The expectations towards the nurse of the chronically ill patients

Introduction

Pascoe [1] defines the satisfaction of a patient as the “comparative process, engaging both cognitive and emotional reactions of an acceptor of a service to the significant aspects of his/her experiences concerning the structure, the process and the result of care”.
According to Linder-Pelz [2, 3], approach connected with patients’ expectations is the basic theoretical approach used to define the satisfaction. According to this model, a person seeks help because of different causes and the assessment of what one gets depends not only on the intervention alone but also on the whole process of becoming the receiver of help (a client). The satisfaction in this meaning is not only the cognitive activity, but also the emotional one, which depends on variable psychological elements (expectations, the system of values etc.) [2, 3]. In author’s opinion [2, 3], the multidimensional model of satisfaction includes also such dimensions as physician’s actions, availability, comfort and the general feeling of satisfaction.
During the patient’s stay in a hospital it is the nursing care that absorbs the most of time and is characterized by the most intensity of indirect interactions with a patient. Thus it depends on a nurse, to great extent, how a patient copes with the disease, how he bears the nuisances connected with the process of diagnosing and treatment, how he will be prepared to the return to his/her home.
The quality of the nursing care seen and perceived by a patient, that is his/her satisfaction, is one of the measures of the evaluation of the nursing care and the holistic care provided by a given health care institution.
In 2001, Larrabee and Bolden [4], performed the study aimed identification of the components of nursing care for the quality of care from patients’ view, and then compared the obtained results with the similar studies of other authors. The study included 597 patients, that had to answer the question “what does good care mean”? The data obtained allowed to define 5 theme groups concerning the features of “good caring” [4]:
• Providing for my needs, 79.1%, including caring of, checking if everything is all right, reaction to the requests, the fight with pain, providing information and care for the environment;
• Treating me pleasantly, 54.6%, including nice treating, respecting the laws, positive attitude, patience;
• Caring about me, 34.2%, including being “for me”, showing care and interest;
• Being competent, 32.1%, performing skills in a correct way, professionally, striving for perfection;
• Prompt care, 29.1%, being on time, performing the procedures punctually, avoiding unnecessary delay.
The study of Lemke [5] showed that patients who assessed their stay in a hospital as very satisfactory also assessed the nursing care as very satisfying. Only 34% of patients who evaluated the whole of stay less satisfactory, assessed the nursing care very well [5].
Evaluation of expectations of chronically ill people towards the nursing staff was a purpose of the current study as well as the impact of the kind of disease (we included to the study the people with a diagnosis of cancer in the initial stage of its development, in the terminal stage as well as other than cancer, chronic illnesses, in this case, cardiovascular diseases).

Material and methods

We conducted research after obtaining the agreement R-I- 002/64/2010 of the Bioethical Committee of Medical University in Białystok. Three groups of patients: I group – 120 patients with early-phase cancer diseases, group II – 150 with patients terminal-phase cancer diseases, and group III – 160 patients with cardiovascular disorders were examined.
We used the original questionnaire concerning expectations of patients towards the nursing staff (so-called general questions about the branch of the stay of the patient, age, sex, domicile, education, social conditions and welfare) and fundamental – concerning:
• preferred training of nurses looking after them,
• kind of possessed abilities,
• activities regarded as the most important at the work of the nurse,
• a willingness of nurses to discuss with patients their health problems so that they could teach the patient to cope with the illness,
• health problems in the family,
• proceedings would teach the family,
• behavior a nurse should have,
• evaluations of the report nurse – patient in the place of hospitalization,
• informing the sick person of nursing activities undertaken by the nurse and carrying them out only when they will receive the permission,
• respect for the dignity of the sick person, intimacy of sick person,
• self-assessment of the confidence in nurses,
• assessment of the degree of their professionalism,
• level of self-satisfaction of the performed work,
• free access to the chapel.
The standardized Scale of Social Reinforcements, drawn up by Kmiecik-Baran, was used to examine the strength of reinforcements the individual receives from both family and the nursing staff [6]. The scale is based on theoretical assumptions introduced by Tardy who distinguishes four types of supports: information (delivering for the individual of messages important for her functioning, advice, advice, and the like), instrumental (granting the individual the particular aid, e.g. borrowing money, doing the shopping), evaluative (implying for the person that he possesses such possibilities, abilities, skills, and the like, which are essential for groups or persons to function correctly) and emotional (to assure the individual that there is a group or the person he can always count on and at any time a help will be given him). Every scale (a type of the support) still contains subscales as a result of 16 comprising positions included to the conclusive version of scale and calculated in spot categories. The public support is being also judged by taking back them to norms (1-3 low results; 4-7 average results and 8-10 high results) [6].

