38
April 2015 • Nursing Management
www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
By Sue Penque, PhD, RN, ANP-BC, NE-BC, and Gina Kearney, PhD, RN-BC, AHN-BC, CS
N
ursing presence is a known benefit to patient care. However, given care complexities, clinical nurses are often forced to focus on the quantity of work and accomplishment of tasks rather than the quality of their work and interactions with patients. Although the art of utilizing nursing presence potentially may be waning due to the competing priorities of complex patient care and assignments, nurse leaders recognizing the value of nursing presence and utilizing it as an intervention to lessen the clinical nurse’s workload and improve both nurse and patient satisfaction may be beneficial. Through presence, ways of knowing a patient become fuller and deeper. This, in turn, enables the clinical nurse to identify characteristics, subtle changes, and treatment outcomes sooner from the patient interaction. Assessment and anticipation of patient needs are enriched, and interventions
www.nursingmanagement.com
become more individualized when presence is incorporated into nursing care. Enhancing consciousness and transforming self are positive outcomes for both the patient and the nurse when presence is used. Therefore, examining and attempting to quantify the effects of nursing presence on patient care is crucial to nursing practice.
Transcending the tradition The state of nursing presence has been described in conceptual frameworks but little exists in the literature describing how nursing presence used as an intervention can influence patient care and ultimately affect patient satisfaction. The actual time needed to incorporate nursing presence in patient care and achieve positive outcomes needs exploration because little is known about the quantitative effects of nursing presence, particularly in a hospital setting. The emphasis on improving patient satisfaction is forefront in the nurse leader’s mind as pressures mount to improve healthcare reimbursement related to quality indicators. Nurse leaders appreciate
Nursing Management • April 2015 39
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The effect of nursing presence on patient satisfaction
interventions that improve patient satisfaction through knowing the patient and, thus, affecting overall care in a positive manner. The primary aim of this study was to conduct research to determine the effect of nursing presence on nurse-sensitive indicators for patient satisfaction on an inpatient, medical unit in an acute care setting. The secondary aim was to examine the relationship between the dose of nursing presence and patient satisfaction measures. It was hypothesized that the application of nursing presence would improve clear communication by nurses, courtesy and respect by nurses,
satisfaction may be a reflection of nursing satisfaction as there’s a correlation between high staff satisfaction and high patient satisfaction in some settings. Presence may be an intervention that can raise patient satisfaction, as well as reward individual nursing practice. Beyond a merely physical actuality, the concept of presence has also been discussed by several philosophers as an existential phenomenon.1,2 One’s ability to be present begins with a simultaneous expression of awareness of self and another person during an interaction and serves as a means to increased knowing; Sartre coined the term
In healthcare, presence is inherent in the therapeutic relationship between a nurse and a patient. nurse listening with patients, and overall satisfaction as measured on the Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scale with statistical significance, and that 15 minutes of nursing presence would be associated with a positive improvement in these nurse-sensitive indicators and overall patient satisfaction.
Mining the research Today’s healthcare reimbursement in hospitals is dependent, in part, on high patient satisfaction results. As a result, nurse leaders are asked increasingly to implement interventions to raise patient satisfaction measures. In addition, patient
authentic self as a way of truly being with another person.3 Similarly, the term Dasein, or being there for others, describes an experience of sharing one’s authentic self in an interaction with another.2 In healthcare, presence is inherent in the therapeutic relationship between a nurse and a patient.4 As nurses share their authentic self while caring for patients, being with and being there exemplify presence and illuminate the heart of nursing practice.5 Presence consists of three dimensions: (1) illuminating meaning through clarification and communication with the patient; (2) synchronizing rhythms through connection and separation; and (3) mobilizing transcendence.6 In each description
40 April 2015 • Nursing Management
of presence that continued to be articulated in nursing literature, the common themes of psychologically and physically being with, knowing, active listening, and meaningful connection with the patient are evident. In addition, presence is defined as a subconstruct in the theory of caring.7 Presence, as an intervention in nursing, shares characteristics similar to active listening and the concept of mindfulness. The interpretation of the concept of presence may vary depending on one’s experience and education. For the purposes of this research study, the authors defined nursing presence as an intentional communion with the patient leading to more knowing, awareness, and a meaningful connection.
