Challenges of patient-focused care: Nurses’ descriptions and observations before and after intervention

Abstract

The concept of patient-focused care aims to provide an environment in which the healthcare team focuses on the individual patient’s needs. In order to increase our understanding of how nurses perceive and conduct patient-focused care, the issue needs to be studied in various contexts. The aims of the study were to explore nurses’ descriptions of their patient-focused care, what took place during observed situations including the time spent, before and after the change of design from a more traditional to a single-bed hospital in Sweden. Non-participant observations with follow-up interviews were carried out. Data were analysed using qualitative content analysis. Three categories emerged from the analysis: Barriers to being close to the patient, Desire to be close to the patient and The influence of environment on caring. The theme Presence or absence was interpreted as the latent meaning. The conclusion was that being present is crucial in nursing when providing compassionate and effective nursing care.

Background

Presence may be a prerequisite for patient-focused care (PFC). The concept of nursing presence has been widely used in nursing and is a significant component of nursing practice. ¹ Patient-focused care, established in the USA in the 1960s, aims to provide an environment in which the healthcare team focuses on the individual patient’s needs. ² During the 21st century, interest in PFC and related concepts such as patient-closer care, patient-centred care and person-centred care has become increasingly relevant within nursing.^2,3 Regarding hospital care, in the literature patient-centred or patient-focused care are similar terms to describe care focusing on a person with a diagnosis; a patient. ⁴

Person-centred care, one of the six core competencies for healthcare professionals, is characterized by the patient being seen and understood as a unique individual and the patient’s story being at the core of the care they receive.^5–7 A good care relationship between the nurse, the patient and their significant others requires a professional commitment among nurses, where the nurse is responsible for creating this relationship. ⁸ This is emphasized by pointing out that ‘nurses who have a broad behavioural repertoire, effective in interaction and exchange, may be more successful in nurse–client negotiations’.^8(p.119) An established sustainable and lasting relationship with personnel has been shown to be important for patients in hospital care^9,10 and is an important part in promoting health and alleviating suffering for patients. ¹¹

The present study is based on PFC according to Inde ¹² which is based on five foundations:

Vivid values, where one way to keep the values alive may be to continually reflect on the following: why and for whom am I here, and why is the patient here?

Innovative work environment, where patient-focused work means questioning routines and raising awareness about the individual patient’s needs.

Organizational development, which promotes PFC and improves the focus and availability of nursing care.

Effective teamwork, which implies that in a well-functioning team the professionals complement each other and work in an integrated way towards common goals.

Relational leadership, which means inspiring, motivating and creating the structure to enable adherence to goals. ¹²

Health professionals’ adherence to PFC principles and their perception of a positive work climate has been shown to be linked to patients rating the quality of care as high. ² A recently published study ¹³ shows that before the introduction of PFC, nurses in a general ward spent on average two hours or about 23% of their workday with direct patient-related work (in patients’ rooms). Time spent with direct patient-related work did not increase after the introduction of PFC. However, the total time spent with patient-related work such as documentation, reporting and coordination increased. Working according to PFC principles does not only mean that the nurse gives the patient sufficient time, but also that what this time contains is important for staying patient-focused. To our best knowledge there is no research on how nurses perceive and express, in both words and actions, the practice of PFC.

Aim

The aims of the study were to explore nurses’ descriptions of their PFC and also what actually took place during observed situations, including the time spent with the patient, before and after the implementation of PFC.

Methods

An empirical qualitative study with a descriptive design was performed. The study is part of a larger project aimed at analysing a shift from more traditional hospital care to PFC in a new hospital building with single-bed rooms. Consist with principles of PFC the workplaces in the new hospital building were placed close to the patients’ rooms and a specific daytime coordinating nurse post was established to ease the patient-responsible nurses’ administrative tasks including, for example, answering the phone and assisting visitors/families.

