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The Relationship of Oncology Nurse
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Maria Geraldine O'Callaghan McEvoy

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THE RELATIONSHIP OF ONCOLOGY NURSE
CARING AND PATIENT SATISFACTION

By

Maria G. McEvoy

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing
1996

ABSTRACT
THE RELATIONSHIP OF ONCOLOGY NURSE CARING AND
PATIENT SATISFACTION
By

Maria G. McEvoy

Patient satisfaction is a measurable outcome of care provided. Little is known
about the relationship of patient satisfaction and oncology clinical nurse caring. The
purpose of this investigation was to examine the relationship of nurse caring and patient
satisfaction. Caring is examined in terms of Jean Watson’s philosophy of Nursing as
human science and human care. Rationale guiding the study is the lack of investigations
measuring the effect of nurse caring on patient satisfaction. Secondary analysis of a
primary investigation entitled “Rural Partnership Linkage for Cancer Care, " by Drs.
Barbara and CW. Given, funded by the National Cancer Institute, Grant # 1R0]
CA56338-02, was employed. A convenience sample of cancer patients living in
southwestern Michigan counties of Allegan, Barry and Van Buren, experiencing a wide
variety of types and stages of cancers participated. A specially designed intervention was
employed to bring state of the art cancer care, utilizing OCNS nurse caring. Patient
satisfaction with nurse caring was measuredil year after entry into study. Data collection
was through a self-administered, modified, LaMonica-Oberst Patient Satisfaction Survey.
Correlation coefficient Pearson’s r = .2985 (p=.021), indicated a moderately positive
relationship between encounters of nurse caring and patient satisfaction. Implications for

further research, education and advanced practice nursing are discussed.

Copyfightby
MARIA GERALDINE MC EVOY

1996

DEDICATION

To my husband, Jim, for his love, support and patience, and computer expertise --
especially with the word processing, when I would “lose my files”. To my children, Jim,
Kate, Sean and Kelly for their continued love, despite missed meets and forgotten school

treats. To my parents, Hannelore and Jerome, and grandparents Hans and Maria, for

being my first teachers of caring.

iv

ACKNOWLEDGMENTS

I wish to thank my committee, Linda Beth Tiedje, Barbara Given and Celia Wills.
Linda Beth, my chair, thank you for helping me stay focused on caring, the heart of my
nursing. Barbara, thank you for allowing me to use your data set and be your graduate
assistant this past year. In my interviews, I heard over and over again, how much the
caring nurses were a part of the healing, for both patient and caregiver. Celia, thank you
for your insight into the literature; it allowed me to gain further valuable insights. I wish
to thank you all for challenging me to reach for the heights. I also wish to thank Su Hao

Tu, for her assistance with data analysis; it was much appreciated.

TABLE OF CONTENTS

Page
LIST OF TABLES .................................................................................................. vii
LIST OF FIGURES ................................................................................................ viii
INTRODUCTION ..................................................................................................... 1
REVIEW OF LITERATURE .................................................................................... 3
METHODS ............................................................................................................. 25
DATA ..................................................................................................................... 35
DISCUSSION ......................................................................................................... 39
IMPLICATIONS ..................................................................................................... 46
REFERENCES ........................................................................................................ 57

LIST OF TABLES

Table 1: Relationship: Watson’s Concepts (1988) as related to Page

Morse et a1 Traits (1991) ................................................................................... 5
Table 2: Sociodemographic Variables ........................................................................... 27
Table 3: Central Tendencies .......................................................................................... 36

vii

LIST OF FIGURES

Page
Figure 1: Watson’s Model of Nursing ........................................................................... 23
Figure 2: Watson’s Model of Nursing with Study Concepts .......................................... 24

viii

INTRODUCTION

There is no question that the current health care system is in a state of flux.
Money managers of institutions (such as hospitals) and insurers are evaluating
institutional practices to make these practices more cost-efficient (Baer and Gordon,
1994). In order to increase cost-effectiveness, Baer et al. (1994) suggest that institutional
managers view nurses as being expendable, that is, there appears to be a belief that,
“Other less trained individuals may do the job.”

In discussion of machine technologies and caring in nursing, Locsin, (1995)
identifies caring as a “central prominence” of nursing, defining caring as a component of
machine technologies and patient satisfaction. Since technology is a large part of applied
nursing, this is an important reminder of the value of the caring part of nursing.