Illuminating nursing care This research study employed a quasi-experimental design comparing data collected from two independent groups of subjects. The intervention encompassed education of a select group of the hospital’s nurses on nursing presence. The study design was to examine the effects of nursing presence on the nurse-sensitive, patient satisfaction indicators of clear communication by nurses, courtesy and respect of nurses, and nurse listening. These indicators were chosen because of their possible association with the components of the definition of nursing presence—active listening and meaningful connection—used for this research. The effects were also compared with overall patient satisfaction. Data were collected using a proprietary patient satisfaction survey. This survey was a 22-item self-report questionnaire at the time of this research study. The results of the specific questions (nurse-sensitive www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
indicators) were extracted from the questionnaire. At this particular hospital, a convenience sample of 10% of patients is routinely surveyed by a telephone call to the patient by a dedicated patient satisfaction surveyor within 2 weeks of discharge as part of the institution’s routine patient satisfaction monitoring. The surveyor wasn’t aware of this research study. For this study, the vendor was asked to increase the number of telephone surveys to capture 125 patients, which was determined to achieve a power of 0.8 and produce a sample size representing about 25% of the total discharges from this unit.
Discerning presence This study included one 36-bed medical patient care unit to measure the effects of nursing presence. The unit is in an acute care hospital located on Long Island, N.Y. Patients ranged in age from 58 to 83. The unit uses a modified primary care model and the theory of caring, with relationship-based care as the professional practice model. The nurse staffing consists of six RNs and four unlicensed assistive personnel for 36 patients. A charge nurse, free from having a patient care assignment, is available on the day shift to help coordinate work processes and flow. The average BSN rate for this unit is 61.2% and the certification rate is 35%. All patients on this unit received the intervention of nursing presence. As a result of the inability to reach the requested amount of postdischarge patients by the vendor, a final sample of 93 was obtained. Baseline data were collected from a group of subjects (n = 40) before the delivery of staff education and training regarding nursing presence (preintervention). One week after education and training were provided to the www.nursingmanagement.com
staff on the study unit (intervention), data were collected from a separate postintervention group of subjects (n = 53). Both groups of subjects received the same version of the patient satisfaction survey. None of the surveys were excluded.
Centering on the patient The intervention consisted of an experiential, educational program about nursing presence designed for nursing staff by the research investigators and implemented by the professional development staff and clinical nurse specialists. Taught over 4 hours, the education and training consisted of didactic instruction regarding the theory and practice of nursing presence. Multiple techniques for fostering nursing presence were described and then practiced during the training to increase familiarity and encourage their intentional use during interactions with patients. These techniques were chosen to offer the nurses various methods for enhancing presence in multiple practice situations ranging from brief encounters to those requiring a deeper level of interaction and included holding silence with a patient, using the breath for centering, smiling and emoting positive energy, active listening, mindfulness meditation, and guided imagery. For the purposes of this study, nurses were instructed to use the chosen technique for nursing presence as a distinct and unique intervention, not to be used in conjunction with any other task or during an emergency situation. Nurses were also introduced to the concept of reflective practice and were given journals to write about their personal experiences. These journals remain the property of the individual nurse and weren’t used as a source of data for
this research study. Nurses were instructed by the nurse leader not to start using nursing presence until all nurses were trained. Subsequent ongoing mentoring and support for using nursing presence was provided by the professional development staff and clinical nurse specialists. This research study was approved by the institution’s Nursing Research and Evidence Based Committee and the Protocol Review Committee as an exempt research study. The primary investigators weren’t involved in the implementation of the study due to their role in management at the hospital. During weeks 1 through 3 posteducation, nurses began by spending 5 uninterrupted minutes with a patient using nursing presence as an intervention. Again, the nurse was asked to not perform any other nursing care/tasks while being present with the patient and that all patients receive nursing presence intervention. The individual nurse then recorded the patient’s initials and amount of time on an investigator-developed log sheet kept at the central patientcare station. Both the 12-hour day and 12-hour night shift implemented the intervention and kept logs of the times per patient where nursing presence was used. Logs were collected by the staffing office and totaled at the end of each week. By the fourth week, nurses were asked to increase the time spent using nursing presence with each patient to 10 minutes. The process of logging was repeated. Every 2 weeks, the dose of presence was increased by 5 minutes until a total dose of 15 minutes per patient was obtained. Weekly logs were obtained and reviewed by the principal investigators to ensure accurate measurement. The nurse manager on the unit was instrumental in the study by
Nursing Management • April 2015 41
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The effect of nursing presence on patient satisfaction
helping to facilitate time for nurses to be present with their patients.