Thus, the intervention was a shift to a PFC model. ¹² In conjunction with the move to the new hospital, each employee received a copy of the book about PFC by Inde for self-education on the individual level about the concept prior to the change to PFC. ¹²

Participants and settings

Both the hospital board and the ward manager were asked for and gave their permission to conduct and to involve the nurses in the study. Before the intervention, four nurses on an oncology ward situated in the older hospital building with two-bed rooms participated. After the intervention, in the same department but in the new hospital building, four other nurses took part in the study. The observers informed all the nurses about the study at the participating ward and asked them to participate. All nurses agreed to take part in the study. The nurses participating gave their written informed consent on the day for the observations. The patients then at the ward were informed about the study.

Data collection

Non-participant observations with follow-up interviews were chosen as the data collection method. Two registered nurses with long clinical experience and diverse clinical education collected the data, one before the intervention and the second nurse after the intervention. One of the nurses had a Master’s degree and the other nurse had a licentiate degree in philosophy.

Prior to the intervention (October–November 2009), each participating nurse was observed during an eight-hour work shift and then interviewed just after the observation day. On one occasion the observer sat in a two-bed room and observed (over four hours) the meetings between the patients and the nurses (who came into the room). The observations were carried out over a total of 20 hours. After the intervention the observations were conducted during February–March 2011. Four observation sessions with four nurses were performed with a duration of three hours each.

Both the time spent with the patients and the conversations between nurses and patients were recorded in writing by the observers. After each observation, follow-up interviews with the individual nurse were carried out. In the interviews the nurses were asked to describe their experiences of the observed working day regarding PFC. They were asked several times to go into more detail in describing their experiences. The interviews lasted 15–30 minutes, were audiotaped and transcribed verbatim.

Data analysis

The texts were analysed using qualitative content analysis according to Graneheim and Lundman. ¹⁴ The transcripts from both the observations and the interviews were read several times by two of the authors (HR and EP) to get an overall impression of the text as a whole. The meaning was then sought in all parts of the text, and the content related to the aims of the study was identified. Each text was divided into meaning units, which were condensed, abstracted and labelled with a code. Based on differences and similarities, the various codes were compared and sorted into categories. The overall latent content was finally formulated into one theme.

Ethical considerations

The participants were informed both verbally and in a signed letter about the study’s purpose, that participation was voluntary, that the interviews would be recorded and data treated confidentially. Written informed consent was obtained from the participants according to the ethical principles outlined in the Declaration of Helsinki. ¹⁵ The study did not involve intervention or intent to affect, either physically or mentally. To ensure confidentiality, the participants and the department are not described in detail. None of the researchers or the data collectors had any personal connection with the ward.

Results

Data collection before the intervention was performed in the old hospital building, with two-bed hospital rooms. The observed meetings between the nurses and the patients lasted between 10 seconds and 15 minutes (in total, five and a half hours). All meetings took place in the patient’s room.

After the intervention, the data collection was carried out at the new hospital with single-bed rooms. However, due to overcrowding, sometimes two patients were forced to share one room. These nurse–patient meetings lasted between 2 and 20 minutes (in total, 2 hours and 15 minutes) and took place anywhere on the ward. The quotations are numbered, with the nurse’s number and N1 to indicate before and N2 to indicate after the intervention.

Three categories emerged from the content analysis: Desire to be close to the patient, Barriers to being close to the patient and The influence of environment on caring. The theme Presence or absence was interpreted as the latent meaning.

Presence or absence

In both parts of the study the nurses showed a desire to work closely with patients, being present, but the observations correlated poorly with what the nurses expressed in the interviews. Before the intervention the nurses expressed in interviews that during the work session they had time for conversations and to be close to patients. Working closely with the patients was described as desirable and the most important part of the work. This, nevertheless, could not be observed. During the observations the nurse–patient meetings were often short and consisted mostly of significant information about, for example, medications, tests and treatments, the nurses seemed to be mentally absent. The observations could not confirm the desire to be close in that the nurses did not seem to respond to the patients’ concerns or questions.