Results

In group I, men accounted 42.5% and woman 57.5%. In group II, 53.3% were men and 46.7% were women. In group III, 53.1% were men and 46.9% were women.
Patients below the age of 20 constituted 1.7% examined in group I; 26% in group II, and the 1.3% in group III. People at the age more than 20 up to 30 years accounted for 1.7% in group I; the 11.3% in group II and the 1.9% in group III. Patients in the range from 31 up to 40 years accounted for 12.5% in group I; 6.7% in group II and the 1.9% in group III. People in the range from 41 up to 50 years accounted for 30% in group I; 12% in group II and the 8.8% in group III people in the range from 51 up to 60 years accounted for 21.7% in group I; 20% in group II and the 28.1% in group III. Patients in the range from 61 up to 70 years accounted for 22.5% in group I; 16% in group II and 24.4 % in group III. Patients over 70 constituted 10% in group I; 8% in group II and the 33.8% in group III.
In group I, the majority respondents (71.7%) declared the marital status as the “married/married”, while the (22.5%) “widower/widow”, and “bachelor/spinster” (5.8%). In group II, married people dominated – the 52.7% and the single – 24%. Widowers and widows represented 8.7%, but persons divorced – 4.7%. In group III – married people constituted 65%, widows/widowers – 30%, bachelors/spinsters – 4.4% and divorced – 0.6%.
Most of the patients lived in the city, in group I – 57.5%, in group II – 69.3%, in group III – 66.9%. 39.2% of persons in group I; 21.3% in group II and the 20.6% in group III lived with the spouse. 30.8% in group I; 28% in group II and the 23.8% in group III lived with the spouse and children.
No significant differences were found in the structure of the patients education. Secondary education had 37.5% in group I; 52% in group II; and 44.4% – group III. The vocational secondary education had 46.7% of patients in group I, 38% in group II and the 40% in group III. 15.8% of the respondents in group I, 38% in group II, and 40% in group III had a higher education. 69.2% of sick persons characterized the social and welfare conditions as “very weak”.
The expected level of education of the nurse was not important for a 50.8% of the examined people in group I; 54% in group II, and 35% in group III. 46.7% of sick persons in group I; 30.7% in group II and the 35% in group III preferred the higher education medical. 2.5% of persons in group I; 15.3% in group II and 15.6% in group III. Differences between groups were significant (p < 0.001).
The majority of the examined population of patients irrespective of the stage and the kind of illness (p = 0.589) appraised the entirety of the relation highly patient-nurse. It was competent in the opinion of the 71.7% examined in group I; 74% in group II, 73.8% in group III. 26.7% of sick persons in group I described it as “rather appropriate”; 25.3% in group II and the 25.6% in group III described it rather “not appropriate”.
Also, a help of nurse in the free access to the chaplain was analysed and they demonstrated, that 90.6% of patients in group III, 88% in group II and the 85.8% of the group III, confirmed that they had had help in the free access to the chaplain. 2.5% examined in group I, 8% in group II and the 1.3% in group III had a different opinion. The contact with the chaplain was not significant for a 7.5% of patients in group I; 2.7% in group II and the 4.4% in group III had a problem with the unequivocal answer. There was stated the weak relation between the kind and the staging of the disease and expecting the assistance of the nurse in the accessibility to the clergyman at the hospital (p = 0.0161).
In the detailed Table 1, showed beneath, the number and the percentage of sick people from each examined group were presented. It indicated different characteristics of nurses, as the ones most desired and expected. In the opinion of patients in group I, conscientiousness was the most desired feature of the nurse (88.3%) as well as goodness (82.5%); in group II – patience (81.3%) and the ability of inspiring the confidence (80%), and in group III – patience (81.9%), and responsibility (75%).