Analysis Patient satisfaction data were collected for 6 weeks preimplementation and for 7 weeks postimplementation of the intervention. The alpha level was set at P < 0.05. The KruskalWallis test was used to determine significant differences between the pre- and postintervention groups for the overall patient satisfaction scores related to the three nurse-sensitive indicators with respect to the intervention (nurse education and training). In addition, the Kruskal-Wallis test was used to determine whether there were significant differences among the levels of the intervention (5 to 15 minutes) with respect to each of the three specific nurse-sensitive indicators within the domain of nursing communication. Independent sample two-tailed t-tests were calculated for specific nurse-sensitive indicators for data within the domain of nursing communication and overall patient satisfaction to compare the preintervention weeks with the postintervention weeks. Overall patient satisfaction was collected pre- and postintervention, and the Kruskal-Wallis analysis of variance
was performed. Spearman’s correlation coefficients were estimated between the amount of self-reported time, or dose, of presence and the nurse-sensitive indicators for patient satisfaction. The question of what was the optimal dose of presence was investigated. A post hoc power analysis was calculated and a power of 0.68 was observed based on the 93 subjects obtained in this research study.
Being present The primary aim of this study was to determine the effect of nurses’ training with respect to implementing standardized amounts of nursing presence in relation to the outcome on patients’ reported scores on nurse-sensitive indicators of patient satisfaction. Pre- and posteffects of nursing presence related to patient satisfaction were calculated using the mean ranks of each variable and the Kruskal-Wallis test. (See Table 1.) The between group pre-and postimplementation patient satisfaction scores showed significant increases in patient satisfaction for two of the four measured indicators. The indicators showing statistical significance were courtesy and respect of nurses (P < 0.05) and listening by nurses (P < 0.01). Large effect sizes were observed and are represented as
Table 1: The means and standard deviations of the pre- and posttreatment effects for patient satisfaction indicators Primary outcome
Pretreatment M (SD) n = 40
Posttreatment M (SD) n = 53
P value
Clear nurse communication
3.67(0.69)
3.75(0.43)
0.98
Courtesy and respect of nurses
3.7(0.46)
3.86(0.44)
< 0.05*
Nurse listening
3.42(0.63)
3.73(0.55)
< 0.01**
Overall patient satisfaction
8.57(1.94)
8.84(1.19)
0.83
*Correlation is significant at 0.05 **Correlation is significant at 0.01
42 April 2015 • Nursing Management
follows: (1) courtesy and respect of nurses (r = 0.37) and (2) nurse listening (r = 0.52).8 The hypothesis that nursing presence would improve postintervention nurse-sensitive indicators was supported for courtesy and respect and listening by nurses. The hypothesis that nursing presence would significantly improve postintervention measures for clear communication and overall patient satisfaction, however, wasn’t supported. A correlation of nurse-sensitive indicators postintervention to overall patient satisfaction was performed. Nurse listening and courtesy and respect showed higher levels of correlation to overall patient satisfaction than clear communication. (See Table 2.) The second aim of the study was to measure the association of the dose of nursing presence with nurse-sensitive indicators for patient satisfaction. The total amount of nursing presence was computed on a weekly basis. The total time for nursing presence was then correlated with the patient satisfaction indicators. (See Table 3.) A nursing presence dose of 5 minutes was correlated with statistical significance for nurse listening. A nursing presence dose of 15 minutes was also correlated with statistical significance for courtesy and respect by nurses and nurse listening. The relationship wasn’t significant for clear communication at these dose ranges. The hypothesis that nursing presence would be significantly associated with the nurse-sensitive indicators for courtesy and respect and nurse listening with 15 minutes of nursing presence was supported. The hypothesis that the dose of nursing presence was significantly related to clear communication wasn’t supported. Of note, 5 minutes of nursing presence was correlated with statistical significance for nurse listening. www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The unknown Although this study found statistically significant results consistent with the hypotheses, there are a number of features that might be interpreted as limitations. Nursing presence was studied for a short period of time and it’s unknown how acceptable and useful this type of intervention will be for nurses over the long term. This study wasn’t a controlled or randomized trial, and the sample was a self-selected group of nurses who were interested in nursing presence. The study sample needed to power this research wasn’t obtained and may have influenced the overall results. The findings are limited to one hospital in the New York area. Investigator effects were minimized but not totally eliminated. All doses of nursing presence were self-reported and open to response bias. Limitations include the lack of a comparison group and small sample size that may not be representative of a larger population outside the context of this study.
