Research Article

Journal of Patient Experience

2019, Vol. 6(3) 194-200
Perception of Caring Among Patients ª The Author(s) 2018
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and Nurses DOI: 10.1177/2374373518795713
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Diane Thomas, MSN, RN, CNL1, Patricia Newcomb, PhD, RN2,

and Phylann Fusco, PhD, RN2

Abstract
Background: Empirical evidence supports the contention that implementing caring nurse behaviors results in improved
patient experience; however, previous studies find differences between patient and nurse perceptions of caring. Significance:
Good patient experience is positively related to desired clinical and financial outcomes. Nurse caring is a critical component in
the patient experience. Objective: The purposes of this project were to evaluate the congruency between nurse and patient
perceptions of nurse caring in a long-term acute care hospital and to determine how much patient perception of nurse caring
changes over time. Method: The study employed mixed methods using a triangulation strategy in which quantitative data
from patients and qualitative data from nurses were collected simultaneously and compared for interpretation. Results: Time
affected patient perception of caring significantly. Patients and nurses disagreed about the extent to which nurses ask patients
what they know about their illnesses, help them deal with bad feelings, and make them feel comfortable. Conclusion: Patients
and nurses do not always agree about the quality of caring behaviors, but exposure to nurses over time positively affects
patient perception of nurse caring.

Keywords
clinician–patient relationship, nursing, empathy, patient/relationship-centered skills, patient perspectives/narratives

While there is inherent value to patients and their families correlation between profitability and patient experience for
that makes delivering a high-quality patient experience all hospital types (7).
important, a positive patient experience is also associated In their 2013 Research Brief, National Research Corpo-
with improved clinical outcomes, enhanced revenue, and the ration identifies a link between patient experience and rep-
less tangible outcome of hospital reputation (1). Evidence utation. National Research Corporation found this was
supports the notion that a good patient experience is posi- especially true for hospitals with below-average scores for
tively related to desired clinical outcomes including lower patient experience. National Research Corporation noted
readmission and mortality rates (2,3). Additionally, patients’ that what happens within a health-care facility at any given
experience of care, particularly communicating with their time may impact the reputation of the hospital in the near
care providers, leads to improved adherence with care advice future even among individuals who have never had any
and treatment plans, especially among patients with chronic direct health-care experience (1).
conditions (4,5). From the financial perspective, Medicare’s Because nursing care is of paramount importance to
Hospital Value-Based Purchasing program directly rewards patients and families, studying the congruency between
hospitals that have better patient experience scores, and there nurse and patient perceptions of caring behavior can help
are indirect revenue enhancements for the hospitals related health-care facilities provide positive patient and family
to lower medical malpractice risks and lower staff turnover
(6). Deloitte investigated the association between patient
experience and hospital financial performance, including 1
Texas Health Specialty Hospital, Fort Worth, TX, USA
2
operating and net profit margins and return on assets, and Texas Health Resources, Fort Worth, TX, USA
found that “hospitals with excellent HCAHPS patient
Corresponding Author:
ratings between 2008 and 2014 had a net margin of Patricia Newcomb, Texas Health Resources, 7216 Meadowbrook Dr, Fort
4.7 percent, on average, as compared to just 1.8 percent for Worth, TX 76112, USA.
hospitals with low ratings.” (7, p1). Deloitte notes the Email: patricianewcomb@texashealth.org