Measurements of outcome are the major means of demonstrating effectiveness of
nursing care provided (Jones, 1993). Rettig (1991) identified outcome measurement as a,
“national opportunity to build a stronger research underpinning to nursing.” Marek
(1989) identifies patient satisfaction as one of fifteen specific outcome measures. Further,
the degree to which a patient believes the health care provider cares about them maybe
the most important element in determining client satisfaction. (Woolley, Kane, Hughes
and Wright, 1978). Ware and Davies (1983) cite three reasons for measurement of

satisfaction. 1)Satisfaction is an ultimate outcome of health care delivery; that is,

2

satisfaction is an evaluation of how well and how acceptable health care providers
provide services; 2) Satisfaction ratings provide information about the structure, process
and outcome of care; and, 3) Dissatisfied patients may choose not to utilize health care
services further. Behavioral consequences of patient dissatisfaction with health care must
be considered as a reason to examine patient satisfaction with caring. With the abundance
of factors that may lead to dissatisfaction, such as poor communication or lack of
availability of one’s ‘personal’ health care provider (W eyrauch, 1996); the importance of
describing the factors related to satisfaction become evident. Wiggers, Donovan, Redman
and Sanson-Fisher (1990) identify cancer patients as having multidimensional needs.
Measurement of satisfaction is an index of the adequacy of care provided. Further, caring
received may be one of the factors related to that satisfaction.
Problem Statement

The Advanced Practice Nurse (APN) must be responsive to outcomes based
research in health care (McCormick, 1992), including the impact of nurse caring on
outcomes. Caring in nursing is a nebulous entity. The purpose of the proposed research
is to examine the relationship of nurse caring and patient satisfaction, using a sample of
clients from several southwestern Michigan county rural Oncology Clinical Nurse
Specialist (OCNS) practices. Specifically, the purpose of this investigation is to examine
the relationship of patient satisfaction and number of caring nurse encounters. The
hypothesis is that as the numbers of caring encounters increase, patient satisfaction also

will increase.

3
Review Of Literature

Integral to this study are the concepts of patient satisfaction and caring. The
definition and literature review of caring will be followed by the definition and literature
review of patient satisfaction.

Cmptual Definition of Caring

The conceptual definition of caring for the purposes of this study is nurturance,
knowledge provision, mutual respect, empathy and congruence. Caring is a multi-faceted
concept, with facets involving a way of being, a thing to do, and something given, as
well as received.

Caring is defined in Webster’s Collegiate Dictionag (1992) as a regard coming
from desire or esteem. Unfortunately, when attempting to define caring as a nursing
concept, the literature is much less clear. The American Nurses’ Association defines
nursing as the diagnosis and treatment of human responses to actual or potential health
problems (American Nurses Association, 1980). Swanson (1991) defines caring as “a
nurturing way of relating to a valued other toward whom one feels a personal sense of
commitment and responsibility" ( p. 354). Nurses develop care plans for their patients,
yet caring remains uncleme specified. Multiple theories of caring abound; among them
Boykin and Schoenhofer (1991), Leininger (1993), Swanson (1991) and Watson (1988).
Essays on caring as loving (Jacono, 1991) and caring versus empowerment (Malin, 1993)
appear in the literature. The parameters of caring are difficult to define. Caring is not a
concept with clear physiological delimitation, such as heart rate or blood pressure.

Leininger (1993) defines caring as “the essence of nursing and as a central and

major domain of nursing knowledge and practice.” Caring involves the whole patient

4
(Hill, 1991). Burfitt, Greiner, Miers, Kinney and Branyon (1993), when examining

professional nurse caring relating to patient perception, conclude caring is a mutual
process in which intentions between the nurse and patient are joined to form a shared
experience.

Watson (1988) eschews linear definitions of concepts but describes caring as “the
moral ideal of nursing, consisting of person to person undertakings to protect, enhance,
and preserve humanity by aiding a person to find meaning in illness, sufi‘ering, pain and
existence; to help a person gain self-knowledge, control and self-healing where a sense of
inner harmony is restored regardless of external circumstances” (p.54). Watson (1988)
proposes nursing to be a human science and human care process significant to and
preserving of humanity. The nurse providing care develops a helping/trusting
relationship with the patient. Integral to the helping/trusting relationship are the aspects
of congruence and empathy. Congruence involves being genuine, authentic and honest.
Empathy involves the ability to experience, understand and communicate understanding
of another’s perceptions and feelings.

In a comparative analysis of caring literature; Morse, Bottorff, Neander and
Solberg (1991), defined 5 major conceptualizations of caring: caring as a human trait;
caring as a moral imperative; caring as an affect; caring as an interpersonal interaction;
and caring as a therapeutic intervention.

Table 1 depicts the extension of nurturance to be both a human trait and an
interpersonal interaction. Respect is a moral imperative and an interpersonal interaction.