Finding the right dose This research study shows promise for expanding the current empirical
Table 3: Spearman’s correlation coefficients of dose of nursing presence and nurse-patient satisfaction indicators Clear communication 0.303 0.384
Presence 5 minutes Presence 15 minutes
knowledge base regarding nursing presence and its impact on patients in a hospital setting. Although further study is recommended, it’s anticipated that nursing interventions, similar to nursing presence used in this study, may contribute to the creation of new models of care and new methods to improve patient satisfaction. Such nursing-led interventions and research will also serve to uphold the standards that nurses receive education on communication skills to achieve optimal patient care. Questions raised during this study, which will need to be explored in greater depth, are whether there’s a ceiling effect or “maximum dose” of time spent using nursing presence and to determine if there’s a relationship between the dose of nursing presence compared with nursing
Clear communication
Courtesy and respect
Nurse listening
Overall satisfaction
Clear communication (n = 53)
—
0.263
0.442**
0.150
Courtesy and respect (n = 53)
0.263
—
0.490**
0.359**
Nurse listening (n = 53)
0.442**
0.490**
—
0.278*
Overall patient satisfaction (n = 53)
0.150
0.359**
0.278*
—
www.nursingmanagement.com
Nurse listening 0.466* 0.632*
*Correlation is significant at 0.05 **Correlation is significant at 0.01
Table 2: Spearman’s correlation coefficients of postintervention nurse-sensitive indicators in patient satisfaction
*Correlation is significant at 0.05 level **Correlation is significant at 0.01 level
Courtesy and respect 0.403 0.646*
expertise, self-efficacy, or comfort levels among nursing staff.
Making time for patients This research study demonstrated the effectiveness of an experiential, didactic education program for clinical nurses on two of the nursesensitive indicators in patient satisfaction: nurse listening and courtesy and respect. A small dose of 5 continuous minutes of nursing presence had a positive influence on nurse listening measures on the patient satisfaction survey. Fifteen minutes of continuous nurse presence positively influenced both nurse listening and courtesy and respect. Although this study demonstrated an improvement in overall means for clear communication and overall patient satisfaction, results weren’t statistically significant. Nurses reported they had little difficulty providing 5 minutes of continuous nursing presence. When the time was increased, clinical nurses needed support from their nurse leader to reprioritize their work or rearrange their assignments. Clinical nurses reported they had difficulty providing 15 or more minutes of continuous presence to patients due to interruptions and other patient care responsibilities assigned. The importance of providing coaching and mentoring on how to deliver nursing presence by nursing leadership was key to nurses’ ability to deliver 15 minutes of nursing presence. This research study demonstrated statistical significance regarding
Nursing Management • April 2015 43
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The effect of nursing presence on patient satisfaction
the use of nursing presence and its effect on patient satisfaction for selected nurse-sensitive indicators despite the relatively small sample size. The low cost of the intervention, ease of implementation, and potential for significant impact for both patients and financial considerations are strengths of such a program and warrant further testing and investigation. Nurse leaders’ requisite need to demonstrate effective care, one measure of which is patient satisfaction, will continue to demand attention and effort in the intensifying landscape surrounding pay-for-performance models. The findings from this study raise questions for future research. This study should be replicated with other groups of nurses; randomization and
use of a control group would add strength, especially in critical care units and with new graduate nurses. The effect of nursing presence on patient safety indicators may also warrant further exploration. NM REFERENCES 1. Sartre JP. Being and Nothingness. New York, NY: Washington Square Press; 1943:1984. 2. Heidegger M. Being and Time (J. Macquarrie & E. Robinson, Trans.). San Francisco, CA: HarperCollins Publishers; 1962. 3. Penque S, Snyder M. Presence. In: Lindquist R, Snyder M, Tracy MF, eds. Complementary and Alternative Therapies in Nursing. 7th ed. New York, NY: Springer Publishing Company; 2013: 27-37. 4. Vaillot SM. Commitment to Nursing: A Philosophic Investigation. Philadelphia, PA: Lippincott; 1962. 5. Nelms TP. Living a caring presence in nursing: a Heideggerian hermeneutical analysis. J Adv Nurs. 1996;24(2):368-374.