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Thomas et al 195

experiences. The Quality-Caring Model (QCM), developed admission in an acute care hospital (5 days). The hypothesis
by Joanne Duffy, contends that caring relationships between advanced for the quantitative portion of the study was that
the nurse and the patient or family are the central focus of patient perception of nurse caring changes positively over
nursing’s work. Furthermore, Duffy asserts that caring rela- time. The objective of the qualitative portion of the study
tionships are cultivated and sustained over time (8). When a was to explore differences in patient and nurse perceptions
hospital system in north Texas created a new nursing pro- of nurse caring.
fessional practice model (PPM), Duffy’s QCM was inte-
grated in it to help promote patient- and family-centered
care experiences. This mixed-methods study compared Methods
patient perceptions of the caring they received from nurses, Design
as defined by Duffy, to nurse interpretations of their own
caring behaviors. The study employed mixed methods using a triangulation
strategy in which quantitative data from patients and quali-
tative data from nurses were collected simultaneously from
Problem patients and nurses and compared for interpretation (17).
Patient-centered care (PCC) is an important goal for health Weight was applied equally to quantitative and qualitative
care that is increasingly consumer-driven in the United data. This design permitted analysis and interpretation from
States. In 2001, the Institute of Medicine defined PCC as both patient and nurse perspectives. Data were collected
“providing care that is respectful of and responsive to indi- during a single phase of the project and were analyzed inde-
vidual patient preferences, needs, and values and ensuring pendently using traditional methods.
that patient values guide all clinical decisions” (9). Donald
Berwick later proposed a definition consistent with the con- Human Subjects’ Protections
temporary patient experience movement: “The experience
This study was approved by the institutional review board
(to the extent the informed, individual patient desires it) of
governing research at the study hospital and complied with
transparency, individualization, recognition, respect, dig-
principles set forth in the Belmont Report (18) and Declara-
nity, and choice in all matters, without exception, related
tion of Helsinki (19) for protection of human research sub-
to one’s person, circumstances, and relationships in health
jects. The investigators have no conflicts of interest to
care” (10).
declare. Subjects provided written consent to participate in
Good quality patient–clinician relationships are essential
the study.
to the application of PCC principles (11). Recognizing this
fundamental belief, implementation of PPMs structured
around caring relationships has swelled. Duffy’s QCM, Sample and Setting
which targets nursing care specifically, assumes when caring The setting for the study was a 10-bed LTACH in North
characterizes nurse–patient–family relationships, patient Texas. The study hospital admits patients with complex con-
outcomes are better than when relationships are indifferent ditions who have had an extended stay in an acute care
(12–14). However, previous studies have also demonstrated hospital and need a minimum of 25 more days of acute
differences between patient and nurse perceptions of the medical management. This setting is a highly specialized
caring relationship (15). Thus, nursing has embraced PCC environment in which nurses and patients interact over a
and the centrality of the nurse–patient relationship in theory longer period than typically occurs in acute care hospitals.
for many years, but problems applying PCC in nursing prac- The convenience sample included 25 nonventilated, Eng-
tice may continue to challenge the profession (16). lish- or Spanish-speaking adult patients without cognitive
impairment who completed an objective measure of per-
Purpose ceived nurse caring behaviors for the quantitative part of the
study. The majority of patients were nonminority and cov-
The patient-centered approach holds that patients know bet- ered by private insurance. Any registered nurse (RN)
ter than health-care providers if they are experiencing quality employed full-time by the study hospital was eligible to
care, and patient ratings of the quality of care received are participate. Seven day-shift nurses of diverse ethnicities,
essential for improving patient outcomes. Therefore, judg- races, and ages consented to participate in the qualitative
ments about the quality of caring behaviors manifested by part of the study and wrote 85 brief stories describing patient
nurses must be based on information obtained from patients, or family encounters.
as well as nurses. With the foregoing in mind, we asked the
following research questions: (1) Are perceptions of nurse
caring congruent between nurses and patients in a long-term
Procedures
acute care hospital (LTACH) and (2) How much does patient Patients and nurses were informed about the study by the
perception of nurse caring change over time when patients investigators and provided written consent prior to partici-
are exposed to nurses over periods greater than the usual pation. To assess the patient experience of nurse caring
196 Journal of Patient Experience 6(3)

Table 1. Major Themes From Nurse Narratives and Related Patient Perception Items and Theoretical Domains.

