease.3 Different literature reviews show that patient-centered care has different characteristics in different cultures and settings.4,5 Patient interaction with health care Author Affiliations: Nursing and Midwifery Care Research Center (Dr Cheraghi), School of Nursing and Midwifery (Ms Esmaeili and Dr Salsali), Tehran University of Medical Sciences, Tehran, Iran. This study was one part of a PhD dissertation of the first author, financially supported by Tehran University of Medical Sciences. The authors thank the nurses for their sincere cooperation during the different stages of this study. No conflict of interest has been declared by the authors. Correspondence: Mohammad Ali Cheraghi, School of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St, Tohid Sq, Tehran 1419733171, Iran ([email protected]). DOI: 10.1097/HNP.0000000000000002
staff, the cooperation of the patient and family, consistency in caregiving, physical comfort, and liaison between different care services are some aspects of patient-centered care.5-8 Furthermore, the perception of health care workers and patients about patient-centered care varies across cultures, which causes difficulty in understanding and using this concept.7 Many case studies have recognized communication with the patient as the central element of patientcentered care.5,9 Furthermore, some studies mentioned the need of patients’ participation in the self-care, decision making, and independence. Also, in these studies, patients’ preferences were regarded.8,10,11 To define patient-centered care, different approaches have been used.4,12,13 Paying attention to the personal needs of patients, satisfaction, participation, and quality of care are common themes that have been used in the definition of patientcentered care, although there is no consensus on an acceptable definition thus far.8 A review of literature shows that although patient-centered care is one of the key elements in quality of care, there is little attention to nurses’ experience regarding this concept.14 Most surveys about patient-centered care have obvious shortcomings because of the weak analysis of patients’ perception and health care workers.6 A review on other studies in patient-centered care has shown that the critical care context is more closely associated with patient-centered care, which may be the result of higher care levels and greater observance 31
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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of standards in these units.5 Giving care in these areas is not a simple job. It is compulsory for caregivers to be highly skilled and prepared with the necessary knowledge of new care and treatment technologies to provide high-quality care.15 Emphasis on observing the patients’ rights charter, adherence to ethical considerations in nursing, and technological progress in clinical environments, especially in critical care units, affects care provision. Thus, nurses play an important role in giving care, which is focused on the patient, while working in advanced technological environments.16,17 Studies from Iran show that patients’ satisfaction with quality of care is of a higher level in critical care units than in other units.18,19 After a literature review, researchers highlighted the need for qualitative studies about patient-centered care in various settings.5 Therefore, considering existing evidence in Iran and lack of a comprehensive study on the patient-centered care, this study explores the understanding of nurses working in critical care units concerning patient-centered care in the cultural context of Iran.
METHODS Research design To evaluate the understanding of critical care nurses concerning patient-centered care while working in an Iranian context, a qualitative exploratory study was conducted using a conventional content analysis approach.
Participants In this study, 21 nurses (16 female and 5 males) working in critical care units in educational hospitals in Iranian urban areas were selected through purposive sampling. The inclusion criteria were at least 2 years of work experience and a willingness to participate. In this study, the head nurse was asked to nominate nurses who provided quality care. To reach the maximum variation, nurses of both genders with bachelor’s and master’s degrees were chosen.
Data collection Semistructured interviews were used individually and face-to-face. Each interview lasted 30 to 55 minutes and was performed in a quiet place in participants’ working units. The first author of this article
conducted and recorded the interviews, and all the recordings were transcribed verbatim immediately after the interview. The interview included the following main questions: What is your understanding of patient-centered care? In your opinion, what are the important reasons for patient-centered care? In addition, some probing questions were asked for additional clarification to answers given by participants.
Ethical consideration The Ethics and Research Committee of Tehran University of Medical Sciences approved this study (91D130168). Participants were informed about the objectives and method of the study. In addition, they were informed that they could withdraw at any time without penalty. Moreover, their permissions were secured for recording the interviews. All participants were assured of the confidentiality of the information.
Data analyses Data analyses were performed using a conventional content analysis approach. Qualitative content analysis simplifies data and provides structure and discipline, whereas content analysis explores the real meaning behind raw data.20 To analyze the data, the recorded interviews were transcribed verbatim and then read several times to gain a general impression. The resulting text from the interviews was divided into meaning units, which were then condensed, abstracted, coded, and labeled. These codes were then arranged into categories and subcategories according to their similarities and differences. In this study, the first author performed the data coding and all coauthors supervised the coding. If we disagreed over the coding, we discussed the codes until a consensus was achieved.