44 April 2015 • Nursing Management
6. Parse R. The Human Becoming School of Thought: A Perspective for Nurses and Other Health Professionals. Thousand Oaks, CA: Sage Publications, Inc.; 1998. 7. Watson J. Nursing: Human Science and Human Care: A Theory of Nursing. Norwalk, CT: Appleton-Century-Crofts; 1985. 8. Cohen J. A power primer. Psychol Bull. 1992;112(1):155-159. At South Nassau Communities Hospital in Oceanside, N.Y., Sue Penque is the SVP/CNP and Gina Kearney is the director of Community Education. The authors have disclosed that they have no financial relationships related to this article. The authors would like to acknowledge Dr. William Jacobowitz, EdD, RN, assistant professor at Adelphi University’s School of Nursing, for his help with statistical analysis, and the staff from SNCH Nursing Education for their help in implementation of this program. DOI-10.1097/01.NUMA.0000462367.98777.40
www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
April 2015 • Nursing Management
www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
By Sue Penque, PhD, RN, ANP-BC, NE-BC, and Gina Kearney, PhD, RN-BC, AHN-BC, CS
N
ursing presence is a known benefit to patient care. However, given care complexities, clinical nurses are often forced to focus on the quantity of work and accomplishment of tasks rather than the quality of their work and interactions with patients. Although the art of utilizing nursing presence potentially may be waning due to the competing priorities of complex patient care and assignments, nurse leaders recognizing the value of nursing presence and utilizing it as an intervention to lessen the clinical nurse’s workload and improve both nurse and patient satisfaction may be beneficial. Through presence, ways of knowing a patient become fuller and deeper. This, in turn, enables the clinical nurse to identify characteristics, subtle changes, and treatment outcomes sooner from the patient interaction. Assessment and anticipation of patient needs are enriched, and interventions
www.nursingmanagement.com
become more individualized when presence is incorporated into nursing care. Enhancing consciousness and transforming self are positive outcomes for both the patient and the nurse when presence is used. Therefore, examining and attempting to quantify the effects of nursing presence on patient care is crucial to nursing practice.
Transcending the tradition The state of nursing presence has been described in conceptual frameworks but little exists in the literature describing how nursing presence used as an intervention can influence patient care and ultimately affect patient satisfaction. The actual time needed to incorporate nursing presence in patient care and achieve positive outcomes needs exploration because little is known about the quantitative effects of nursing presence, particularly in a hospital setting. The emphasis on improving patient satisfaction is forefront in the nurse leader’s mind as pressures mount to improve healthcare reimbursement related to quality indicators. Nurse leaders appreciate
Nursing Management • April 2015 39
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The effect of nursing presence on patient satisfaction
interventions that improve patient satisfaction through knowing the patient and, thus, affecting overall care in a positive manner. The primary aim of this study was to conduct research to determine the effect of nursing presence on nurse-sensitive indicators for patient satisfaction on an inpatient, medical unit in an acute care setting. The secondary aim was to examine the relationship between the dose of nursing presence and patient satisfaction measures. It was hypothesized that the application of nursing presence would improve clear communication by nurses, courtesy and respect by nurses,
satisfaction may be a reflection of nursing satisfaction as there’s a correlation between high staff satisfaction and high patient satisfaction in some settings. Presence may be an intervention that can raise patient satisfaction, as well as reward individual nursing practice. Beyond a merely physical actuality, the concept of presence has also been discussed by several philosophers as an existential phenomenon.1,2 One’s ability to be present begins with a simultaneous expression of awareness of self and another person during an interaction and serves as a means to increased knowing; Sartre coined the term
In healthcare, presence is inherent in the therapeutic relationship between a nurse and a patient. nurse listening with patients, and overall satisfaction as measured on the Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scale with statistical significance, and that 15 minutes of nursing presence would be associated with a positive improvement in these nurse-sensitive indicators and overall patient satisfaction.
Mining the research Today’s healthcare reimbursement in hospitals is dependent, in part, on high patient satisfaction results. As a result, nurse leaders are asked increasingly to implement interventions to raise patient satisfaction measures. In addition, patient
authentic self as a way of truly being with another person.3 Similarly, the term Dasein, or being there for others, describes an experience of sharing one’s authentic self in an interaction with another.2 In healthcare, presence is inherent in the therapeutic relationship between a nurse and a patient.4 As nurses share their authentic self while caring for patients, being with and being there exemplify presence and illuminate the heart of nursing practice.5 Presence consists of three dimensions: (1) illuminating meaning through clarification and communication with the patient; (2) synchronizing rhythms through connection and separation; and (3) mobilizing transcendence.6 In each description
40 April 2015 • Nursing Management
of presence that continued to be articulated in nursing literature, the common themes of psychologically and physically being with, knowing, active listening, and meaningful connection with the patient are evident. In addition, presence is defined as a subconstruct in the theory of caring.7 Presence, as an intervention in nursing, shares characteristics similar to active listening and the concept of mindfulness. The interpretation of the concept of presence may vary depending on one’s experience and education. For the purposes of this research study, the authors defined nursing presence as an intentional communion with the patient leading to more knowing, awareness, and a meaningful connection.
