Nurse Caring and Perceived Caring Related To Patient Satisfaction: A Critical Literature Review

Running head: NURSE CARING AND PERCEIVED CARING 1
NURSE CARING AND PERCEIVED CARING RELATED TO PATIENT SATISFACTION

A CRITICAL LITERATURE REVIEW
SUBMITTED TO THE DEPARTMENT OF
GRADUATE STUDIES IN NURSING EDUCATION

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
For the degree NURSE
MASTER OF SCIENCE
by
REBECCA L. DORTON

INDIANA WESLEYAN UNIVERSITY

MARION, INDIANA

JULY, 2014

NURSE CARING AND PERCEIVED CARING

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NURSE CARING AND PERCEIVED CARING - Abstract
In light of the current significance of the measurement of patient satisfaction for full
reimbursement from the Centers for Medicare and Medicaid, the author critically reviewed
current literature regarding nurse caring and perceived caring related to patient satisfaction. In
recent years, due to government regulations, patient satisfaction has been an important factor in
measuring the quality and financial well being of health care organizations. Also, patient
satisfaction has been identified as a possible factor in promoting safety and other beneficial
health outcomes. Caring was explored in the literature and related to patient satisfaction through
the theoretical framework of Jean Watson. Articles were accepted for review if they were peer-
reviewed studies published between 2008 and 2014; and were related to nurse caring, perceived
caring, and patient satisfaction. There were 23 total articles selected that met the criteria. It was
found that nurse caring factors affect perceived caring and patient satisfaction, and the idea that
higher patient satisfaction is correlated with positive health outcomes was supported in this
critical literature review.


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Nurse Caring and Perceived Caring Related to Patient Satisfaction: A Critical Literature Review
Part I Introduction and Analysis of the Issue
Introduction
Caring is a foundational concept in nursing. In the past 35 years it is a topic that has been
a subject of study, research, and theory in nursing literature. Many questions have been brought
to the forefront of discussion related to the subject, such as:
Is caring the essence of nursing, is it the fields special knowledge area, is it equal to the
discipline of nursing, is it a central concept in nursing, or is it the core of its domain? Is it
the goal or the mission of nursing, or is it a goal and a mission of nursing? (Meleis, 2012,
p. 91)
The purpose for this critical literature review is to explore several facets of caring including
caring theory, caring history, and perceived caring in the literature, and to relate them to the
significant topic of patient satisfaction in todays health care environment. The aim of this
project is to analyze and synthesize current research on the topics described to confirm that
patient satisfaction is a result of nurse caring and perceived caring and, that it is vital to the
concern of nurses for financial as well as moral and ethical reasons. Patient satisfaction appears
to bring about positive health outcomes in patients. If this could be established through current
research, a clearer direction in additional research, theory, and practice could occur
understanding that in promoting patient satisfaction, the nurse is promoting health.
Caring Defined
Most individuals who have chosen nursing as their lifes work have done so with an
altruistic desire to care for others (Vance, 2003). Humans have innate temperament traits which
are acquired through environmental factors (Eley, Eley, Bertello, & Rogers-Clark, 2012). Caring

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is characterized by effective and skillful nursing, compassion, and understanding (Finfgeld-
Connett, 2008). For caring to occur the care recipient needs to be open to receiving and the care
provider needs to exhibit professional maturity with an underpinning of morality. A conducive
work environment for the implementation of caring is necessary (Finfgeld-Connett, 2008).
Caring has been defined by Jean Watson as a fundamental value that guides nurses
ethical decision making and provides a basis for nurse caring actions (as cited in Dingman,
Williams, Fosbinder, & Warnick, 1999, p. 31). Jean Watson describes caring as preserving
dignity while addressing the persons needs. It is a commitment to alleviate anothers
weaknesses by giving attention and concern for the other (as cited in Vance, 2003). Caring is
both a construct and a concept. There is an emotional and subjective aspect of caring that cannot
be measured. There is also a behavioral, quantifiable dimension.
Looking at the stated definitions of Jean Watson, caring is a value and a commitment. In
addition, she designed ten carative factors that are elements of caring (Watson, 2008). These
factors are interventions which require an intention to develop a relationship and actions that
give substance to the plan. The commitment is a principle of ethics fixed on preserving
humanity and affirming the individual (Watson, 2008). Actions are presupposed by a foundation
of knowledge and proven competence. Watsons carative factors consist of:
Values based on a humanistic-altruistic system
Faith - hope
Understanding of self and others
Helping and trusting
Expression of both positive and negative emotions
Creative problem solving

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Transpersonal teaching and learning
Providing an environment that supports and provides for spirituality, mental growth, and
physical wholeness
Assistance with human needs
Allowance for the phenomenological and spiritual (Watson, 2008)
The following is a description of caring by Jean Watson:
The discipline of nursing, from my position, is/should be grounded in Caring Science;
this, in turn, informs the profession. Caring Science informs and serves as the moral-
philosophical-theoretical-foundational starting point for nursing education, patient care,
research, and even administrative practices (Watson, 2008, Chapter One, para. 5).
When looking at caring through a humanistic worldview, one would say that caring is
intrinsic to being human and nurses demonstrate caring behaviors because they are human. In
contrast, Christian nursing is a ministry of holistic, compassionate care, responding to Gods
grace towards a sinful world, which aspires to promote optimal health and to bring comfort to the
suffering, the needy, and the dying (Shelly & Miller, 2006). A Christian nurse operating under a
Christian worldview would view caring as a ministry of Jesus Christ. The motivation for caring
would come from Christian principles of scripture to minister to those who are in distress.
A view of caring based on the French philosopher Paul Ricoeurs work proposes that
ethics, which is the goal of an accomplished persons life, is more desirable than morality, which
is compulsory (Fredriksson & Eriksson, 2003). Caritas is human love and charity in wanting
what is good for the other. Caritas, as depicted in the narrative of the Good Samaritan,
motivates the nurse to take care of the other (Fredriksson & Eriksson, 2003, p. 146). Solicitude

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is thoughtfulness and consideration. In French, it means tender care (Fredriksson & Eriksson,
2003).
Expert nursing is the basic component of caring, but interpersonal sensitivity is key to the
caring process and is empathetic insight into another persons suffering (Eriksson 1997;
McNamara, 1995). Eriksson (1997) states,
True caring is not a form of behavior, not a feeling or state. It is an ontology, a way of
living. It is not enough to be there - it is the way, the spirit in which it is done; and
this spirit is caritative. (as cited by Eriksson, 1997, p. 9).
Madeleine Leininger developed the Cultural Care Diversity and Universality Theory.
She defines care as both an abstract and-or a concrete phenomenon as those assistive,
supportive, and enabling experiences or ideas towards others with evident or anticipated need to
ameliorate or improve a human condition or lifeway (as cited in Leininger & McFarland, 2006,
p. 12). Leininger states that human caring has been learned and Being human was to be caring,
and caring was culturally based (as cited in Reynolds & Leininger, 1993, p. 24).
Caring behaviors include a personal introduction; addressing the patient by his or her
name; sitting at the patients bedside for at least five minutes per shift and reviewing care; using
touch; and verbalizing the mission statements in planning care (Dingman et al., 1999). A
concept analysis of caring conducted in 2004 determined that five attributes of caring are evident
in the literature. These attributes are: relationship, behavior, attitude, positive response, and
flexibility (Brilowski & Wendler, 2005).
History of Caring
Caring is a concept that dates back to the beginning of human history. The need for
caring is obvious for humanity to have survived. Historical documentation confirms that ancient