Number of Related Theoretical

Theme Theme Events Related CAT-V Items “Caring Factors”a

Encouragement/reassurance 25 Help me deal with my bad feelings Encouraging manner Attentive

Encourage my ability to go on with life reassurance
Support my sense of hope
Help me see some good aspects of my situation
Help me to believe in myself
Encourage my ability to go on with life
Help me feel less worried
Respect/therapeutic presence 22 Seem interested in me Human respect
Support me with my beliefs Healing environment
Show respect for those things that have meaning
to me
Respect my need for privacy
Respect me
Allow me to choose the best time to talk about my
concerns
Pay attention to me when I am talking
Problem-solving (tailoring care) 18 Know what is important to me Appreciation of unique meanings
Help me figure out questions to ask other health-care Mutual problem-solving
professionals
Are concerned about how I view things
Anticipate my needs
Enhancing family access and 13 Talk openly with my family Affiliation needs
understanding Are responsive to my family
Providing information 12 Help me explore alternative ways of dealing with my Mutual problem-solving
health problems
Physical care 5 Treat my body carefully Attending to basic human needs
Make me feel as comfortable as possible
Eliciting information 3 Ask me how I think my health-care treatment is going Appreciation of unique meanings
Ask me what I know about my illness
Humor 3 Help me deal with my bad feelings Healing environment
Encouraging manner

Abbreviation: CAT, Caring Assessment Tool.

a
From the Duffy Quality Caring Model introduced to nurses as part of a new professional practice model.

behaviors, each patient subject completed the Caring Assess- revised to create the 27-item CAT-V used here. Evidence to
ment Tool (CAT-V) during the first 1 to 2 weeks after admis- support the validity and reliability of the CAT-V has been
sion and again during the week of discharge. published (22,23). The 27-item tool is said to measure a
Information about the Duffy model and its 8 “caring single dimension (caring clinician–patient relationships)
factors” was provided as part of a system-wide educational which includes characteristics (caring factors) listed in
initiative for nurses when the PPM was deployed. This infor- Table 1. The CAT-V is presented in a Likert-style format
mation was reviewed for all nurses in the target hospital prior with a rating scale for items that ranges from never (low
to implementing procedures in this project. Participant RNs caring, 1) to always (high caring, 5). The sum of item scores
wrote reports about patient encounters between the nurses can range from 27 to 135, with higher scores reflecting
and patients enrolled in the study from the perspective of the greater perceived caring globally.
caring factors and the new PPM. Participant nurses were also
told that nurse caring from the patient perspective would be
measured with the CAT-V and they were free to examine the Data Analysis
items, but nurses were asked to classify their stories into the For quantitative data, related-samples Wilcoxon signed
8 “caring factors” classes. They were also free to relate their ranks test was used to test the hypothesis that there was no
stories to specific CAT-V items. Participating nurses were significant difference between CAT-V scores early in hospi-
blinded to subject responses to the CAT-V. Patient subjects talization and at discharge. For qualitative data, content anal-
were blinded to nurse stories. ysis was performed on 85 nurse narratives to count the
Guided by Watson’s Theory of Human Caring (20,21), frequencies of particular behaviors and identify recurring
the CAT was developed in 1990 by Joanne Duffy and later themes. Open coding was performed on the narratives by
Thomas et al 197

Table 2. Frequencies for CAT-V Items.

Standard
Mean Deviation
Standardized Effect
Time 1 Time 2 Time 1 Time 2 Test Statistic P Value Size (r)

Since I have been a patient here, the nurse(s) . . .