Illuminating nursing care This research study employed a quasi-experimental design comparing data collected from two independent groups of subjects. The intervention encompassed education of a select group of the hospital’s nurses on nursing presence. The study design was to examine the effects of nursing presence on the nurse-sensitive, patient satisfaction indicators of clear communication by nurses, courtesy and respect of nurses, and nurse listening. These indicators were chosen because of their possible association with the components of the definition of nursing presence—active listening and meaningful connection—used for this research. The effects were also compared with overall patient satisfaction. Data were collected using a proprietary patient satisfaction survey. This survey was a 22-item self-report questionnaire at the time of this research study. The results of the specific questions (nurse-sensitive www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
indicators) were extracted from the questionnaire. At this particular hospital, a convenience sample of 10% of patients is routinely surveyed by a telephone call to the patient by a dedicated patient satisfaction surveyor within 2 weeks of discharge as part of the institution’s routine patient satisfaction monitoring. The surveyor wasn’t aware of this research study. For this study, the vendor was asked to increase the number of telephone surveys to capture 125 patients, which was determined to achieve a power of 0.8 and produce a sample size representing about 25% of the total discharges from this unit.
Discerning presence This study included one 36-bed medical patient care unit to measure the effects of nursing presence. The unit is in an acute care hospital located on Long Island, N.Y. Patients ranged in age from 58 to 83. The unit uses a modified primary care model and the theory of caring, with relationship-based care as the professional practice model. The nurse staffing consists of six RNs and four unlicensed assistive personnel for 36 patients. A charge nurse, free from having a patient care assignment, is available on the day shift to help coordinate work processes and flow. The average BSN rate for this unit is 61.2% and the certification rate is 35%. All patients on this unit received the intervention of nursing presence. As a result of the inability to reach the requested amount of postdischarge patients by the vendor, a final sample of 93 was obtained. Baseline data were collected from a group of subjects (n = 40) before the delivery of staff education and training regarding nursing presence (preintervention). One week after education and training were provided to the www.nursingmanagement.com
staff on the study unit (intervention), data were collected from a separate postintervention group of subjects (n = 53). Both groups of subjects received the same version of the patient satisfaction survey. None of the surveys were excluded.
Centering on the patient The intervention consisted of an experiential, educational program about nursing presence designed for nursing staff by the research investigators and implemented by the professional development staff and clinical nurse specialists. Taught over 4 hours, the education and training consisted of didactic instruction regarding the theory and practice of nursing presence. Multiple techniques for fostering nursing presence were described and then practiced during the training to increase familiarity and encourage their intentional use during interactions with patients. These techniques were chosen to offer the nurses various methods for enhancing presence in multiple practice situations ranging from brief encounters to those requiring a deeper level of interaction and included holding silence with a patient, using the breath for centering, smiling and emoting positive energy, active listening, mindfulness meditation, and guided imagery. For the purposes of this study, nurses were instructed to use the chosen technique for nursing presence as a distinct and unique intervention, not to be used in conjunction with any other task or during an emergency situation. Nurses were also introduced to the concept of reflective practice and were given journals to write about their personal experiences. These journals remain the property of the individual nurse and weren’t used as a source of data for
this research study. Nurses were instructed by the nurse leader not to start using nursing presence until all nurses were trained. Subsequent ongoing mentoring and support for using nursing presence was provided by the professional development staff and clinical nurse specialists. This research study was approved by the institution’s Nursing Research and Evidence Based Committee and the Protocol Review Committee as an exempt research study. The primary investigators weren’t involved in the implementation of the study due to their role in management at the hospital. During weeks 1 through 3 posteducation, nurses began by spending 5 uninterrupted minutes with a patient using nursing presence as an intervention. Again, the nurse was asked to not perform any other nursing care/tasks while being present with the patient and that all patients receive nursing presence intervention. The individual nurse then recorded the patient’s initials and amount of time on an investigator-developed log sheet kept at the central patientcare station. Both the 12-hour day and 12-hour night shift implemented the intervention and kept logs of the times per patient where nursing presence was used. Logs were collected by the staffing office and totaled at the end of each week. By the fourth week, nurses were asked to increase the time spent using nursing presence with each patient to 10 minutes. The process of logging was repeated. Every 2 weeks, the dose of presence was increased by 5 minutes until a total dose of 15 minutes per patient was obtained. Weekly logs were obtained and reviewed by the principal investigators to ensure accurate measurement. The nurse manager on the unit was instrumental in the study by
Nursing Management • April 2015 41
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The effect of nursing presence on patient satisfaction
helping to facilitate time for nurses to be present with their patients.