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cultures and religions identified caring as an individual and collective responsibility of the
people (Stedman, 2013). The Book of Exodus mentions midwives assisting women in childbirth
in ancient Egypt (Exodus 1:15-19). For centuries, caring was centered in the home and amongst
family members. The responsibility of caring, has historically been dedicated to women and
those of lower social standing (Stedman, 2013).
Madeleine Leininger discussed the differences between caring in a generic and
professional sense. Generic care was described as support for another to improve a human
disorder. Professional caring was explained as being learned behaviors, procedures, or patterned
responses that help another to improve or sustain health (Reynolds & Leininger, 1993). Generic
caring is an ancient expression of human caring needed for the survival and health of Homo
sapiens, including local home remedies and folk care (Reynolds & Leininger, 1993).
For the purposes of this discussion on the history of caring, the profession of nursing and
the activities of nurses will be focused on as being very closely connected with caring.
Although, historically, there have been many non-nurse caregivers who have fulfilled the role of
caring in the home and community.
Anthropologically speaking, caring is one of the oldest and most universal expectations
for human development and survival through our long history and in different places in
the world. Caring for self and other human beings is a universal phenomenon that has
endured beyond specific cultures, and has brought forth important humanistic attributes
of care-givers and care recipients. (Leininger, 1977/2012, p. 57).
The discipline of nursing has its roots in the first century when Christians began to extend
the teachings of Jesus Christ in exhorting believers to care for those in poverty, the sick, and
those who were marginalized in the community. As churches grew larger, deacons were

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appointed to give care to the needy (Shelly & Miller, 2006). In Romans 16, a deacon named
Phoebe is mentioned who is often credited with being the first visiting nurse (Shelly & Miller,
2006). By the third century, groups of deaconesses who cared for the sick, were organized. In
the fourth century, the church started hospitals staffed by nurses (Shelly & Miller, 2006).
Historical records of the fourth and fifth centuries chronicle the monastic movement
when various religious orders cared for and protected the sick and wounded (Evans, 2004). The
St. John of Jerusalem Order was a group of knights called Knight Hospitallers, who defended
Jerusalem during the crusades. The group, later protected pilgrims by building hospitals and
castles across Europe that provided lodging for travellers and places to care for the infirm
(Evans, 2004).
In 1475, a religious order of uneducated craftsmen was formed called the Alexian
Brothers. They preached the Gospel and provided care to the disenfranchised of society,
including the poor, the disabled, and the mentally ill (Evans, 2004). During the years of the
plague, in the fourteenth and fifteenth centuries, the Alexian Brothers were most widely known
for burying the dead. After the plague abated, their hallmark ministry was to the mentally ill
(Evans, 2004). From the sixteenth through the eighteenth centuries, many Catholic religious
orders disbanded and monasteries were dissolved. Hospitals deteriorated and nursing moved
back into the home (Shelly & Miller, 2006).
It is at that time recorded nursing activities fade, but resurface in the 1800s when large
charity hospitals were built, such as the Manchester Royal Infirmary in England (Evans, 2004)
and the founding of missions and ministries such as the Widows Society in New York, the
Sisters of Mercy in Dublin, and the Society of Protestant sisters of Charity in London (Shelly &
Miller, 2006). Theodor and Frederika Fleidner of Germany saw the persistent needs of the

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impoverished and sick in their city and opened a garden house as a respite for orphaned and
marginalized girls. Eventually, they established a group of deaconesses to care for the sick in
their homes. This ministry developed into the Kaiserswerth Institute for the Training of
Deaconesses, consisting of a hospital and school for nurses (Shelly & Miller, 2006).
Florence Nightingale studied at the Kaiserswerth Institute, and at Paris hospitals.
She became a superintendent of a hospital in London, and then was asked by the British
Government to serve as a nurse in the Crimean War. It was during this time that she
began to develop her ideas around infection control, sanitation, and fundamental nursing
care (Straughair, 2012). Nightingales philosophy and theory of nursing is stated clearly
and concisely in Notes on Nursing (1859), Nightingales most widely known work
(Tomey &. Alligood, 2006, p. 81). Florence Nightingale did not use the words
transpersonal human caring, but her writings reveal the timelessness and manifestation of
the concept and values for holistic nursing (Watson, 2010). Her writings were a
foundation for the caring profession of nursing that it is today, setting the stage for it to
develop into a separate and distinct profession. History confirms that nursing has been
viewed as an extension of the medical profession and under its jurisdiction (Stedman,
2013).
Before 1880, it was a rare occurrence for illness to be treated in the hospital. Typically,
the family doctor visited the sick person, gave instructions to the servants or female family
members, and they tended to ill individuals in the home. The discovery of anesthetics and the
advancement of medical and surgical techniques in the middle of the nineteenth century allowed
all classes of society to seek treatment in hospitals (University of Glasgow, n. d.). Beginning in
the 1860s, nursing schools produced educated women who were enthusiastically hired by

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hospital administrators, as by this time, doctors, patients, and the general public were insistent
upon higher levels of skill in nurses (University of Glasgow, n. d.).
In the early 1900s, issues related to sanitation and community health were the
primary concern of healthcare planners and providers. Toward the mid 1900s, a shift in
focus from community health to the health and well being of the individual occurred with
scientific breakthroughs such as antibiotics and vaccinations (Klainberg, 2009). The 20
th

century brought many changes to the profession of nursing, with the addition of programs
and professional organizations designed to address some of the problems in nursing and
promote nursing as a discipline. The American Nurses Association began publishing the
American Journal of Nursing and nursing schools began allowing students to become
licensed practical nurses and have additional training and testing to become registered
nurses (Nursing Schools Path, 2014).
Nurses also began to gain further education and advanced degrees. The rise of
nursing research and nursing theory has brought the profession of nursing into its own.
While Florence Nightingale laid the foundation for nursing to become a distinct
profession, the realization came about later in history, though some nursing sociologists
do not believe that nursing is a profession, but an emerging profession (Chitty, 2005).
Whether or not this is the case, nursing is a very young profession, at best.
Caring is a much discussed topic in current nursing literature. Caring became a
topic of interest in the 1950s (Brilowski & Wendler, 2005). At that time, there was a
deficiency of scholars to investigate caring. In the late 1970s, research on the subject was
raised with the work of Jean Watson and the first National Caring Research Conference
(Brilowski & Wendler, 2005). In 1979, Watson published Nursing: The Philosophy and

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Science of Caring. Her writing changed the face of nursing as it came onto the scene
before formal attention was being given to nursing theory as the foundation for the
discipline of nursing and before much attention had been directed toward a philosophical
foundation for nursing as a distinct discipline (Watson, 2008).
Since then, many nurse caring theories have been developed. Madeleine
Leininger, Katie Erikson, Anne Boykin, and Savina Schoenhofer are a few examples of
nurse theorists who have developed widely referenced caring theories. It was not until
1988 that The Cumulative Index to Nursing and Allied Health (CINAHL) identified
caring as a separate keyword in the database. CINAHL then determined that caring was a
nursing concept within the discipline (Brilowski & Wendler, 2005). In preparation for
this project, the search term caring was submitted in CINAHL, yielding 27,103 sources
in the result list.
Because of the many technological advances in the recent past, nurses can utilize
technology to monitor their patients at a distance. Also, with the addition of the
electronic health record, it could appear to patients and their families that nurses pay
more attention to machines rather than to patients. Hence, there is a controversy over
high-tech versus high-touch nursing care (Chitty, 2005). The argument has been made
that technology and the attention on treating disorders in health care has been at the
expense of caring, and that this is detrimental to nursing as a caring profession
(Leininger, 1977/2012; Watson, 2008). The current state of caring in the U.S. is patient-
centered, consumer driven, and technology-based. The professional care-giver in our
society must be able to coordinate these factors, in addition to demonstrating sensitivity
in the acts of caring to be effective in todays health care environment.