Help me to believe in myself 4.4 4.3 0.81 0.74 0.406 Non-sig 0.06
Make me feel as comfortable as possible 4.7 4.7 0.48 0.54 0.577 Non-sig 0.08
Support me with my beliefs 4.2 4.3 1.12 0.74 0.258 Non-sig 0.04
Pay attention to me when I am talking 4.6 4.7 0.57 0.56 0.577 Non-sig 0.08
Help me see some good aspects of my situation 4.4 4.2 0.86 0.91 1.03 Non-sig 0.15
Help me feel less worried 4.4 4.2 0.70 0.78 0.905 Non-sig 0.13
Anticipate my needs 4.1 4.3 0.83 0.80 1.387 Non-sig 0.20
Allow me to choose the best time to talk about my concerns 4.1 4.4 1.08 0.76 1.73 Non-sig 0.24
Are concerned about how I view things 4.1 4.3 0.87 0.89 1.435 Non-sig 0.20
Seem interested in me 4.6 4.8 0.76 0.66 2.0 .05 0.28
Respect me 4.7 4.8 0.62 0.50 1.89 Non-sig 0.27
Are responsive to my family 4.6 4.8 0.64 0.52 1.732 Non-sig 0.24
Acknowledge my inner feelings 4.18 4.16 0.988 0.85 .000 Non-sig 0
Help me understand how I am thinking about my illness 4.0 4.1 1.08 0.99 0.233 Non-sig 0.03
Help me explore alternative ways of dealing with my health problems 3.98 4.08 1.07 0.997 0.250 Non-sig 0.04
Ask me what I know about my illness 3.5 4.0 1.37 1.06 1.679 Non-sig 0.24
Help me figure out questions to ask other health-care professionals 3.5 4.0 1.17 0.99 2.177 .03 0.31
Support my sense of hope 4.2 4.3 1.09 0.945 0.000 Non-sig 0
Respect my need for privacy 4.3 4.7 0.98 0.63 2.456 .01 0.35
Ask me how I think my health-care treatment is going 3.8 4.2 1.12 0.97 2.392 .02 0.34
Treat my body carefully 4.5 4.7 0.65 0.54 2.236 .03 0.32
Help me with my special routine needs for sleep 4.3 4.7 0.89 0.46 2.251 .02 0.32
Encourage my ability to go on with life 4.1 4.3 1.24 0.95 0.885 Non-sig 0.12
Help me deal with my bad feelings 3.7 4.1 1.31 1.02 2.223 .03 0.31
Know what is important to me 4.1 4.3 1.19 0.94 0.546 Non-sig 0.08
Talk openly with my family 4.2 4.5 1.18 1.05 1.51 Non-sig 0.22
Show respect for those things that have meaning to me 4.3 4.7 1.1 0.69 2.124 .03 0.30

Abbreviations: CAT, Caring Assessment Tool; Non-sig, nonsignificant.

one member of the research team who had no contact with administration of the CAT-V (early during admission) were
patients (Newcomb). This coding process associated themes significantly lower than mean scores on the CAT-V at dis-
from narratives with CAT-V items. Associations were charge (Figure 1). Because CAT-V responses were skewed
inferred on the basis of words and concepts that referred to toward higher scores, the null hypothesis of no significant
any activities in items on the CAT-V tool. Further coding difference in total scores was tested using a Wilcoxon signed
and interpretation was done jointly by the authors. rank test and was rejected (P ¼ .02). The effect of time on
Evidence from texts was sought to assess congruence CAT-V scores was moderate (r ¼ 0.33). Exposure to the cadre
between self-described nurse behavior and patient- of nurses delivering care over the course of the admission
described nurse behavior from the CAT-V tool. Although accounted for about 11% of the variance (r2 ¼ 0.109) in the
an 8-factor structure was originally described for the CAT- responses patients provided to the CAT-V questions.
V (23), work in 2014 established the unidimensionality of The list of CAT-V items (each serving as a theme for
the tool (11), thus statements in nurse texts were compared preliminary coding) is shown in Table 2. After linking each
directly with related items in the CAT-V and no attempt was statement in the texts to one of the CAT-V items, the codes
made to classify nurse texts into discreet “caring factor” were collapsed into broader themes, which roughly matched
categories until the end of the analysis. Each CAT-V item the 8 caring factors originally proposed by Duffy. The 3 most
was an open code (theme). common descriptions of caring in nurse narratives were
respect/presence, encouragement/reassurance, and mutual
Results problem solving/tailoring care (Table 1). Examples
Reliability of the CAT-V was good. Cronbach’s alpha was included,
.93 for the second survey and .89 for the first survey.
Descriptive statistics for individual items on the CAT-V I listened to him explaining what happened to him over years. I
are shown in Table 2. Mean scores on the first was able to listen, reassure, and address some of his questions.
198 Journal of Patient Experience 6(3)

Table 3. Congruence Between Patient and Nurse Perceptions.a

Patient High Patient Low

CAT-V Scores CAT-V Scores

Nurse (High patient score/ (Low patient score/

Strong (high) High nurse theme High nurse theme
narrative frequency) frequency)
evidence of Item 11 Item 24
Caring
Nurse (High patient score/ (Low patient score/
Weak (low) Low nurse theme Low nurse theme
narrative frequency) frequency)
evidence of Item 2 Item 16
caring Item 17
a
Item 2: Since I have been a patient here, the nurse/s make me feel as
comfortable as possible. Item 11: Since I have been a patient here, the
nurse/s respect me. Item 16: Since I have been a patient here, the nurse/s
ask me what I know about my illness. Item 17: Since I have been a patient
here, the nurse/s help me figure out questions to ask other health-care
Figure 1. Differences between mean CAT-V scores over time. professionals. Item 24: Since I have been a patient here, the nurse/s help
CAT indicates Caring Assessment Tool. me deal with my bad feelings.

