A culture of caring: Research abstract and commentary

Abstract and Commentary

Carter, L.C., Nelson, J.L., Siever, B.A., Dukek, s.L., Pipe, T.B., & Holland, D.E. (2008). Exploring a culture of caring. Nursing Administration Quarterly, 32, 57-63.

Author’s Abstract

AIM: The delivery of patient-centered care is basic to a large Midwestern healthcare institution's mission and highly valued by the department of nursing. Even so, nurses on one medical unit questioned whether caring behaviors were devalued in a technology-oriented environment of providing care. The nursing leadership on the unit responded to the inquiry by conducting a research study. This study explored the state of patient-centered nursing care on a 36-bed medical unit as perceived by the nursing staff and patients, using Watson's Theory of Human Caring as a framework. SUBJECTS AND METHODS: The study utilized surveys for both nursing staff (n = 31) and patients (n = 62), and included a focus group of nursing staff (n = 8) to explore ideas for innovation. RESULTS AND CONCLUSIONS: Both nurses and patients perceived a high level of caring on the unit. The overall theme from the focus group was that "caring begets caring," with 2 subthemes: "relationships of care" and "the context of caring." Caring for each other was identified as essential to keep staff energized and able to work lovingly with patients. Nursing leadership brought the research findings to all staff on the unit for discussion and implementation of structural support for the unit culture of caring.

Commentary by Dana Rutledge, RN, PhD, Nursing Research Facilitator

It is helpful to consider a few details about this study methodology. In order to fulfill their purpose, these authors use a dual method study -- combining a descriptive, comparative survey design (staff plus patients) with a qualitative design using a focus group. The study setting was a medical specialty unit where relationship-based care meant that “nursing staff put at the center of their work a personal relationship with patients and family,… ministering to body, mind, and spirit” (p. 58). Staff completed the Caring Efficacy Scale, a 30-item paper and pencil tool that measures one’s belief in ability to build caring relationships and communicate a caring environment with patients. The tool was deemed to contain the majority of Watson’s carative factors. Patients completed the 10-item Client Perception of Caring Scale, which asks about nonverbal/verbal actions signifying that some aspect of care was carried out by nurses.

Survey respondents were 39% of unit staff (87% RNs; age range 20-60; mean caregiving experience of 7 years; 93% women) and 62 patients (mean age, 65 years; 40% men; 45% with college education). How staff and patients were recruited to be in the study is not mentioned. On average, staff reported they were able to demonstrate caring behaviors and patients had high perceptions of caring. One wonders about the 61% of staff who did not fill out the surveys… what is their perception of ability to give relationship-based care? Unfortunately, although the researchers may have wanted to compare nurse/patient perceptions… because they used different tools for the two groups, direct comparison is impossible. The survey component of the study was fairly ineffective in leading to new knowledge, although the researchers concluded that “nurses’ perceptions of care and patients’ perceptions of care were positive and in alignment” (p. 63).

The focus group (7 RNs, 1 assistant) discussed how to enhance the caring environment. The data discussed from the focus group is quite rich, including categories of care relationships: teamwork, building expertise, personal support from peers, and connecting with patients. The context of caring included the organizational culture, the physical unit, and workload… all of these findings resonate with current situations. A strength of the article is the authors’ ability to discuss relevance of these focus group findings to practice.

Focus group “participants were indeed recognizing that the underlying culture of loving-kindness that keeps a group sustained through periods of time when the environment of caring was stressed by demands and changes” (p.61). This supports the theme that “caring begets caring.” This theme points to the need to recruit and retain staff who embrace caring values, to work for stronger connections with students on units, to promote mentoring among staff, to celebrate caring experiences, and to affirm team and staff member contributions. Specific nurse leader and nurse administrator implications are mentioned by the authors: nurse leader education on therapeutic communication, workflow facilitation, and mutual support; caritas circles for connections of “spiritual renewal and dedication to caring”; establishment of a group ethic that expects care and healing environment with reflective practice.