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Perceived Caring
Patient perceived care can be defined as patient assessments of nursing care (Teng
et al., 2009). In 1994, Parasuraman, Zeithaml, and Berry developed a typology of service
quality, which has been widely applied to nursing. They defined service quality as
reliability, responsiveness, assurance, empathy, and tangibles (as cited in Teng et al.,
2009, p. 302). Reliability is defined as the ability to dependably and correctly provide the
promised service. Responsiveness is willingness to assist customers and provide
promptness in fulfilling the needs of the customer. Assurance is described as the
knowledge, courtesy, and ability of the employee to inspire trust and confidence (Teng et
al., 2009). Empathy indicates the care and individualized attention that the organization
provides its customers (Teng et al., 2009, p. 303); and tangibles are the appearance of
the facilities, equipment, and personnel. These parameters can be applied to the
evaluation of nursing care from a patients perspective (Teng et al., 2009).
A qualitative study by Larabee and Bolden (2001) utilized the application of
Parasuramans typology of service quality and identified five themes regarding the
quality of patient perceived care:
Provision of needs
Being pleasant
Personal caring
Competency
Provision of prompt care (Larabee & Bolden, 2001)
Patient perception of care quality is a subjective, dynamic quality of the patients
discernment of the level to which the expectations of health care have been achieved.

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Since 1988, patient perception of care has been considered a health care outcome
indicator and recent models of quality have included patient perception as a key
component (Larabee & Bolden, 2001).
In determining how do deliver care, the caregiver must determine the recipients
expectations (Corbin, 2007). How does a nurse make patients feel cared about as well
as care for? How is the element of caring about another human being communicated
(Corbin, 2007)? According to Mayeroff (1971), caring requires knowing.
We sometimes speak as if caring did not require knowledge, as if caring for
someone, for example, were simply a matter of good intentions or warm regard.
But in order to care I must understand the others needs and I must be able to
respond properly to them, and clearly good intentions do not guarantee this
(Mayeroff, 1971, p. 9)
Caring must be put into action through behaviors that relate to the particular needs of the
person being cared for. These needs are only understood by getting to know the person
behind the patient (Corbin, 2007).
Patient Satisfaction
Patient satisfaction with nursing care has been described as the level of equality
between a patients expectations of excellent nursing care and the perception of the actual
care received (Liu & Wang, 2007). The identification of factors that influence healthcare
consumers to see their care as quality care and be happy with the care received is a
significant approach for drawing patients to a certain hospital, thereby increasing profits
(Otani & Kurz, 2004; Liu & Wang, 2007). Even more importantly, patient satisfaction is
viewed as a predictor of subsequent health related behavior (Mahon, 1996).

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Patient satisfaction may be considered to be one of the desired outcomes of care,
even an element in health status itself. An expression of satisfaction or
dissatisfaction is also the patients judgment on the quality of care in all its
aspects, but particularly as concerns the interpersonal process. By questioning
patients, one can obtain information about overall satisfaction and also about
satisfaction with specific attributes of the interpersonal relationship, specific
components of technical care, and outcomes of care (Donabedian, 1988/1997, p.
1746)
Donabedian continues on to say that behaviors which indirectly suggest
dissatisfaction are termination of care before release, noncompliance of treatment
prescriptions, ending affiliation with a health plan, and seeking treatment outside the plan
(Donabedian, 1988/1997). These effects could deter needed health care interventions and
ultimately hinder health outcomes. Satisfied patients are dependable and may be
expected to return and provide referrals, leading to expanded profits for the institution
and very likely, better clinical outcomes (Greeneich, 1993).
Evidence suggests that caring behaviors greatly influence patient satisfaction
(Burtson & Stichler, 2010; Dingman et al., 1999; Henderson et al., 2007; Vahey, Aiken,
Sloane, Clarke, & Vargas, 2004) and that nursing care is important in improving overall
patient satisfaction (Abramowitz, Cote`, & Berry, 1987; Larabee & Bolden, 2001; Otani
& Kurz, 2004; Wagner & Bear, 2009). Patients reporting that their expectations have
been fulfilled through experiencing care, is the most significant predictor of overall
patient satisfaction (Bjertnaes, Sjetne, & Iversen, 2011).

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In 1957, the first instrument to measure patient satisfaction was developed by
Abdellah and Levine (Wagner & Bear, 2009). Since that time, many tools have been
designed to measure patient satisfaction, as the understanding of the factors that influence
healthcare consumers is crucial for nurses, other health care workers, and administrators.
Since 1986, the Joint Commission on Accreditation of Health Care Organizations has
required measurement of patient outcomes and demonstration of continuous quality
improvement (Mahon, 1996).
In 1988, the Office of Technology and Assessment identified patient satisfaction
as a significant consideration in the provision of health care services and defined patient
satisfaction as an important aspect in the measurement of health outcomes (Mahon,
1996). On March 23, 2010, President Obama signed the Patient Protection and
Affordable Care Act into law (U.S. Department of Health and Human Services, 2014).
According to the law, full Medicare and Medicaid reimbursement is withheld from
institutions that have not followed through with surveying patients with the Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (CMS,
2013).
Patient satisfaction scores are determined by the HCAHPS survey, which is an instrument
for collecting data pertaining to patients satisfaction of their hospital experience (CMS, 2013).
HCAHPS is the first standardized national survey of patients perceptions of hospital care. It is
publicly reported; therefore consumers can compare hospital scores online (CMS, 2013). The
goals of the HCAHPS initiative are:
To produce and publish data of patients perspectives of hospital care that
provides meaningful comparisons between institutions

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To establish incentives for hospitals to improve care quality
To augment accountability of hospitals and health care organizations by
increasing the transparency of the quality of care provided in return for public
funds (CMS, 2013).
It is imperative that hospitals receive the highest patient satisfaction scores possible for financial
reimbursement and for public perception of the quality of care that the hospital delivers.
Hospital administrations are pushing for excellent HCAHPs scores and will continue to do so.
In our current health care environment, patient satisfaction is a very important
factor to measure, collect the data upon, and report. Because of governmental
regulations, competition between healthcare organizations and the connection with
caring, perceived quality of care, and outcomes, this subject is important for nurses and
other health care providers to grasp. In the balance of this critical literature review, the
focus will be on caring theory, application of theory to topics presented, synthesis of
current literature related to these topics, recommendations, and interventions to improve
outcomes.
Part II Theory, Analysis, and Application
Caring Theory
Nursing theory emerged over a period of years when the discipline of nursing was
becoming autonomous, separating from the medical model and developing its distinct identity.
Nurses began obtaining higher education degrees with a new awareness of nursing as a
profession and an academic discipline in its own right (Tomey & Alligood, 2006). Research was
recognized to be a path to new nursing knowledge. However, it was soon realized that research