After the PFC intervention the interviewed nurses talked more about barriers to being close to the patients. However, the observations revealed that the nurses showed a genuine interest, listened empathically, were present and addressed the patients’ questions and issues. There was a clear desire and a longing to work more closely with patients, but lack of time and many different tasks too often made it impossible. Despite their desire to work more closely with patients, the nurses were critical of the concept of PFC because they felt that this approach was imposed on them by the hospital authorities.

Desire to be close to the patient

In both parts of the study many of the patients were hospitalized for treatment on a regular basis. Thus, it was possible for the nurses to form a closer relationship with them. Before the PFC intervention the nurses expressed that even though patients with newly diagnosed cancer were often anxious, they primarily needed medical information. In cases where the nurse could be present at the patient–physician meetings it was perceived as a positive opportunity for follow-up conversations.

The nurses in the study were all experienced and saw themselves as responsive and open to patients’ questions and concerns, and believed in their own ability to converse about existential issues. However, the observations before the intervention revealed conversations that were often short.

N1: I worked during the weekend, but didn’t happen to meet you.

P: A lot of people around me. I have felt so ill.

N1: You’ve been dazed by fever so it’s not so strange.

P: What I … [patient was interrupted].

N1: This is a broad-spectrum antibiotic [the nurse mentions that the temperature is going down before she leaves the room].

The nurses expressed a desire for a caring relationship with the patients, regarding them as individuals. This could be shown by the way nurses talked with the patients about everyday life, including family, work and interests.

You see what they have on the table next to the bed … many times, you see what they have and thus you can find a common interest … it’s often men and women of my age … it’s clear that we have much to talk about. (N1:1)

Another way of arriving at a deeper knowledge of the patients’ needs and concerns was to combine nursing actions with small talk, where the focus was on listening to the patient. It could be just a matter of a glass of water and simultaneously listening to the patient’s concerns or questions.

Well, how are you today? I might know that someone may have a nosebleed; somebody might be a little sad, it’s not only about the medical issues like the administration of tablets, but knowing a little bit about how they feel and things like that. (N1:2)

Observational occasions after the intervention showed how nurses tried to form a good relationship with patients by showing interest in the patient as a person. This was demonstrated when the nurses stayed to help with what was needed and did not hurry on. The nurses were careful not to interact too quickly with activities in daily life. They were eager to let the patients try for themselves first, but also to give a helping hand if needed. What then emerged was their interest in the patient’s comfort and satisfaction. Seriousness and humour mixed with an undertone of thoughtfulness played an important part in forming good conversation and closeness. Nurses could show patients a respectful tenderness.

Coming close to the patient was exemplified when the nurses focused on listening when the patient expressed sadness and when the nurses acknowledged suffering, both in words and by gently caressing or hugging the patient.

[Patient is crying].

Yes, it isn’t easy [the nurse hugs the patient]. You have been through a lot in a short time. (N2:2)

Conversations with patients and their significant others gave the nurses a sense of increased patient security and also ensured that the patient felt trust. When it was stressful and hard to find enough time the nurses, rather than talking to the patients, consulted the medical records. However, coming close to the patients was at the same time described as something to prioritize.

Barriers to being close to the patient

Lack of time was described in both parts of the study as a barrier to being close to patients. After the intervention the nurses were responsible for more patients and the ward was often overcrowded, resulting in two patients instead of one patient per room.

Many patients have severe diagnoses and need someone to talk to and to air thoughts and time is not always available, you have to prioritize as best you can … but it’s not always possible. (N2:1)

There was an awareness of the value of talking and listening to patients to increase their wellbeing. The nurses expressed frustration when they could find neither the time nor the opportunity for this even though they did their outmost, since they were aware of their ability to relieve the patient’s pain and anxiety simply by being present. The observations revealed that the work day was fragmented with many different tasks such as documentation or other administrative work, but also medical tasks. Fragmented work practices often entailed a sense of dissatisfaction for the nurses, since they found it hard to concentrate on the patients’ needs.