80.8% of sick persons in group I; 75.3% in group II and the 61.9% in group III assessed informing the patient of nursing-therapy activities as correct, 19.2% of persons in group I; 21.3% in group II and the 30.6% in group III as “rather correct”, 1.9% of patients in group III – “rather not correct” and 0.6% from them – recognised it as “wrong deciding”. 3.3% examined in group II and the 5% in group I had a problem with the declaration. Diversifying in this issue among groups was significant statistically (p = 0.007).
The respect for the intimacy of the patient had an important dimension, similarly as in the case of the respect for the dignity, while performing the care. The most positive recommendations to this question were amongst patients in group II (74%), and then III – 58.1% and then I – 55%. 41.7% of sick persons in group I, 25.3% in group II and the 38.1% in group III claimed the fact that the respect for the intimacy was “than followed”. 0.7% examined in group II had a problem with the reply, 3.3% of persons in group I and the 3.8% in group III declared the different opinion. Patients opinions in both issues differed significantly (p = 0.006).
The vast majority of patients in confirmed its confidence in nurses. 77.5% of sick persons in group I; 74.7% in group II and 70.6% in group III, 19.2% of persons in group I; had the absolute confidence in nursing staff. 24% in group II and the 26.9% in group III did not display such a confidence and 1.3% of patients in group III had a problem with the unequivocal answer. The disease type did not diversify the opinion of sick people clearly in this issue (p = 0.2772).
Table 2 presents the spot characterization of the degree of the evaluation of chosen characteristics of nurses. In the table information about the average assessment of nurses was placed in the given category, made by patients, as well as the median and diversifying evaluations in the form of the standard deviation. The evaluation was conducted in the 10-point scale. Differences in the assessments of nurses among groups were assessed with the Kruskal-Wallis test.
In the Tables 3, 4 and 5 an accurate picture of the scoring of chosen characteristics of nurses was described. Generally a high evaluation of the professionalism and the step of the confidence in the medical staff been characteristic is paying attention.
The statistical significance was also shown by the test of the independence chi-square and connected e.g. with the fact that in group of people with the advanced condition of cancer they stated relatively more over half of readings of the maximum evaluations of the professionalism on level 10 of pt. However, it was balanced by the fact that it was also relatively more often evaluated as level 6 of pt 11.3% in this group.
Expectations of patients concerning professional skills of nurses differed in the conducted examination depending on the stage and the kind of illness. In case of sick persons in group I at nurses an ability of the transmission of information was most important medical 89.2% of the examined population, iatrology 88.3%, and the ability of observation 83.3%. Sick persons in group II above all expected the medical assistance of the care and the gentleness in performing treatments to minimize pain complaints 62.7%, and from the III group – of humanitarian attitude to the patient 59.4%. Details are shown in Table 6.
The hierarchy of the importance of individual activities made by nurses was also diversified depending on the examined group of sick persons. Provided for patients in group I almost all exchanged tasks of the nurse were significant, and have most often been exchanged activities: education 89.2%, streamlining sick persons 88.3% and helping with the service 82.5%, as in group III, an efficient performance of the injection was most important 56.3% and provision of support 53.1%. In group II, sick persons but the most significant activities recognized: provision of support 61.3% and performed the injection and the help in the self-service for the 60%. Apart from performing the injection and hygienic activities perceiving all other activities was characteristic statistically and the diseases dependent on the kind. Details are shown in Table 7.