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alone produced only information, lacking a framework. Nursing science was produced as a
combination of research and theory (Tomey & Alligood, 2006).
Caring theory gave nurses the language of caring that they needed to communicate the
substance of their practice. Caring in the health care environment was described as a way of
being (ontology) as opposed to just knowing what to do (epistemology) (Dyess, Boykin, &
Bulfin, 2013). Caring theorists began developing their theories in the 1980s, being influenced by
existential philosophy. The questions that guided the advancement of caring theories are: What
do nurses do? (care for patients) and How do nurses do what they do? (by caring for patients)
(Meleis, 2012). Caring theories clarify the act of caring in interactive situations based on values
that honor and respect humanity: spirituality, worth as an individual, and hope.
According to Meleis (2012) caring theory has added knowledge to nursing, which
includes:
The basic act of caring is central in ways that unite patients and nurses
Caring is foundational to nursing as a discipline
When nurses give care, relationships are transformed because caring for another
human deeply affects the caregiver
Meanings of health and illness are lived individually and adapted in community
Choices, values, and interpretations, are privileges of being human. Nurses and
patients who understand each others viewpoints are part of the act of caring
Nurse-patient encounters involve communication as to expectations and how
the relationship will progress
Even if the nurse and patient have a historical background, it is the current
moment that shapes their present relationship

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Madeleine Leininger. Madeleine Leininger practiced as a clinical specialist in child
psychiatric nursing in the 1950s. She realized that culture differences between patients and
nurses affected health outcomes. This discovery led her to study cultural differences in caring
and later to pursue cultural anthropology as a complement to her nursing knowledge and practice
(Reynolds & Leininger, 1993). Leininger believed that care and culture were inextricably
linked together and could not be separated in nursing care actions and decisions (as cited in
Reynolds & Leininger, 1993, p. 3). With a background in nursing and anthropology, she was
able to mesh the two disciplines each contributing to the other. She observed that medical
practice was oriented toward treating a disease, while nursing was focused on caring
interventions that influence the health of individuals and communities (Reynolds & Leininger,
1993).
Leininger developed the Culture Care Diversity and Universality Theory, through which
she became known as the foremost supporter of the idea that nursing and caring were one and the
same. She made statements such as caring is the central, unique, dominant, and unifying focus
of nursing and caring is nursing (as cited in Reynolds & Leininger, 1993, p. 7). She
developed the sunrise model, which is a theoretical model that portrays transcultural dimensions
for nursing care utilizing the nursing process (Reynolds & Leininger, 1993). Leininger
developed other models, including a taxonomy model used to help nurses understand categories
of caring phenomenon (Reynolds & Leininger, 1993). Leininger states,
Nursing is the learned humanistic and scientific art of caring for or with people who
have varying care needs based upon diverse cultural life styles and human environments.
Indeed, nursing is the profession which should be deeply concerned about and involved
with caring behaviors, caring life styles, caring processes, and caring consequences. In

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fact, the linguistic derivation of nursing pertains to nurturance, or caring and growth
processes. No construct could be more central, more essential and more promising for
teaching, research, and practice, than ideas related to care and caring for the nursing
profession. (Leininger, 1977/2012, p. 1389)
Leininger prefers qualitative methods in studying cultural characteristics. Her ethnonursing
method is based on emic views, which are beliefs of the person experiencing the phenomena, as
opposed to etic views, which are beliefs and practices of the researcher (Tomey & Alligood,
2006). Leininger has advanced the profession of nursing and contributed immensely to the
academic and theoretical foundation of the discipline.
Jean Watson. Jean Watson earned a masters degree in psychiatric nursing and a
doctorate in educational psychology at the University of Colorado (Tomey & Alligood, 2006).
She joined the School of Nursing faculty of the University of Colorado where she served as a
faculty member (Tomey & Alligood, 2006). Watsons first major work was published in 1979,
Nursing: The Philosophy and Science of Caring, which began as class notes for a course she was
developing. The purpose of the book was to contribute new meaning and dignity to the
discipline of nursing and nursing care, which seemed to be under achieving in its potential,
lacking in identity and largely defined by medicines theoretical framework and biomedical
models (Tomey & Alligood, 2006). This book defined early stages of her theory development,
which she explained in her second book, Nursing: Human Science and Human Care (McCance,
McKenna, & Boore, 1999).
Watsons original work provided the basis for her Theory of Human Caring: Ten
Carative Factors. She describes caring as being a science that incorporates human processes,
phenomena, and experiences. It comprises the arts and humanities and is based in an existential

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study between people and their world. Her theory is made up of carative factors that promote
health and healing and contribute to humanity. These factors were designated as the foundation
of caring in nursing, without which nurses may still be functioning as technicians within the
prevailing model of medicine (Watson, 2008). Her theory is based on humanism, with its origins
in metaphysics (McCance et al., 1999).
Watsons writings reflect the evolution of her theory of caring and have been geared
toward educating nursing students and providing them with an ontological, ethical, and
epistemological basis for their practice and research (Tomey & Alligood, 2006). The goal of
nursing within Watsons theory revolves around helping people gain a higher degree of harmony
within the mind, body, and soul. She believes that caring transactions are the avenue through
which this is achieved (McCance et al., 1999).
Theory Applied
Twenty-three articles have been selected for the core investigative set for this critical
literature review relating nurse caring and perceived caring to patient satisfaction. Five studies
out of the 23 designated a nursing theory as the foundation for the research; four utilized
Watsons Caring Theory of Transpersonal Nursing (1979); and one elected Boykin and
Schoenhofers Nursing as Caring theory (1990).
For the application of a theoretical basis for this critical literature review, Jean Watsons
theory of transpersonal caring will be highlighted. Watson developed the caring theory of
transpersonal nursing in which she proposed that the development of a helping-trust relationship
between the nurse and patient is imperative for effective nursing. A trusting relationship
promotes and accepts the expression of feelings involving honesty, empathy, warmth, and
effective communication (Tomey, & Alligood, 2006). She states that by responding to others as

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unique individuals, the caring person recognizes the uniqueness of the other through the
perception of their feelings (Tomey & Alligood, 2006).
According to a very large study of American patients, the highest priority in receiving
care was to be treated with courtesy and respect (Otani, Herrmann, & Kurz, 2011). A study in
five European countries found that individualized care is a predictor of patient satisfaction
(Suhonen et al., 2011). A Colorado study concluded that the highest priorities for patients were
listening to the patient and being sensitive to the patient, and that nurse behaviors demonstrating
patience and attention to individual needs in an interpersonal environment were most highly
valued (Merrill, Hayes, Clukey, & Curtis, 2012). Watson proposed that caring is moral rather
than task oriented and is made up of transpersonal caring moments as an experience of a caring
relationship between nurse and patient (Alligood & Tomey, 2006). Most of the recent studies on
caring align with Watsons ideas of transpersonal nurse caring.
Process of Literature Selection
Caring was searched in the Cumulative Index to Nursing and Allied Health (CINAHL)
resulting in 27,103 sources in the result list. Combining caring with the terms or the phrases
patient satisfaction: perceived care; outcomes; patient perceived care; and patient safety reduced
the number. Since the purpose of the review is to focus on current literature, the dates of January
2008 to June 2014 were set as parameters. Further limiting the articles to those written in
English, published in an academic journal, and identified by CINAHL as peer reviewed yielded a
practical amount of studies on which to focus. Characteristics for exclusion were as follows:
Articles that consisted of personal narratives and stories that lacked data analysis
Articles having specific disease processes or conditions in the title
Articles having to do with nursing education