Rigor Similar to other qualitative approaches, content analysis entails discovering and evaluating processes to use the findings.21 To achieve credibility, member checking was used. The first author performed a member check for 8 participants. Data were coded by the authors after they were compared with one another. In cases of dissension, explanation and clarification were used to reach the final acceptance. Furthermore, a compendium of identified themes was given to participants for confirmation.
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Patient-Centered Care
Findings The findings are the result of continuous interviews with 21 nurses until data saturation was reached. Nurses’ mean age was 33.61 years, and participants’ work experience ranged between 2 and 18 years, with a mean of 10.35 years. Data analysis resulted in identifying 3 main themes: from accepting to understanding the patient; improved care as the result of skill and expertise; and adherence to patients’ rights charter. The second theme of the study includes 2 subthemes: managerial skills in caring and the importance of getting to know the patient. The rest of the text discusses the meaning of each theme, with quotations from participants. From accepting to understanding the patient When nurses were asked about their experience of patient-centered care, they pointed to respecting patients’ dignity as human beings who have various biopsychosocial aspects. In fact, they believed that patients’ illnesses increased the importance of paying attention to and respecting them. They stated that accepting patients as human beings enhances communication, leads to respecting their customs and culture, considers patients’ preferences, and promotes punctual responses to patients’ requests. If we just see the patient, it is more like mechanical work. I mean that what happens when you do a series of tasks without any relation, but when you consider someone as a human being, you would not look down at him or her, and the patients’ opinion becomes important to you. It also becomes so important that what he/she thinks. (Nurse with 13 years of nursing experience)
To nurses, patient-centered care is preserving proper treatment according to patients’ preferences. Furthermore, considering patients’ preferences about their lifestyle and culture is central to quality patient care and is a way to provide comfort to patients. I put the patient in a proper position and then ask him or her whether or not he is ok, sometimes when the head of the bed is about 30 degrees, angled upward, they are uncomfortable, and when I explain them they do not accept. In a situation like this, I try to stay calm and tell them that’s all right, whatever you want.” (Nurse with 16 years of nursing experience) Sometimes we have some patients who do not eat the food that is served in the hospital. Well, they have special eating habits. I believe that the hospital is not a place for changing culture and lifestyles. I let their
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relatives bring them the food they like from home. (Nurse with 8 years of nursing experience)
Participants also mention the importance of punctual response to a patient’s demands. They believe that responding to a patient’s demands should be done in a timely manner. Nurses mentioned punctual response to a patient’s needs, especially to a patient’s first request, as an element in respecting the patient’s status; they believe that ignoring a patient’s requests is disruptive to the patient’s value and dignity. I believe when the patient calls you for the first time, you should see what he wants, if you don’t do this the first time it will be of no value if you sit beside him the next other times. The first time he calls is important. (Nurse with 16 years of nursing experience) The patient does not like it at all to call a nurse, then if she doesn’t answer and says I didn’t hear you and leaves, the patients would say “We called the nurse and she didn’t answer and she didn’t come.” (Nurse with 5 years of nursing experience)
The theme of “accepting the patient” was followed by the theme “understanding the patient and his or her condition.” By empathizing and through applying the patients’ condition to themselves, they try to meet what would be their own expectations about care as if they were ill. Using this thought process enhances the quality of care given and heightens the attention paid to patients. Most of the time, I consider myself in the situation in which the patient is. I mean that I really think if I was ill what I would expect from the caregiver? (Nurse with 3 years of nursing experience) I’ve always thought the patient could be me or a member of my family. Well then, what do I expect from the nurse? How would I like them to solve my problem? I notice if they pass me regardless or keep checking me. In this way, I tried to fulfill those expectations for them that I may have had myself in this kind of situation. (Nurse with 18 years of nursing experience).
Improved care as the result of skill and expertise In this study, nurses pointed to the unique nature of critical care settings. In fact, they refer to the continuing nature of a relationship with the patient. They believe that patients expect more from a nurse working in a critical care unit. Also, nurses believe in skill and expertise as key components in achieving patient-centered care. According to them, patient-centered care requires the expertise of the nurse.