In case of concerning questions of the need to discuss health problems and the need of the education of sick persons and their families about illness, expressed voices backing such activity of nurses up 65% of patients in group I; 42.7% in group II and the 50.6% in group III. Rather about such a need was convinced 15% examined in group I.
Convinced rather of such a need was 17.5% of persons in group I; 21.3% in group II and the 22.5% in group III. Determination on “not” was 12.5% of sick persons in group I, 9.3% in group II and the 3.8% in group III, and “rather than that on not” – 2.5% of persons in group I; 2% in group II and the 1.5% in group III. Above made the 1.4% conditional on the circumstance examined in group II and the 0.6% in group III, but undecided was 6.7% of sick persons in group II and the 4.4% in group III.
Amongst the examined patient groups the most it granted such a reply sick persons in group I 60% of readings, and less in group II 46.7% and III 48.1%. It was about it convinced 18.3% examined in group I; 21.3% in group II and the 27.5% in group III. Different expressed opinions, as “determination not” – 10% of persons in group I; 14% of patients from the II influenza and the 2.5% in group III, and “rather than that not” – 5.8% of persons in group I; 12% of persons from the II influenza and the 15.6% in group III. one’s made opinions conditional on the existing situation – 1.3% of persons in group III, and hesitated, which to file the declaration – 5.8% examined in group I; 6% in group II and the 5% in group III. Making the progress report of illnesses get in three examined categories a statistical difference was stated p = 0.0027.
In the examination getting to know the opinion of the examined population on the subject was real meaning of education of families of patients. Results were characteristic statistically and diversified on account of the group of examined patients p < 0.001.
Sick persons in group II best assessed the respect for the dignity of the sick person, shown by nurses during performed treatments 70.7% of respondents, and in group I relatively have most often shown the reply the variant “depends on the nurse 48.3% of the examined population what he is suggesting, that they had the most critical relationship to of them of some activities”. What however most important, irrespective of the kind of disease the straight majority of polled sick persons judged nurses, as calm and/or friendly of persons usually over the 80% examined. Details are shown in Table 8.
Results are showing characteristics of the degree of the evaluation of chosen characteristics of nurses. In the Table 9 information about the average assessment of nurses was placed in the given category, made by patients, as well as the median and diversifying evaluations in the form of the standard deviation. The evaluation was conducted in the 10-points scale. Differences in assessments of nurses among groups was being assessed with the Kruskal-Wallis test. An influence of the kind of disease on an overall view of nurses was not stated under the angle of the professionalism, the job satisfaction and the step of the confidence.
Analyzing information about the level of the support received on the part of the nurse by polled sick persons they attracted the attention to the fact that patients in all examined groups much higher assessed the level of the information and emotional support granted by the nursing. It also existed characteristic statistically diversifying specific types of supporting disease depending on the kind between the level. Table 10 is illustrating the detailed schedule of the response. The overall level of the support received from nurses expressed in paragraphs of the Scale of Social Reinforcements was higher amongst sick persons in group II and III, than in group I.
Table 11 depicts the participation in individual groups of people declaring the highest level of supporting on the part of the nursing staff. It results from conducted analyses that the participation of such evaluations in the issue of instrumental and assessing reinforcements was slight – lowest they were observing in and for group of people.