Analysis Patient satisfaction data were collected for 6 weeks preimplementation and for 7 weeks postimplementation of the intervention. The alpha level was set at P < 0.05. The KruskalWallis test was used to determine significant differences between the pre- and postintervention groups for the overall patient satisfaction scores related to the three nurse-sensitive indicators with respect to the intervention (nurse education and training). In addition, the Kruskal-Wallis test was used to determine whether there were significant differences among the levels of the intervention (5 to 15 minutes) with respect to each of the three specific nurse-sensitive indicators within the domain of nursing communication. Independent sample two-tailed t-tests were calculated for specific nurse-sensitive indicators for data within the domain of nursing communication and overall patient satisfaction to compare the preintervention weeks with the postintervention weeks. Overall patient satisfaction was collected pre- and postintervention, and the Kruskal-Wallis analysis of variance
was performed. Spearman’s correlation coefficients were estimated between the amount of self-reported time, or dose, of presence and the nurse-sensitive indicators for patient satisfaction. The question of what was the optimal dose of presence was investigated. A post hoc power analysis was calculated and a power of 0.68 was observed based on the 93 subjects obtained in this research study.
Being present The primary aim of this study was to determine the effect of nurses’ training with respect to implementing standardized amounts of nursing presence in relation to the outcome on patients’ reported scores on nurse-sensitive indicators of patient satisfaction. Pre- and posteffects of nursing presence related to patient satisfaction were calculated using the mean ranks of each variable and the Kruskal-Wallis test. (See Table 1.) The between group pre-and postimplementation patient satisfaction scores showed significant increases in patient satisfaction for two of the four measured indicators. The indicators showing statistical significance were courtesy and respect of nurses (P < 0.05) and listening by nurses (P < 0.01). Large effect sizes were observed and are represented as
Table 1: The means and standard deviations of the pre- and posttreatment effects for patient satisfaction indicators Primary outcome
Pretreatment M (SD) n = 40
Posttreatment M (SD) n = 53
P value
Clear nurse communication
3.67(0.69)
3.75(0.43)
0.98
Courtesy and respect of nurses
3.7(0.46)
3.86(0.44)
< 0.05*
Nurse listening
3.42(0.63)
3.73(0.55)
< 0.01**
Overall patient satisfaction
8.57(1.94)
8.84(1.19)
0.83
*Correlation is significant at 0.05 **Correlation is significant at 0.01
42 April 2015 • Nursing Management
follows: (1) courtesy and respect of nurses (r = 0.37) and (2) nurse listening (r = 0.52).8 The hypothesis that nursing presence would improve postintervention nurse-sensitive indicators was supported for courtesy and respect and listening by nurses. The hypothesis that nursing presence would significantly improve postintervention measures for clear communication and overall patient satisfaction, however, wasn’t supported. A correlation of nurse-sensitive indicators postintervention to overall patient satisfaction was performed. Nurse listening and courtesy and respect showed higher levels of correlation to overall patient satisfaction than clear communication. (See Table 2.) The second aim of the study was to measure the association of the dose of nursing presence with nurse-sensitive indicators for patient satisfaction. The total amount of nursing presence was computed on a weekly basis. The total time for nursing presence was then correlated with the patient satisfaction indicators. (See Table 3.) A nursing presence dose of 5 minutes was correlated with statistical significance for nurse listening. A nursing presence dose of 15 minutes was also correlated with statistical significance for courtesy and respect by nurses and nurse listening. The relationship wasn’t significant for clear communication at these dose ranges. The hypothesis that nursing presence would be significantly associated with the nurse-sensitive indicators for courtesy and respect and nurse listening with 15 minutes of nursing presence was supported. The hypothesis that the dose of nursing presence was significantly related to clear communication wasn’t supported. Of note, 5 minutes of nursing presence was correlated with statistical significance for nurse listening. www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The unknown Although this study found statistically significant results consistent with the hypotheses, there are a number of features that might be interpreted as limitations. Nursing presence was studied for a short period of time and it’s unknown how acceptable and useful this type of intervention will be for nurses over the long term. This study wasn’t a controlled or randomized trial, and the sample was a self-selected group of nurses who were interested in nursing presence. The study sample needed to power this research wasn’t obtained and may have influenced the overall results. The findings are limited to one hospital in the New York area. Investigator effects were minimized but not totally eliminated. All doses of nursing presence were self-reported and open to response bias. Limitations include the lack of a comparison group and small sample size that may not be representative of a larger population outside the context of this study.