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HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2014
When I go over to a patient, I think that I should inject only a single needle, and there would not be a second one, this is important to me. I mean that I do my best not to harm the patient. This is my first thought when I go over to a patient. (Nurse with 4 years of nursing experience)
discharging the patient from the hospital sooner. For nurses, patient-centered care is making efforts to increase patients’ satisfaction. In this way, follow-up of the care and treatment are ways that make this satisfaction likely.
It is the art of a nurse to recognize the risk before the patient undergoes “myocardial infarction” once again. It means that before the patient has an ST elevation you heed the signs and not allow the patient to be in pain. (Nurse with 13 years of nursing experience).
Importance of getting to know the patient Attention to the patients’ awareness of their condition, medical history, and their problems are also considered important components of patient centered care, particularly in their first interactions with patients. Thorough assessment of a patient’s background and condition leads to a proper care plan that is specific to that patient’s condition.
Nurses who participated in the study considered that the nurse manager’s assessment of the performance of nurses working in critical care units through regular testing is important. They mention attending training classes and specialized courses for working in critical care units as ways to improve skills and expertise. Furthermore, they expressed that nurses’ up-to-date knowledge to provide appropriate care that considers specific circumstances of each patient is of great importance in patient-centered care. When my patient has Premature Ventricle Contractions (PVC), I should know what causes this problem and what I should do for the patient. When I have satisfactory scientific information, it would be much easier to recognize their problem and help the patients. (Nurse with 3 years of nursing experience)
Managerial skills in caring Managerial skills and follow-up care are other skills of nurses that contribute to patient-centered care. Nurses believe that outcomes of patient-centered care are as follows: punctual follow-up (carrying out paraclinical tests and follow-up counseling), highlighting preferences, and planning to provide care to avoid prolonged hospitalization and imposed added costs. After the doctors have visited patients, I prefer to do some tasks for the patient, based on what things have been done and what things will take priority. I mean that I do my best to help the patient not to stay here for a long time and wait for no reason. (Nurse with 16 years of nursing experience) I try to avoid wasting time as much as I can. I mean in a way that avoids keeping the patient in the hospital for extra days. By contrast, it had been seen that when coordination and follow-up are delayed, the patient has to wait in the hospital a few extra days. (Nurse with 17 years of nursing experience)
In fact, nurses believe that overseeing care and carrying out paraclinical tasks punctually would lead to acceleration of care and treatment and in
What I experienced most during these years was understanding and recognizing their mood and personality. It means that I tried to know the patient first, to know how they would be happy and how I should treat them. (Nurse with 18 years of nursing experience)
Another skill mentioned by nurses of critical care units was gaining comprehensive information about the patient’s condition to provide patient-centered care. In fact, nurses try to provide patient-centered care by checking the patient regularly, communicating with the patient, and considering the patient’s complaints. I must get to know the patient; I mean their first name, last name, diagnosis, their major problem, and the reason that has caused them to be admitted to this unit. How did they sleep last night? Did they have any problem? Do they have pain? I ask the patient all of these questions. (Nurse with 8 years of nursing experience)
Adherence to patients’ rights charter According to nurses who participated in the study, observing patients’ rights during the care is important in achieving patient-centered care. In fact, nurses mentioned providing fair and humane care for all patients with different social conditions as patients’ right. Also, providing good quality care, the right of patients to choose their nurse, patient education, and paying attention to their complaints have been identified as respecting the rights of patients. Maybe the patient is not a good citizen or a good father, but for us, as a patient, he is to be respected. We just do the same that we do for a person of a sound societal level. It is not acceptable to check that one’s blood pressure two times and check this one’s only once. (Nurse with 18 years of nursing experience)
Some participants pointed to gaining acceptable information about care and treatment as rights of the
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Patient-Centered Care
patient. Also, they mentioned the importance of educating patients to empower them about self-care. To be precise, they believed that patient-centered care is an interactive human communication with a patient and is associated with offering enough and essential information to the patient and his or her family. I think the patient has the right to know that what we are doing for them is adhering to the charter of patients’ rights: the patient and family deserve to be aware of what should be done. When I go to a patient to give their medications, I tell the patient what those medications are and how they can help the patient. In this way, they are more satisfied and would interact more. (Nurse with 15 years of nursing experience)