Before the intervention, nurses stated that the creation and maintenance of caring relations with patients did not have to be a natural part of their professional role. Tangible tasks, such as changing a drip or leaving medicine were thought to facilitate contact with the patients, and when there were no such things to do it could be difficult just to go into the patient’s room and have a little chat. Other professionals, such as welfare officers and staff from the hospital church, were expected to talk about existential issues with patients.

One can always do a professional job, but you cannot talk to all the patients … (N1:1)

On stressful occasions the nurses described how they just asked questions that needed to be answered with short responses, for example whether the patient had slept well during the night or were in pain.

… when they are in pain, they will tell you and so I get them an injection and then it will be fine. There’s so much anxiety in this too, so they would certainly have to talk too but there is usually no time for that. (N1:1)

The influence of environment on caring

Before the PFC one problem described was that patients were moved around, both on the ward and also between wards due to overcrowding. This resulted in more work for the nurses and a sense of inadequacy because they witnessed the suffering of their patients. The nurses after the intervention described how patients appreciated having their own room in the new hospital. For the nurses it was easier to focus on one patient at a time because there was no roommate who could insist on attention and it was easier to talk about sensitive issues when there was no one else listening. However, the nurses found it time consuming since it takes more time to visit more rooms and because the hallways were long.

… I can’t put into words exactly what I think it is when we moved here, it’s more cumbersome, there’s much more running, fetch, fetch, fetch, medicines and run back and forth. (N2:3)

The interviews also revealed that the nurses could find it difficult to stay focused on one patient at a time when there was more than one patient in the room. It was difficult to ask the other patient to wait when he or she asked for help. The strategy was to sit close to the patient and talk more quietly if any other patient was close by. The nurses were used to this strategy from working in the old hospital building.

Discussion

The latent meaning was interpreted in the theme Presence or absence. The nurses expressed a desire to work closely with patients but the observations before the PFC showed that the reality was different. The nurses were not fully present in the meetings.

After the PFC intervention the nurses experienced more barriers to being close to the patients. However, the observations revealed that the nurses showed a genuine interest, listened empathetically and addressed the patients’ questions and issues; thus, the nurses were more present in the meetings. Being present is vital in practising PFC, as stated by Laurel: ‘Being present with a patient requires the ability to be open to possibilities in the moment, along with a strong ethical commitment’.^1(p.ii) In the studied context it was made mandatory by the management to work according to PFC without a grounded implementation and also without real opportunities to actually be close to the patient as a person since medical and administrative tasks were prioritized. Guidelines (e.g. managerial technologies) in the organization must not be allowed to override the nurses’ opportunities for personal care planning. Today’s lean healthcare organizations are focusing on discharging patients leading to a task-focused rather than a person-focused model of care. ¹⁶

The observations showed fragmented dialogues and that the nurses did not listen or respond to the patients’ concerns; they were mentally absent. This phenomenon contradicts the essence of the implemented person-focused care based on the patient’s story. ⁶

Nurses’ desire to be close to patients and to spend more time with them has also been described in other studies.^9,17 The friendly atmosphere in patients’ multiple-bed rooms has been described as appreciated by nurses. It also meant a great deal for patients just to be seen by the nurses. ⁹ Patients have a need to be recognized and confirmed since they sometimes are forced to put their lives in the hands of the health personnel. ¹⁸ For patients to take an active part in their own care, they must feel acknowledged as a person. This assumes that the nurse is present for the patient and not preoccupied with her/his own need to be confirmed in her/his professional role. ¹⁷

In a professional relationship between nurse and patient, the nurse has an open mind, is present in the moment and listens to the patient’s story in order to share and understand what is essential for the patient’s recovery.^1,18 Progression towards the ability to be present with a patient requires knowledge of the process of healing, self-knowledge, and full engagement in the shared experience with the patient. ¹⁹ The interviews in the present study revealed different meanings that the nurses ascribe to the concept of being close to patients. Some thought that being close to the patient meant participating in basic care and found that this participation helped them to have a sense of being in control. Other nurses found that being close to the patient had a much deeper meaning. These nurses could find a value in being present in the situation, quietly sharing some of the brief moments, for example when giving a patient a glass of water.