22
Editorial pieces, letters to the editor, book reviews, and other types of non-research
oriented articles
There were 23 total articles relating nurse caring or perceived caring to patient satisfaction
published from 2008 to 2014, that met the criteria as explained. All of these articles were read
and the information was categorized on a spreadsheet listing author; title; study type; journal;
theoretical framework; hypothesis; sample size; analysis; and conclusions.
Measurement
Surveys. In measuring perceived caring and patient satisfaction, surveys are the most
commonly used methods utilized in quantitative research studies. They can provide information
about a certain point in time (a cross-sectional study) or over a period of time (a longitudinal
study). The formation of questionnaires is extremely complex, as they need to developed and
tested for appropriateness in collecting the required data. The wording, construction, format,
layout, and method of administration of questionnaires are capable of producing bias (Hamer &
Collinson, 2005). Most surveys are a form of Lickert scale, which is an ordinal scale that utilizes
subjective data to assign a rating (Plichta & Kelvin, 2013).
An advantage of conducting research based on surveys is that a great deal of information
can be obtained from a large population fairly inexpensively, and the research tends to be
accurate, utilizing a relatively small number of participants (LoBiondo-Wood & Haber, 2006).
A weakness of surveys is that the information tends to be superficial. Also, conducting a survey
requires a great deal of expertise in various research areas, including sampling techniques,
questionnaire construction, interviewing, and data analysis (LoBiondo-Wood & Haber, 2006).
Sampling and design. In surveying a population, care and attention must be paid to the
sampling, which may be a simple random sample or convenience sample (Hamer & Collinson,

23
2005). In a random sample, each individual in the population has an equal probability of being
selected. In a convenience sample, the subjects are chosen based on their availability, which is
not as desirable (Creswell, 2009).
Wolfs (2012) conducted a systematic review of the effect of nurse caring of adults in a
hospital setting. The purpose of the review was to find outcome research in which caring
protocols, interventions, or standards were related to patient satisfaction. He found that the
studies represented a variation of designs but none were randomized controlled trials. There
were no precise descriptions of the intervention protocols. Therefore, no comparative
effectiveness statements could be made. The samples were predominately convenience in nature
(Wolf, 2012). He stated that there is a need to create caring interventions that can be tested and
replicated so researchers can document the effectiveness of nurse caring in the context of
outcomes. He believes that patient satisfaction is not a health outcome for an illness, nor is a
caring intervention a treatment modality (Wolf, 2012).
Wolfs findings suggest that caring research has not been performed rigorously, although,
many studies have been done with the intent to measure caring and the effects it has on patient
satisfaction and health outcomes. These studies have indicated that there are measurable results
of nurse caring, such as increased patient satisfaction and medical compliance, and decreased
injurious falls, nosocomial infections, pain, and anxiety. It is the belief of this author that the
emotive, non-tangible nature of a caring attitude, respect, and the communication of value to
other human beings could be a factor in the illusiveness of caring measurement.
Larabee and Bolden (2001) propose that nurse perceived caring and patient satisfaction
be measured qualitatively. They contend that patients and nurses differ greatly on defining
nursing care quality and ranking importance of quality factors. Also, they argue that validity of a

24
patient satisfaction survey is doubtful when it is not based on information from a patient
(Larabee & Bolden, 2001). Further, researchers need to use patient satisfaction instruments that
include measurement of patient-defined aspects of quality nursing care (Larabee & Bolden,
2001).
Often the distinction between qualitative and quantitative research is described in terms
of using words and open-ended questions (qualitative) rather than numbers or closed-ended
questions (quantitative) (Creswell, 2009). Newman and Benz (1998) state that the qualitative
and quantitative approaches should not be viewed as polar opposites but as different ends on a
continuum (as cited in Creswell, 2009). Creswell recommends that research design methods be
looked at based on philosophical assumptions. Until the late 19
th
century up until the mid 20
th

century, quantitative methodology was the gold standard in research.
In the 1960s, interest in qualitative research increased, followed by the development of
mixed methods (Creswell, 2009). Qualitative research is a way to explore and understand the
meaning individuals or groups give to a social or human problem with the data typically being
collected in the participants setting and analyzed by looking at themes. Quantitative research
tests measurable hypotheses by examining the relationship among variables. The variables can
be measured and the data analyzed using statistical procedures (Creswell, 2009). In the grouping
of 23 research studies on nurse caring, perceived caring and patient satisfaction for this critical
literature review, 18 of the studies were quantitative; two were qualitative in nature; and three
utilized mixed methods (see Table 1 in the Appendix).
Instrumentation. Out of the quantitative studies, five of them utilized the HCAHPS
survey instrument and three used the Wolf Caring Behaviors Inventory. Two of the 23 core
studies used the Patient Satisfaction Scale (PSS) developed by Kim (1991), which examines

25
patients satisfaction with nursing care (Palese et al., 2011; Suhonen et al., 2012). It was
designed to gather patient views about nursing care, comparing patient satisfaction with care
received (Palese et al., 2011). The PSS is an 11-item instrument based on patients care needs
and evaluation criteria.
One Swiss study implemented the Basel Extent of Rationing of Nursing Care (BERNCA)
survey to determine how rationing nursing care affected patient-reported outcomes. Nursing care
rationing is defined as the withholding of or not following through on all needed nursing
interventions due to lack of time, staffing, or adequate skill mix (Schubert, Clarke, Glass,
Schaffert-Witvliet, & De Geest, 2009). The Service Quality Scale developed by Parasuraman,
Zeithaml, and Berry (1994) was utilized in a Taiwanese study to measure patient perceived care
quality (Teng et al., 2009). A survey conducted in a tertiary care Indiana hospital implemented
the National Research Corporation Picker survey to examine an intervention developed to
decrease patient uncertainty regarding nurse availability in response to immediate needs
(Woodard, 2009). The Picker Patient Experience Questionnaire (PPEQ-15) demonstrated a high
correlation of selected items and a high transcultural validity (Al-Abri & Al-Balushi, 2014).
One study implemented the Quality from the Patients Perspective (QPP) questionnaire
which evaluates patients perceptions of care quality categorized in four dimensions: medical-
technical competence; physical-technical conditions; identity-oriented approach; and socio-
cultural atmosphere (Frojd et al., 2011). The QPP has demonstrated acceptable reliability (Frojd,
et al., 2011).
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is
a survey which is sent to patients within 48 hours after discharge from the hospital. It was
developed by the Agency for Healthcare Research and Quality (AHRQ), part of the Department