Common understanding is an effective strategy in achieving patient-centered care. In fact, nurses believed that ignoring patients’ rights by some health care providers and doctors causes patient dissatisfaction and alienation during their time in the hospital. To nurses, coordination and cooperation of all health care workers to respect the rights and interests of patients is important to achieve patient-centered care. These days, each doctor expects their order to be done first, they do not even think about which one would be useful to the patient. Unfortunately, they think about themselves first, not to waste their time. But they do not consider what the right of the patient is. (Nurse with 14 years of nursing experience)
DISCUSSION Through examining the first theme of this study, nurses highlighted accepting patients as human and understanding their conditions. To nurses, patientcentered care means considering patients as more than just patients. However, they believed that in the process of patient-centered care, the first step is to accept patients as perfect human beings. The next step is to try to understand their conditions. Over time, having this attitude could increase nurses’ knowledge about patients’ life context, which would result in the increase of care quality.22,23 Eijk et al13 studied people with Parkinson disease in 2011. They conducted focus group interviews and mentioned psychoemotional support, respectful empathy, and accepting patients as human beings rather than as patients as their perception of patient-centered care.13 Patient-centered care focuses on understanding patients as persons with specific
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characteristics, needs, values, and preferences, in particular respecting morals and preferences in care decision making.24-26 The results of Aita et al27 study showed that respecting values, culture, and patients’ expectations would result in an effective relationship between patients and health care workers. In this study, the nurses considered patients’ preferences about their culture and customs as being important. Saha et al28 asserted that a focus on understanding patients’ cultures and knowledge about cultural differences can help achieve quality care in health care systems. Participants also mentioned the importance of a punctual response to patients’ needs as central to the delivery of patient-centered care and as a way to respect the dignity of patients. Furthermore, when nurses put themselves in the patients’ position, they believe that this leads to improved understanding of the patients’ conditions. Prompt access to services and health care workers are components of patientcentered care.3 With respect to the second theme of the study, nurses’ skill and expertise in performing tasks and actions prevent harming patients and help relieve their pain. Nurses’ expertise is an important theme found in studies conducted in the field of patient-centered care.3,26 Typically, experience is related to years of performance whereas the expertise of nurses in clinical decision making is based on knowledge gained for the reflective performance and the continuous care of patients in similar clinical conditions. Researchers found that nurses’ expertise and competencies positively correlated with patient satisfaction.26 Furthermore, the result of the study of Rauta et al29 demonstrated that nurses’ expertise in technical performance as well as their scientific knowledge are crucial to achieving positive outcomes in patient care. In fact, nurses’ expertise is effective in preventing complications and increasing patient satisfaction. The Hobbs5 review of published studies on patient-centered care found that positive outcomes occur when the actions and processes engaged by nurses reduce or eliminate harm to patients. With respect to this study’s third theme, adherence to patients’ rights, nurses believed that patientcentered care enhanced the rights of patients in receiving high-quality care. However, nurses also referred to the importance of other health care workers respecting patients’ rights to achieve patient-centered care. Further studies should be conducted to further explicate this aspect of patient-centered care. Patients’ rights are directly associated with patients’
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HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2014
satisfaction of care in a way that following the rights of the patient is an indicator for achieving quality in care and patient satisfaction.30 The result of the study by Fotaki31 shows that health care providers must consider the rights of patients, although patients may not be familiar with their own rights. In Iran, the charter of patients’ rights includes receiving suitable services, receiving acceptable and correct information, the right to choose, free decision making, respecting patients’ privacy, and listening to patients’ complaints. Providing good-quality services to patients by expert nurses, getting clear information about the treatment, and receiving fair and satisfactory care are examples mentioned by nurses who participated in the study. One of the challenges to protecting the rights of patients to be fully aware of health care policies is lack of patients’ access to information resources and shortcomings in patients’ gaining essential information about the disease and treatment.32 The results of a study by Malinger et al33 revealed that identifying information needs of patients and educating them play important roles both in patient-centered care and in increasing satisfaction among cancer patients.
CONCLUSION On the basis of the findings of this study, accepting patients as human beings and not only as patients, putting oneself in patients’ position to further understand their condition, relieving their pain, avoiding harm to patients, and adhering to the rights of patients could be effective in achieving patient-centered care. Achieving patient-centered care entails team work and managers’ attention to providing thorough and holistic attention to the patient. This study explored only critical care nurses’ understanding of patient-centered care, a limitation of the study. Furthermore, other studies are suggested to understand patients’ attitudes concerning the concept of patient-centered care.
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