Discussion

The quality of the nursing can be assessed from a point of view of the service provider – nurses and beneficiaries – the patient and his family [7–9]. This evaluation is not only the issued opinion, but also an emotional state expressed by him in the form of satisfaction or it’s lack. The systematic analysis of the care is giving the possibility of improving the entire system of the health and of it’s individual elements. A nurse, providing care in the interdisciplinary team, must be conscious of her competence, the ability, laws and the responsibility and know that a first impression, affecting the more distant frame of mind of the sick person in the course of his/her stay in a hospital depends on her attitude and the behaviour [7–9].
In Johansson’s et al. opinion [10] the quality of nursing perceived by the patient depends on many factors, which a nurse, who wants to improve the quality of care perceived by the patient, must take into account. Authors [10], based on the literature review, identified eight categories of factors affecting the satisfaction of the patient from nursing, so as: social and demographic factors age of the patient, education; expectations towards the care and previous experiences of patients during the stay in a hospital concerning not only high professional competence and the knowledge, but also an individualized approach, treating like a friend, advising, due announcing, announcing, physical and emotional pushing, the good cooperation of doctors and nurses; external environment cleanness, meals, noise, beauty of rooms, comfort; communicating and the transmission of information easiness for establishing the communication, appropriate announcing; the complicity and involving patients in the decision making concerning the care good interpersonal relationship between the nurse and the patient; technical and manual competence including appropriate advice handed over to the patient, the competent performance of treatments and the effective fight against pain and organization of the health care continuity of the care, availability of nurses, job satisfaction of nurses. They stated that the more attention a nurse had devoted to the patient, the higher level of his satisfactions was, and an emotional commitment to the patient care additionally influenced raising his level of satisfaction [10]. Patients expressed the opinion that an emotional commitment of the nurse into the care was even more important for them than her manual and technical efficiency.
In the Otani and Kurz study [11], nursing outweighed 0.53 attributes affecting the evaluation of comprehensive satisfaction from the stay in hospital. Next there were: procedure of admitting to the hospital 0.15, pleasant environment 0.11, approach towards the family and friends 0.10, medical attention 0.05, getting the certified information on leaving the hospital 0.03. A statistical analysis showed that the influence of the nursing on general satisfaction from the hospitalization had been 3.5 times bigger, than second as for the gravity of the attributethe procedure of the admission to the hospital. According to authors one should at first correct satisfaction from the nursing to improve satisfaction from the comprehensive stay in hospital [11].
Pałyska et al. [12], think that, from the point of view of the patient, the care should be directed at a patient feeling satisfied and therefore the quality of the care should encounter requirements of the sick person and give him expected benefit and satisfaction. In the subjective quality assessment of medical services the sick person is taking into consideration not only a quality of delivered benefits, but also entire surrounding, the attitude of the medical staff to him/her, and many times also an interpersonal relationship between employees of the hospital [12].
Wasilewski’s opinion [13], based on own findings obtained at the and Children’s Neurosurgery Department and Department of General Surgery and Transplantology conducted in group of patients who underwent neurosurgery, stated that the evaluation of satisfaction from the offered nursing had developed both on high average level in hotel conditions, in which a care was provided, and the help patients got from nurses and concerned: cleanness and pleasant look of rooms in the hospital, the necessary assistance while washing or the bath of the ill child, conditions of the rest and the dream and assuring help at getting up, sitting down and walking. Evaluation of satisfaction from the offered nursing care was on a low level when it concerned the hotel conditions, in which a care was provided, and the help patients got from nurses in airing rooms, in physiological duties, free time activities and the motor and rehabilitation assistance in performing exercises [13].
In the other work, the same author [14] made the subjective evaluation of selected aspects of satisfaction from the stay in hospital, made by patients with damage to the right and left cerebral hemisphere, relating to the control group. He conducted research amongst 173 patients hospitalized at the Department of Neurosurgery and of Childrenʼs Neurosurgery and Neurology. He showed that nearly the half of ill people in every of examined groups had known the chief nurse, but the smaller per cent of patients identified the nurse looking after the specific group of patients. About 70% of patients in every group were informed of their rights as the patients. A statistical analysis of obtained findings pointed at high evaluation of ensuring religious needs and the contact with the family. Over the 90% of patients in studied groups and the control group were pleased with the care in this respect. The evaluation of satisfaction of the patient from the offered nursing pointed at the average level of satisfaction in analysed aspects of the care [14].