26
of Health and Human Services (Otani et al., 2011). The Harvard Medical School, the RAND
Corporation, and the American Institutes for Research have rigorously and scientifically tested
HCAHPS for validity, reliability, credibility, and usefulness for research (Otani et al., 2011).
The utilization of HCAHPS is an initiative by the government to standardize and publicly report
patient satisfaction with hospitals, thereby enhancing accountability of health care organizations
and creating incentives for hospitals to improve their quality of care (CMS, 2013).
The possible answers for the HCAHPS survey are never, sometimes, usually, and always
(two of the questions relating to nursing are yes/no). There are 32 questions in the survey, with
11 of the questions having to do with demographics: three questions directly relating to care
from physicians; two questions relating to hospital environment; and two questions pertaining to
the hospital in general (CMS, 2013). The remaining 14 questions are directly related to nursing
care. They pertain to nurses:
Treating patients with respect
Listening carefully to patients
Explaining things to patients in a way they can understand
Giving prompt help after call button activation
Helping patients to the bathroom in a timely manner
Implementing pain control measures
Giving medication instructions regarding the purpose of the medication and possible side
effects
Finding out if the patient would need help after discharge from the hospital
Giving thorough discharge instructions to patients as to what symptoms or health
problems to look for after going home

27
Including family members/caregivers in discharge planning (CMS, 2013).
The Caring Behaviors Inventory, developed by Zane Wolf, is based on a conceptual
definition of caring by Jean Watson (1988), and describes nurse caring as an interactive process
that occurs during shared openness between nurses and patients (as cited in Palese et al., 2011).
The instrument includes four factors:
Nurses dealing with patients needs and insecurities
Nurses demonstrating skill and knowledge
Nurses demonstrating respect and showing interest
Nurses helping patients through positive connectedness (Palese et al., 2011).
The original Wolf Caring Behaviors Inventory (1981) was a 75-item instrument, and was
reduced to a 42-item tool, and then shortened to a 24-item version (Merrill et al., 2012). All
versions have been tested as to their completeness, reliability, and validity (Coulombe, Yeakel,
Maljanian, & Bohannon, 2002). The Caring Behaviors Inventory for Elders was implemented in
evaluating community-dwelling elders perception of staff caring (Wolf & Goldberg, 2011).
The researchers of the remaining quantitative studies developed their own measurement
instruments in the form of various Lickert scales. Patient surveys were designed to measure
satisfaction in meeting the particular characteristics of their studies (DeJesus, Howell, Williams,
Hathaway, & Vickers, 2014; Liu et al., 2010; Maxson, Derby, Wrobleski, & Foss, 2012). The
qualitative studies used ethnographic qualitative methods (Coughlin, 2012); observation of
caring behaviors (Liu et al., 2010); and the nurse-patient bonding instrument (Tojero, 2012). The
mixed method studies implemented Lickert scale surveys in combination with interviews and
observation (DeJesus et al., 2014; Liu et al., 2010; Merrill et al., 2012).


28
Summary
Part II of this critical literature review discusses a few caring theories with Jean Watsons
Theory of Transpersonal Nurse Caring being the most applicable to the present study of nurse
caring and perceived caring related to patient satisfaction. Sampling, research methods,
instrumentation, and specific attributes of the research studies of interest related to the topics,
were examine as well. Research findings and applications will be presented in Part III.
Part III - Research Findings and Applications
Overview and Synthesis of Findings
Demographics. The core articles for this critical literature review exhibit an
international scope in research application. A total of fourteen different countries are represented
in eleven studies out of the set of 23 (See Table 1). The studies performed in foreign countries
explored the:
Relationship between individualized nursing care and patient satisfaction (Suhonen et al.,
2011)
Identification of the most important caring behaviors as perceived by patients (Suliman,
Welmann, Omer, & Thomas, 2009).
Relationship of nurse professional commitment to patient safety and care quality (Teng et
al., 2009)
Association of higher levels of patient safety culture and rationing of nursing care with
frequency of adverse events (Ausserhofer et al., 2013)
Identification of areas in need of quality improvement and differences related gender,
age, and type of admission (Frojd, et al., 2011)

29
Identification of incidents and nurses behaviors that influence patients participation in
care (Larsson, Sahlsten, Segesten, & Plos, 2011)
Correlation between caring as perceived by patients and patient satisfaction and
differences between the six European countries (Palese et al., 2011)
Description of levels of nursing care rationing and identification of levels of rationing
related to patient safety and satisfaction (Schubert et al., 2008)
Relationship of proactive nursing care to patient safety (falls), patient experience, and
staff satisfaction (Ciccu-Moore et al., 2014)
Direct and indirect relationships between nurse characteristics, patient characteristics, and
patient satisfaction (Tojero, 2012)
Relationship between nurse staffing, patient outcomes, and patient satisfaction (Zhu et
al., 2012)
All of the European, Asian, and Middle Eastern studies were performed on either medical
or surgical inpatients, except the Taiwanese study, which took into account all inpatient units in
the hospitals except pediatric, intensive care (ICU), and psychiatric. Private patients (self pay)
were excluded in the Taiwanese study as well (Teng et al., 2009). The study performed in the
Philippines included medical, surgical, obstetrical, and ICU patients (Tojero, 2012).
Research studies based in the United States occurred in different areas of the country:
Nebraska (Snide & Nailon, 2013); a Midwestern state (DeJesus et al., 2014; Maxson et al., 2012;
Woodard, 2009); New York, California, and Florida (Tzeng, Hu, Yin, & Johnson, 2011);
Pennsylvania (Wolf & Goldberg, 2011); a Northeastern State (Coughlin, 2012; Radwin, Cabral,
& Wilkes, 2009); Colorado (Merrill et al., 2012); Indiana, Michigan, Alabama, and Washington

30
D.C. (Liu et al., 2010); and 32 hospitals in the Midwest, Southeast, and Northeast (Otani et al.,
2011), were represented in the research articles.
The U.S. studies showed a variety in areas of nursing care as well. Some studies utilized
HCAHPS to determine certain dimensions of patient reported care quality. These studies
typically had very large samples and data were gathered from inpatients who had been in a
variety of care settings (Otani et al., 2011; Tzeng et al., 2011). Variations in care practice areas
include emergency department (Liu et al, 2010); elder outpatient care (Wolf & Goldberg, 2011);
hematology/oncology inpatient (Radwin et al., 2009); rehabilitation nursing (Seeber, 2012);
mental health outpatient (DeJesus, et al., 2014); ICU trauma nursing (Merrill et al., 2012);
surgical cardiac (Coughlin, 2012); and medical/surgical inpatient (Maxson et al., 2012; Snide &
Nailon, 2013; Woodard, 2009). These studies researched the:
Perceptions of care of nurses and patients during main events of hospitalization
(Coughlin, 2012)
Effectiveness of care managers in promoting patient self-care and improvement in
depressed individuals (DeJesus, et al., 2014)
Effect of caring behaviors of emergency department nurses and other personnel that lead
to patient loyalty (Liu et al., 2010)
Relationship of bedside report of nurses to patient satisfaction with plan of care and
perception of teamwork (Maxson et al., 2012)
Difference gender and ethnicity makes in relationship to the interpretation of nurse caring
behaviors (Merrill et al., 2012)
Relationship between staff care, nursing care, physician care, and environment with
perception of overall hospital care (Otani et al., 2011)