Finding the right dose This research study shows promise for expanding the current empirical
Table 3: Spearman’s correlation coefficients of dose of nursing presence and nurse-patient satisfaction indicators Clear communication 0.303 0.384
Presence 5 minutes Presence 15 minutes
knowledge base regarding nursing presence and its impact on patients in a hospital setting. Although further study is recommended, it’s anticipated that nursing interventions, similar to nursing presence used in this study, may contribute to the creation of new models of care and new methods to improve patient satisfaction. Such nursing-led interventions and research will also serve to uphold the standards that nurses receive education on communication skills to achieve optimal patient care. Questions raised during this study, which will need to be explored in greater depth, are whether there’s a ceiling effect or “maximum dose” of time spent using nursing presence and to determine if there’s a relationship between the dose of nursing presence compared with nursing
Clear communication
Courtesy and respect
Nurse listening
Overall satisfaction
Clear communication (n = 53)
—
0.263
0.442**
0.150
Courtesy and respect (n = 53)
0.263
—
0.490**
0.359**
Nurse listening (n = 53)
0.442**
0.490**
—
0.278*
Overall patient satisfaction (n = 53)
0.150
0.359**
0.278*
—
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Nurse listening 0.466* 0.632*
*Correlation is significant at 0.05 **Correlation is significant at 0.01
Table 2: Spearman’s correlation coefficients of postintervention nurse-sensitive indicators in patient satisfaction
*Correlation is significant at 0.05 level **Correlation is significant at 0.01 level
Courtesy and respect 0.403 0.646*
expertise, self-efficacy, or comfort levels among nursing staff.
Making time for patients This research study demonstrated the effectiveness of an experiential, didactic education program for clinical nurses on two of the nursesensitive indicators in patient satisfaction: nurse listening and courtesy and respect. A small dose of 5 continuous minutes of nursing presence had a positive influence on nurse listening measures on the patient satisfaction survey. Fifteen minutes of continuous nurse presence positively influenced both nurse listening and courtesy and respect. Although this study demonstrated an improvement in overall means for clear communication and overall patient satisfaction, results weren’t statistically significant. Nurses reported they had little difficulty providing 5 minutes of continuous nursing presence. When the time was increased, clinical nurses needed support from their nurse leader to reprioritize their work or rearrange their assignments. Clinical nurses reported they had difficulty providing 15 or more minutes of continuous presence to patients due to interruptions and other patient care responsibilities assigned. The importance of providing coaching and mentoring on how to deliver nursing presence by nursing leadership was key to nurses’ ability to deliver 15 minutes of nursing presence. This research study demonstrated statistical significance regarding
Nursing Management • April 2015 43
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The effect of nursing presence on patient satisfaction
the use of nursing presence and its effect on patient satisfaction for selected nurse-sensitive indicators despite the relatively small sample size. The low cost of the intervention, ease of implementation, and potential for significant impact for both patients and financial considerations are strengths of such a program and warrant further testing and investigation. Nurse leaders’ requisite need to demonstrate effective care, one measure of which is patient satisfaction, will continue to demand attention and effort in the intensifying landscape surrounding pay-for-performance models. The findings from this study raise questions for future research. This study should be replicated with other groups of nurses; randomization and
use of a control group would add strength, especially in critical care units and with new graduate nurses. The effect of nursing presence on patient safety indicators may also warrant further exploration. NM REFERENCES 1. Sartre JP. Being and Nothingness. New York, NY: Washington Square Press; 1943:1984. 2. Heidegger M. Being and Time (J. Macquarrie & E. Robinson, Trans.). San Francisco, CA: HarperCollins Publishers; 1962. 3. Penque S, Snyder M. Presence. In: Lindquist R, Snyder M, Tracy MF, eds. Complementary and Alternative Therapies in Nursing. 7th ed. New York, NY: Springer Publishing Company; 2013: 27-37. 4. Vaillot SM. Commitment to Nursing: A Philosophic Investigation. Philadelphia, PA: Lippincott; 1962. 5. Nelms TP. Living a caring presence in nursing: a Heideggerian hermeneutical analysis. J Adv Nurs. 1996;24(2):368-374.
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6. Parse R. The Human Becoming School of Thought: A Perspective for Nurses and Other Health Professionals. Thousand Oaks, CA: Sage Publications, Inc.; 1998. 7. Watson J. Nursing: Human Science and Human Care: A Theory of Nursing. Norwalk, CT: Appleton-Century-Crofts; 1985. 8. Cohen J. A power primer. Psychol Bull. 1992;112(1):155-159. At South Nassau Communities Hospital in Oceanside, N.Y., Sue Penque is the SVP/CNP and Gina Kearney is the director of Community Education. The authors have disclosed that they have no financial relationships related to this article. The authors would like to acknowledge Dr. William Jacobowitz, EdD, RN, assistant professor at Adelphi University’s School of Nursing, for his help with statistical analysis, and the staff from SNCH Nursing Education for their help in implementation of this program. DOI-10.1097/01.NUMA.0000462367.98777.40
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