Implementation of PFC was expected to result in more time spent with the patients, but the study could not confirm this, and our result is corroborated by other studies.^2,13 Even if the nurses in our study had a desire to work closely with patients, they were critical of how the PFC implementation had been conducted. The implementation was initiated by the hospital board without any discussion of the meaning of PFC. Personnel were given a book by Inde ¹² where PFC was described and from which they were supposed to appreciate the meaning and translate it into practice. This was the only way personnel were given the opportunity to embrace this new work philosophy.

To implement PFC, according to Inde, ¹² all personnel need to be properly engaged during the entire process of implementation, to overcome problems such as nurses seeing barriers to using evidenced-based knowledge. ²⁰ When nurses actually feel confident enough to use research, organizational support is imperative since a key element in getting evidence into practice is facilitation. ²¹ Successful nurse–client negotiations as in PFC depend on nurses’ behavioural repertoire ⁸ and motivation. ²⁰ Recurring theme days may help, focusing on what will be implemented, increasing awareness of core values, and knowing that it may take time to fully implement a new work philosophy. The challenge is to ensure that each part of the implementation is as robust as possible, and is integrated coherently and sensibly in practice. An awareness of the benefits of evidence-based practice can help healthcare providers to improve quality of care and clinical effectiveness. ²⁰ In order to maintain the change, a meeting structure is needed in the clinic or department. This includes regular team meetings and ensuring that PFC is always a recurring issue at workplace meetings. If management does not show engagement there is a great risk that the implementation will not settle. ¹²

In the current study various obstacles to being close to patients were described, especially in the interviews with the nurses after the PFC implementation intervention. Examples of obstacles were the heavy workload, as a considerable amount of time was spent dealing with daily questions about medical issues. There is a risk that the requirements of efficiency and effectiveness are considered more important among nurses than discussions of the patients’ needs, as an interview study with managers showed. ²⁰ A favourable work climate has been seen to affect how patients value the quality of care. ² However, healthcare teams with conflicts and lack of time are factors shown to reduce nurses’ ability to support patients’ needs. ²³

Discussion of method

As the number of interviews and observations in the present study was relatively small, it is with some caution that we draw conclusions. Although we believe that the richness of the data was enough, more interviews and observations might have given more diverse insights into the studied phenomenon.^24,25 Moreover, the very fact that situations in patient care were being observed may constitute an influence on the informants. ²⁶

In qualitative research, credibility concerns the trustworthiness of the findings. ²⁷ To achieve credibility in this study, continuous discussions of the findings were conducted by the authors during the entire analysis process to ensure that the interpretations were valid and grounded in the data. According to Graneheim and Lundman, in ensuring credibility ‘another way is to seek agreement among co-researchers, experts and participants’.^14(p.110) The authors’ discussions included judgement of the similarities within and differences between categories. Representative quotations from the transcribed text verified this.

Conclusions and clinical implications

The results revealed a strong desire to work closely with patients and the nurses saw the value of a good care relationship both before and after the PFC intervention. After the intervention the nurses described barriers, such as heavy workload, but reached further in their quest to apply PFC than before. When PFC is to be implemented, it is necessary that the concept is grounded and that facilitators are available, thus improving the influence of the environment on caring. Furthermore, it is vital that personnel understand the meaning of presence. To understand the value of working with PFC and to be present in meetings, reflection in practice may be a tool that can help caregivers. It is imperative not to prioritize organizational factors over the care of the individual patient thus overriding the barriers to being close to the patients.