31
Correlations between patient-centered nursing care, patient attributes, and health
outcomes (Radwin et al., 2009)
Effect of the Kind Peace of Mind hourly rounding model on patient satisfaction (Seeber,
2012)
Relationship of nursing staff creative care implementation to overall patient satisfaction
(Snide & Nailon, 2013)
Correlations between HCAHPS scores related to overall hospital satisfaction and hospital
fall rates according to age groups (Tzeng et al., 2011)
Perceived care in relation to elderly enrolled in an outpatient day program (Wolf &
Goldberg, 2011)
Difference between fall rates, patient satisfaction, and frequency of call light use among
patients who received standard care related to patients who received hourly rounding
(Woodard, 2009)
Some researchers measured data in their studies pertaining to demographic aspects of
patient populations in relation to perceived caring and satisfaction. These factors included age,
ethnicity, gender, and education. In a Saudi Arabian study of 393 patients, it was found that men
and women viewed the importance of caring behaviors differently. Women ranked five caring
behaviors as more important than did men (Suliman et al., 2009).
In a study done in Sweden, older patients scored higher in 18 out of 23 items pertaining
to patient satisfaction than did younger patients; womens reports of care quality perception in
the area of having the chance to make decisions related to their care was higher than mens; and
men gave higher scores than women in questions concerning food, comfort of beds, and the
overall mood on the unit (Frojd et al., 2011). In the same study, patients who had planned

32
admissions expressed higher satisfaction in care quality in the manner in which treatments and
examinations took place; useful information provided; relief for pain; respect of doctors towards
them; and opportunity to speak with doctors in private, than patients who had been admitted to
the hospital through the emergency department (Frojd et al., 2011).
Radwin et al. (2009) did not find a difference between male and female cancer patients
conceptions of quality care, or a difference related to age, race, ethnicity or educational level. In
a Pennsylvania study of a group of diverse elderly patients in an outpatient program, no
difference was found between perceptions of care by distinction of gender or ethnicity (Wolf &
Goldberg, 2011).
Safety. When individuals come to a hospital to receive surgery, testing, and/or treatment,
they expect that they will be protected and unharmed while they are there. A very large Swiss
study related the organizational variables of nurse practice environment quality; implicit nurse
care rationing; and levels of skill mix with the patient outcomes of medication errors, urinary
tract infection, falls, pressure ulcers, sepsis, pneumonia, and patient satisfaction. It was found
that higher levels of implicit nursing care rationing resulted in a substantial decrease in the odds
of patient perceived quality of care and a significant increase in the projected likelihood of
medication errors, sepsis, and pneumonia (Ausserhofer et al., 2013).
Tzeng and associates (2011) studied HCAHPS results of 478 U.S. hospitals from three
states and found that patient satisfaction and injurious fall rates were negatively correlated. It is
suggested from this study that consistently, across hospitals and in all three states, the higher the
patient satisfaction scores with the cleanliness and quietness of the environment and nursing staff
responsiveness, lower fall rates were reported (Tzeng et al., 2011). In Florida, the higher patient
perceived quality care in relation to all factors measured in the study (quietness and cleanliness

33
of environment; communication with nurses; responsiveness of staff; and medication teaching),
the lower were injurious fall rates (Tzeng et al., 2011).
A Swiss study demonstrated that the factors of nosocomial infections, pressure ulcers,
and patient satisfaction were sensitive to low levels of nurse care rationing with negative effects.
In this study, the fall rate was not affected; neither were nurse reported medication errors or
critical incidents (Schubert et al., 2009). In an Indiana hospital, a clinical nurse specialist
implemented a program of charge nurse rounding every two hours with the intention of
decreasing patient uncertainty in a hospital environment. The results indicated a significant
increase in patient satisfaction, decrease in call-light use, and a decrease in patient falls
(Woodard, 2009).
Research in Scotland revealed that the initiation of a care and comfort rounding program
over a period of one year improved patient satisfaction ratings and decreased patient fall rates
(Ciccu-Moore et al., 2014). A study in Taiwan showed that professional commitment on the part
of nurses improved patient safety by decreasing falls and medication errors, and also improved
documentation and responsiveness. Patient perceived care quality was also enhanced (Teng et
al., 2009). In China, it was found that higher nurse to patient ratios had significant positive
effects on the outcomes of nurse-reported quality of care, patient-reported quality of care,
patients confidence and ability for self-care upon discharge, and adverse events during
hospitalization (Zhu et al., 2012).
Health outcomes. A mixed study in the Midwestern United States found that
implementing a care manager program in outpatient care of depressed patients improved
perceived care satisfaction, increased their understanding of depression, and promoted
depression self-management abilities. These outcomes increased the probability of treatment

34
response and remission of depression (DeJesus et al., 2014). The skill of motivating patients to
participate in their own care is an integral part of nursing practice. Self-care participation
decreases anxiety and stress, yields better treatment results, and increases medical compliance
(Larsson et al., 2011). A qualitative Swedish study demonstrated that positive incidents of
nursing care stimulated patient participation and increased patient satisfaction, while negative
occurrences with care inhibited patient participation and decreased patient satisfaction. In this
study, it was found that nurses communicating information that is consistent and relevant to
patients care and valuing their patients through meaningful interactions are the most significant
interventions for promoting patient participation (Larsson et al., 2011).
In a study of a rehabilitation unit, a model of hourly rounding, increased touches, and a
program to increase socialization and decrease boredom was implemented with resultant
improved patient satisfaction, lower call-light usage, and increased pain control (Seeber, 2012).
According to Wagner and Bear (2009), patient satisfaction influences whether patients utilize
health services at a later date, affecting follow-up care and impacting compliance to prescriptive
treatments and recommendations. This very likely would have consequences as to the health
status and severity of the condition (Wagner & Bear, 2009). A New England study indicated that
individualized nursing interventions were positively related to the desired health outcomes of a
sense of well-being, positive attitude, and authentic self-representation (Radwin et al., 2009).
Discussion
In this critical literature review regarding nurse caring and patient perceived care related
to patient satisfaction, some factors have been analyzed. This continuum of logical correlations
are based on the previous discussion:
Nurses provide care

35
Nurses care by demonstrating certain behaviors and attitudes called caritative factors
Patients perceive the care and have a certain level of satisfaction with the care
Patient satisfaction can be measured
Higher satisfaction promotes results such as financial gain for institutions and increased
safety and positive health outcomes for patients
It is the duty of those in the nursing profession to continue measuring patient satisfaction
and applying the data to nursing practice, thereby promoting health
Otani and associates analyzed data from 31,471 patients HCAHPS results. The results
revealed that nursing care is the most influential factor on overall rating of patient satisfaction
and intention to recommend (Otani et al., 2011). In addition, this study demonstrated that the
highest priority for patients is to be respected and treated with courtesy by nurses and physicians.
It was reported that patients want information regarding their health concerns including their
medications and treatments, and that they desire to be listened to. Patients expect that their
surroundings to be clean and quiet and that their pain be controlled and comfort increased (Otani
et al., 2011). The result of this massive study is notably interesting since these issues are the
very ones that Florence Nightingale discussed in her Notes on Nursing in the 1850s (Tomey &.
Alligood, 2006).
Recommendations
One need for additional research related to the topics of this critical literature review is a
continued search for an operational definition of caring. As of 1977, Madeleine Leininger had
not found a universal definition of caring (Leininger, 1977/2012), and other caring theorists have
concurred (Meleis, 2012). In searching for such a definition, it is the belief of this author that
additional knowledge will be discovered and the discipline, profession, and practice of nursing