The atmosphere gradually relaxed. (Reassurance/nursing into categories that might relate to helping patients with their
presence) “bad feelings,” no examples of helping patients with bad
Room temp, coffee mixture, meds before his bedtime: When feelings, specifically, other than encouragement and reassur-
you could get this just right he was a great [patient]. (Problem- ance, were found.
solving/tailoring care) The term “bad feelings” was vague enough that patients
We discussed together [nurse and patient] what we needed to and nurses weren’t sure how to interpret it. The most com-
get done on this day and we set up a planned time table. (Prob- mon question from patients regarding the CAT-V tool was
lem-solving/tailoring care) the meaning of the term “bad feelings.” Patients usually
I talked on and off all day with this patient’s wife. She is very wondered if this term referred to depression or suicidal
stressed out with the patient’s condition and her financial situ- thoughts. In most nurse narratives, bad feelings referred to
ation. I gave her reassurance that it is OK to wait a few days
unpleasant physical symptoms, such as dyspnea, rather than
before making big decisions. (Reassurance, nursing presence,
emotional distress. Nurses responded in most cases with
family access and understanding)
reassurance or framed the bad feeling as a problem and tried
to solve the problem.
The caring behaviors nurses described least were helping
Patients assigned low scores to nurses for asking about
patients with basic human needs and providing a healing
patients’ knowledge of their illnesses. What nurses described
environment. For example,
on their side was informing patients about their illnesses, not
asking about the patient’s knowledge of their illnesses. Para-
I talked to her while giving her total care. (Nursing presence,
doxically, nurses rarely mentioned helping patients feel
physical care)
comfortable or attending to their basic physical needs, but
I turned and cleaned this patient every 2 hours. (Physical care)
patients gave high scores to nurses for these caring activities.
“Privacy: close door at all times” sign on the door. He didn’t
want anyone to see him, his Foley bag, wound vac canister, his
The most frequent theme in nurse narratives was encour-
bedside commode. (Respect, healing environment) agement, which was almost always confused or paired with
reassurance. Hope appeared to be the most salient concept for
Congruence between nurses’ narrative evidence and nurses writing about reassurance and encouragement. Most
CAT-V item scores was mixed (Table 3). Patient and nurse nurse stories about encouragement/reassurance referred to
data were congruent in regard to nurses showing respect. communicating hope by informing patients about possible
Patients and nurses also agreed that nurses often failed to good outcomes. This was consistent with the high mean score
help patients figure out questions to ask other health-care on the CAT-V item, “nurses support my sense of hope.”
professionals, although the score for this item on the
CAT-V increased with time. In other areas, patients and Discussion
nurses disagreed. Patients gave nurses low scores on helping
patients deal with “bad feelings,” but nurses described them-
Patient Perception of Care Improves Over Time
selves as providing strong care in this area when they clas- The hypothesis that patient perception of care improves over
sified their stories. Although nurses classified many stories time was supported by the quantitative patient data. In this
Thomas et al 199