Grabska and Stefańska [15] conducted study amongst 90 adult patients of the Hospital in Włocławek. They demonstrated, that examined persons valued the most the care and the accuracy in performing treatments and the cordiality and the politeness of the nurse in the approach towards the sick person. Patients appraised highly level of education of the nurse and specializations obtained by her. The vast majority of examined patients expected the tender care of the nurse, as well as the support [15].
Ozga and Binkowska-Bury [9], assessed the satisfaction of 100 patients from the nursing at the surgical wards: of traumatology and orthopaedics. Examinations showed, that in the opinion of examined patients, the evaluation of the experiences concerning the nursing was in the range from 39.1 to 94.8 from 100 maximum points. The level of satisfaction from the nursing in the examined patient group was in the range from 32.8 to 100 points. Men assessed higher experience and satisfaction from the nursing in comparison with examined women. The general satisfaction of the patient from the nursing was good 73.3% [9].
The examined people in group I – patients with the preliminary phase of cancer have most often mentioned the conscientiousness, the goodness and the diligence amongst the most preferred features in nurses. Patients with the advanced cancer expected the nurse be patient, inspiring the confidence and responsible, however patients with chronic diseases of the cardiovascular system preferred a nurse to be patient and responsible. In the assessment of almost all examined patients relations nurse – patient were correct. Nurses informed patients of performed activities, and carried them out with the respect for the dignity and the intimacy of the patient. In group II – patients with advanced cancer- skills required by patients from nurses included the ability to provide medical information, an extensive medical knowledge and the ability of observation and – in group with chronic illnesses of the cardiovascular system – humanitarian attitude to the patient.
In the opinion of the studied population educating and streamlining were the most important activities provided by nurses. Discussing health problems by nursing staff was more frequent pointed by patients with the preliminary phase of cancer, than patients in remaining groups examined. The health education about disease is important in the opinion of patients with chronic disease of the cardiovascular system and patients with early phase of cancer. In the opinion of the studied population treatments performed by nurses were done in the calm and friendly atmosphere in spite of the lack of the essential statistical significance, and especially patients with the advanced stage of the disease stressed the respect for the human dignity of the ill person. The level of nurses’ education did not have the significant influence on the provided nursing from patient’s view.
Patients of different faith, during the stay in hospital, have different needs resulting not only from the very illness, but also from their spiritual sphere. It is important so that provide the care of the sick person to be aware of religious differences and not to hurt emotions of sick persons what prevents growing of the emotional stress at sick persons as well as their careers.
Krajewska-Kułak et al. [16], evaluated nurses opinions on the possibility and needs of the completion of religious observances at the hospice. The clergyman should be permanently in the hospices 77.7%. The priest should provide the priestly ministry for patients 84.6% and their families 60.0%. According to students, patients of the hospice should be able to talk with the clergyman within the week, at least 4 times 50.3% or 2-3 times 28.0%. Almost all 98.8% reported that at the hospice the sick person should have an ensured contact with the clergyman of its faith [16].
Mickiewicz et al. [17], studied 83 randomly chosen, professionally active nurses and judged perceiving the palliative care by them. According to the respondents, patients at the hospice should grant the spiritual support: permanent clergyman 80.9% and nurse 49.2% [17].
In the current study, it only exchanged the contact with the clergyman, as the crucial factor conditioning the correct comfort of patients 4.0% of sick persons in the advanced staging disease and the 6.9% of patients from the control group and everyone matched as for the help in this issue on the part of nursing staff.
Nursing, according to Cox and Bowman [18], it is one of the small professions which in the society is placed one’s trust. Warin [19] is emphasizing that the nurse is playing the major role not only in the curing process, but they perform the educational function.

Conclusions

1. Patients highly appraised the level of the interpersonal relationship “patient – nurse” irrespectively of the stage of the illness.
2. An influence of the kind of the disease on the general evaluation of nurses’ work under the angle of the professionalism, the job satisfaction and the step of the confidence wasn’t stated.
3. Expectations towards nursing staff concerning professional skills differed statistically significantly depending on the kind and the stage of illness.
4. Patients in all examined groups assessed much higher the level of the information and te emotional support than instrumental support delivered by nursing staff.

The authors declare no conflict of interest.

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