36
will be promoted. Besides defining the concept of caring, practicing nurses need to be able to
understand the significance of the quality of care. The grasping of this concept and construct has
the potential to further refine nursing as a discipline (Burhans & Alligood, 2010), thereby adding
to the nursing paradigm. Many surveys have been designed to measure patient satisfaction and
more reliable and valid tools need to be further developed through additional research and
understanding of the significance of patient satisfaction.
Since nurses perception of care given and patients perception of care received are often
very different (Coughlin, 2012; Palese et al., 2011), it would be prudent for nursing researchers
to continue searching for the factors that conceptualize patients perceptions of care in all
settings, including various cultural contexts. Even though there was a representation of many
countries and ethnicities in this study, there is still much to learn about different cultural
perceptions of nursing care quality. Other recommendations for further research would be
To explore interventions to improve emotional support and health education to
patients (Wagner & Bear, 2009)
To identify organizational factors related to patient outcomes to foster incentives
for safety improvements (Ausserhofer et al., 2013)
To study ethnic differences utilizing large sample sizes (Merrill et al., 2012)
Interventions that Could Improve Outcomes
Education of patients. Several of the studies identified a need for patients to receive
relative, consistent information regarding their health (Coughlin, 2012; DeJesus et al., 2014;
Frojd et al., 2011; Larsson et al., 2011; Otani et al., 2011). It is the belief of this author that
nurses need to have more information on how to educate patients and institutions need to foster
patient education to a greater degree. Nurses have a wealth of knowledge to share. Encouraging

37
questions from patients, anticipating needs related to specific conditions, and utilizing certain
teaching methods are skills that can be encouraged to help nurses educate patients, thereby
improving patient satisfaction.
Education of nursing students. Education planning for promoting caring behaviors and
nursing students relationship with patients is of utmost importance (Palese et al., 2011). A study
at the University of Wisconsin-Madison found that compassion may be taught through
meditative activities (Weng, Fox, Shackman, Stoldola, Caldwell, & Olson et al, 2013). Increased
altruistic behaviors after compassion training were associated with altered activation in brain
areas related to social, cognition, and emotion regulation. Results were validated with a
functional brain MRI. The compassion training utilized guided audio instructions with practice
of feeling compassion for different targets (a loved one, self, a stranger, and a difficult person).
The findings supported the possibility that compassion and altruism can be viewed as trainable
skills rather than stable traits (Weng et al., 2013). Reflective education can help an individual
develop self-awareness, motivation, empathy, purpose, and social responsibility, teaching
students to identify their intentions and motivations (Horton-Deutsch & Sherwood, 2008).
Education of practicing nurses. In a study of six European countries in which the
sample was 1,565 surgical patients, it was reported that the most frequent nursing behavior
exhibited was knowledge and skills. However, this feature of the Caring Behaviors Inventory
had no effect on patient satisfaction (Palese et al., 2011). Positive connectedness was the
factor that most served patients requests regarding satisfaction in this study. This factor entails
teaching, spending time with and including the patient in planning care, and suggests
understanding and relationship (Palese et al., 2011).

38
This data identifies a disconnect between nursing knowledge and nursing practice. It is
necessary for nurses to be educated on the importance of patient satisfaction, not only for
financial justification, but for ethical reasons, as well. It is the observation and experience of this
author that most nurses have no idea of the connection of patient satisfaction with positive health
outcomes. Administrators continually talk about financial responsibilities regarding patient
satisfaction, while ignoring the health ramifications.
Recommendations for administrators. Nurses need to have support in their efforts to
interact with patients appropriately so they can be effective in delivering care (Palese et al.,
2011). Ways to enhance professional commitment of nurses need to be adopted to a greater
degree, with incentives for obtaining specialty certifications and advanced degrees (Teng et al.,
2009). Nursing and other administrators would be wise to invest highly in two areas: high
quality, caring, and competent nurses, and staff who ensure that the hospital is clean and quiet
(Otani et al., 2011; Tzeng et al., 2011).
Conclusion
In this critical literature review regarding nurse caring and patient perceived care related
to patient satisfaction, very current literature referring to these topics were analyzed.
In 2001, Larabee and Bolden concluded that nursing care should be based on patient-centered
interventions, as it is the most significant predictor of patient satisfaction. This was also
confirmed in later research (Larabee & Bolden, 2001; Palese et al., 2011; Wagner & Bear, 2009).
It has been demonstrated in some of the research studies for this review that nurse caring,
patient perceived caring, and patient satisfaction are related, and are important dimensions in the
current health care environment. The literature supports the ideas that improved patient

39
satisfaction can benefit the health care system through monetary means and through improved
health outcomes of patients.


40
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Appendix A

Table 1 Core Articles
Authors/Year Country Method Sample
Ausserhofer,
Schubert et al.
2012
Switzerland Quantitative 1630 nurses working in
35 acute care hospitals
Ciccu-Moore,
Grant et al
2014
United Kingdom Quantitative 604 patients in
12 months
Coughlin
2012
United States Qualitative 238 older persons
DeJesus, Howell,
Williams et al.
2014
United States Mixed 125 patients
Frojd, Swenne,
Rubertsson et al.
2011
Sweden Quantitative 2734 patients
Larsson, Sahlsten,
Segesten, & Plos
2011
Sweden Qualitative 17 patients
105 critical incidents
Liu, Franz, Allen,
Chang et al.
2010
United States Mixed 728 observed patients
619 unobserved
patients
Maxson, Derby,
Wrobleski, & Foss
2012
United States Quantitative 60 patients
Merrill, Hayes,
Clukey, & Curtis
2012
United States Mixed 103 trauma patients

Otani, Herrmann,
& Kurz
2011
United States Quantitative 31,471 patients
Palese, Tomietto,
et al.
2011
Cyprus, Czech
Republic,
Greece, Finland,
Hungary & Italy
Quantitative 1,565 surgical patients
Radwin, Cabral, &
Wilkes
2009
United States Quantitative 173 hematology/
oncology patients

Schubert, Clarke,
et al.
2008
Switzerland Quantitative 1338 nurses
779 patients
Seeber
2012
United States Quantitative 24 patients

51
Snide & Nailon
2013
United States Quantitative 21 quarters
top-decile ratings
Suhonen,
Papastavrou,
Efstathiou et al.
2011
Czech Republic,
Cyprus, Finland,
Greece, and
Hungary
Quantitative 1315 surgical patients
Suliman, Welman,
Omer et al.
2009
Saudi Arabia Quantitative 393 patients
Teng, Dai, Shyu,
Wong, Chu, & Tsai
2009
Taiwan Quantitative 248 nurse/inpatient
dyads
Tojero
2012
Philippines Qualitative 210 nurse/patient
dyadic interactions
Tzeng, Hu, Yin &
Johnson
2011
United States Quantitative 478 hospitals
HCAHPS results
Wolf & Goldberg
2011
United States Quantitative 238 older persons
Woodard
2009
United States Quantitative 9 charge nurses
Zhu, You Zheng,
Liu, Fang et al
2012
China Quantitative 181 hospitals
5,430 patients
7,802 nurses

Note. Description of core research studies regarding countries in which they were performed,
methodology, and sample characteristics.

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NURSE CARING AND PERCEIVED CARING RELATED TO PATIENT SATISFACTION

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