LTACH setting, each patient was exposed to the same nurses Limitations
over many weeks. The improvement in CAT-V scores from
The sampling of nurse texts in the study ceased when satura-
admission to discharge suggests that as patients are exposed
tion was attained. Because the number of nurses in the study
to the same cadre of nurses over time, perception of nurse
hospital is small, saturation would be expected quickly and
caring improves, most likely through establishing trust as
samples of nurses in additional LTACH facilities would
suggested by prior research (24). However, if building trust
improve the study. Although some methodologists argue that
in nurses requires exposure to the same nurse multiple times
the notion of generalizability is not relevant to qualitative
over longer periods than a few days, earning patient trust
research (29), confidence in findings can only be enhanced
may challenge nurses providing care in shorter stay
with larger samples. Regarding the quantitative aspect of the
facilities.
study, the sample of patients was large enough to demon-
Strategies to build trust quickly have been suggested in
strate the within-group effect of time, but the sample was too
business literature. Recommendations for building trust with
small to perform multivariable analysis with confidence.
consumers range from microactivities, such as crafting
In 28% of cases, patient ratings of caring behaviors deliv-
memorable first impressions, to overarching relationship-
ered by nurses worsened over time. Because of small sample
building practices, such as avoiding manipulation, being
size, common themes that might associate with their disaf-
consistent, and engaging in real dialog (25). Coaching
fection were not identified. Further research specifically on
regarding evidence-based trust-building behaviors might
factors that trouble patients about nursing care is important
benefit nurses who do not have long periods with patients
and should stretch beyond the limited responses to commer-
to build relationships.
cial patient satisfaction surveys that drive reimbursements
for hospitals.
Patients and Nurses May Not Share Perceptions
of Nursing Care Behaviors Conclusions
Findings are consistent with prior evidence of incongruence Nursing care in the study LTACH was guided by a PPM
between patient and nurse perceptions of care. Most research rooted in a patient-centered, quality care framework.
on quality of nursing care has been conducted from the nurse Patients were generally positive about the caring behaviors
perspective (26).. The scant evidence that compares patient their nurses demonstrated, but nurses are not always aware
and nurse perceptions of nurse caring suggests that patients’ when their perceptions of caring behavior is not shared by
perceptions of care are not always congruent with nurses’ patients. Nurse responses indicated that additional training
perceptions (27,28). In this study, the areas in which nurses on specific strategies that convey empathy or promote less
and patients disagreed on the delivery of caring behaviors directive patient teaching could be useful for enhancing the
are shown in Table 3. patient experience. Finally, time affects patient perception
The finding that patients did not endorse the notion that of care, and very short hospitalizations may present chal-
nurses help with negative feelings while nurses thought they lenges to establishing caring relationships between patients
helped substantially in this regard may have been related to and nurses.
listening. Helping with negative feelings typically involves
listening. The word “listen” occurred in 6% of the narratives. Declaration of Conflicting Interests
Terms most frequently used to describe conversing with The author(s) declared no potential conflicts of interest with respect
patients included “talk to,” “explain,” “teach,” and “inform.” to the research, authorship, and/or publication of this article.
The quality of listening provided by nurses is impossible to
ascertain, but if nurses listen passively without providing Funding
feedback to indicate patient concerns are heard and under- The author(s) received no financial support for the research, author-
stood, the interaction may be dissatisfying to patients. Like- ship, and/or publication of this article.
wise, perceiving negative feelings as problems to be solved
likely promotes the use of favored approaches, such as teach- References
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16. Hughes R. Overview and summary: patient-centered care:
challenges and rewards. Online J Issues Nurs. 2011;16. Diane Thomas has served Texas Health Specialty Hospital for 22
17. Creswell JW, Plano Clark VL, Gutmann M, Hanson W. years. She is a Clinical Nurse Leader, an advanced practice nurse
(Clinical Nurse Specialist), and a certified wound ostomy care
Advanced mixed methods research designs. In: Tashakkori
nurse (CWOCN).
A, Teddlie C eds. Handbook of Mixed Methods in Social and
Behavioral Research. Thousand Oaks, CA: Sage; 2003: Patricia Newcomb has served as a nurse scientist facilitating nur-
209-40. sing research at Texas Health Resources for 6 years. She came to
18. National Commission for the Protection of Human Subjects of industry following a decade in academia and twenty years experi-
Biomedical and Behavioral Research. The Belmont report: ence as a pediatric nurse practitioner.
ethical principles and guidelines for the protection of human Phylann Fusco is the Director of Patient and Family Experience at
subjects of research. 1979. Retrieved from: https://science.edu Texas Health Resources. She led numerous patient experience
cation.nih.gov/supplements/webversions/bioethics/guide/ initiatives at small and large health care systems before joining
teacher/Mod5_Belmont.pdf. Accessed August 9, 2018. Texas Health Resources 5 years ago.