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QUESTION: What are the perceptions of patients with cancer about the attributes and outcomes of high quality nursing care?
Design
Grounded theory.
Setting
The haematology-oncology service of a medical centre in Boston, Massachusetts, USA. The service used a primary nursing care delivery system.
Patients
22 patients with cancer (age range 27–82 y, 68% women) who were fluent in English. All were receiving or had recently received chemotherapy, radiation, or surgery.
Methods
Patients participated in semi-structured interviews, which were audiotaped and transcribed verbatim. Data analysis was concurrent with collection, and involved the constant comparative method of open, axial, and selective coding until theoretical saturation was achieved. Qualitative researchers, colleagues, and all patients were asked to review the analysis; 8 patients responded and confirmed that the findings reflected their experiences.
Main findings
Patients described 8 attributes of high quality nursing care and related how specific attributes contributed to 2 general outcomes: a sense of wellbeing and fortitude. A sense of wellbeing was described as feeling more comfortable and at ease and included the components of trust, optimism, and authenticity (eg, freedom to be themselves). Increased fortitude reflected the readiness, strength, and stamina to face their illness.
One attribute of quality nursing care was professional knowledge, which comprised both experiential knowledge gained from caring for similar patients, and technical competence in performing such skills as starting IVs and monitoring chemotherapy infusions. Continuity reflected the importance of repeated sequential encounters with 1 nurse in facilitating trust and increased fortitude for treatment. Attentiveness described nurses who took the time to find out what was wrong and followed through in a timely way. Coordination was about nurses having primary responsibility for ensuring that transitions among providers were seamless. Patients valued providers who passed along information, as this spared them the burden of giving the same information over and over and helped to avoid repeating interventions that were not effective in the past. Partnership was described in terms of episodes when patients felt included as partners in decision making, and when their skills, knowledge, and appraisals were respected by and acted upon by nurses. Nurses empowered patients to be partners by sharing professional knowledge (eg, explaining why a procedure was necessary and what to expect). Individualisation described nurses who knew their patients and individualised care to acknowledge, for example, patient perceptions and preferred coping strategies. Rapport comprised patients knowing about their nurses' families and outside interests. This mutual sharing helped them to feel bonded to their nurse, and to feel more comfortable revealing their own vulnerabilities. Caring described nurses who expressed concern, were nurturing, and remembered the patient. Caring nurses supported patients during vulnerable times, and helped them to feel mothered, comforted, and soothed.
Conclusion
Patients with cancer described 8 attributes of high quality nursing care, which contributed differentially to a sense of wellbeing and increased fortitude.
Commentary
The study by Radwin contributes to the expanding body of knowledge on quality nursing care, nurse-patient relationships, and caring. The components of quality nursing care described are consistent with previous research in this area,1 and such description should be helpful to administrators, educators, and clinicians in guiding nursing practice.
But the study goes a step further: it examines the perceived impact of high quality nursing care. As such, the study might offer the beginning of a solution to the dilemma of patient versus nurse perspectives of quality nursing care2: the outcome of quality nursing care will dictate what is important. This is the major implication of the findings of Radwin—that is, high quality nursing care does matter. In a nutshell, patients tell us that quality nursing care affects their ability to live through the cancer experience. It is hard to imagine a more powerful expression of the importance of the work done by nurses. Nurses can use these findings in many areas where their contributions need to be defended.
Caution, however, must be exercised in extrapolating the findings. Although patients perceived that quality nursing care was linked to their wellbeing and fortitude, the association between these outcomes and health outcomes, such as length of remission or death, has not yet been established. Further study in this area should be encouraged.
Finally, one must remember that these data were generated from a group of patients with cancer. It will be important to determine whether these attributes and their impact can be generalised to all patients, and if not, to discern how other types of patients may differ. Previous studies do seem to indicate similarities rather than differences among the many illness experiences,3, 4 but more research is needed before we can assume that the described attributes and their impact are pertinent for most patients.
Footnotes
Sources of funding: Sigma Theta Tau International, Alpha Chi and Theta Alpha Chapters.
For correspondence: Dr L Radwin, Department of Adult and Gerontological Nursing, College of Nursing, University of Massachusetts Boston, 100 Morrissey Blvd, Boston, MA 02125–3393, USA. Fax +1 617 287 7527.