The helping/ trusting aspects of caring, which are empathy and congruence, are both an

5

affect and a therapeutic intervention. Finally, knowledge provision is shown as a
therapeutic intervention.

Table 1

Relationship: Wilson’s Concepts (1988) to Morse et al. Traits (1991)

 

N urturanee Respect Empathy Knowledge

Congruence Provision

 

Human ' X

Moral X

Affect I x
Interpersonal X X

Therapeutic X X X

 

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Mayer (1987) identified differences in patients’ perceptions of nursing care and
nurses’ perception of caring. Mayer identified that what nurses perceive to be caring and
what patients perceive to be caring are different entities. Patients identify knowledge
provision, technical care, competence and respect as indicators of caring; while nurses
identify non-verbal communications and personal respect as indicators of caring. In this

study, it is the patient perception of nurse caring that will be examined.

6
Conceptual Definition of Patient Satisfaction

Satisfaction, as defined in Webster’s Collegiate Dictionary (1992), is the state of
feeling that desires, expectations or needs are being met. In measuring nursing care
satisfaction, in a primary care perspective, Risser (197 5) noted satisfaction is the
gratification of needs and the fulfillment of expectations. La Monica, Oberst, Madea and
Wolf (1986) defined patient satisfaction as the degree to which there is congruence
between care expected and care received. For the purposes of this study, the conceptual
definition of patient satisfaction is the written expression of gratification of health care
needs.

LaMonica et al. (1986) developed a scale to measure patient satisfaction, which
was found to have better reliability, validity, and sensitivity than other available
instruments. Satisfaction dimensions included in the scale were from Risser’s (1975)
conceptualization of three facets of nursing performance: 1)Technical-professional, 2)
Trusting relationship; and 3) Education relationship. “Technical-professional” facets
include activities that were task oriented and knowledge based. “Trusting relationship”
included behaviors and characteristics which permitted productive nurse-patient
interactions. “Education relationship” included provision of knowledge and information.

LaMonica et al. (1986) noted that patient satisfaction with nursing care is
important to those interested in monitoring quality of care and effectiveness of specific
interventions. Munro, Jacobson and Brooten (1994) state patient satisfaction may be
considered to be a better measurement of outcome of nursing care than morbidity and
mortality, since nurses seldom make diagnostic decisions affecting morbidity and

mortality. This author would disagree with the opinion that nurses seldom make

7
diagnostic decisions affecting morbidity and mortality. APNs make daily strategic and

diagnostic decisions regarding care that does affect the outcomes of morbidity and
mortality, length of stay and patient satisfaction. For example, the APN may recommend
and develop a regular exercise program for a hypertensive patient to minimize the effects
of hypertension on the cardiovascular system. The OCN S in this study may identify and
treat oral candidiasis in the immunocompromised cancer patient, clearly affecting
morbidity outcomes and increasing his/her quality of life.

Examining the concept of satisfaction from the literature, Pascoe (1983) defined
patient satisfaction as the health care receiver’s reaction to the context, process and result
(outcome) of his or her health care experience. The patient evaluates the structure,
process and outcome of the received service. The patient also applies an emotional
component to the same structure, process and outcome of services, leading to a dual
system of evaluation of the provided services: objective as well as subjective. The result
is the structure, process and outcome of received services are judged by the patient in the
subjective as well as the objective realms.

Ware and Davies (1983) cited three reasons for measuring satisfaction. First,
satisfaction is an ultimate outcome of health care delivery; therefore satisfaction must be
evaluated to determine how well and how acceptable health care providers provide
services. Second, satisfaction ratings provide information about structure, process and
outcomes of care. For example, ratings of satisfaction may examine the physical
surroundings (structure); is the office clean, in a new or old building, easy to reach by
public transportation? Examination of process may include large clinic or small private

office; and how they were treated by office or clinic personnel. Outcome ratings examine

8
satisfaction with the speed at which the patient may return to work or level of function

returned post treatment.

Ware, Snyder, Wright and Davies (1983) examined satisfaction as both a
measure of care and a measure of the patient providing the rating defining the
care. They further defined patient satisfaction as a multidimensional concept
corresponding to characteristics of providers and services. Dimensions of patient
satisfaction identified included interpersonal manner, technical quality,
accessibility/ convenience, finances, efficacy/outcomes, continuity, physical
environment and availability.

Eriksen (1995) identifies three antecedents to satisfaction with nursing
care: 1) An interaction between the patient and the nurse; 2) A development of
expectations of the service the nurse provides; 3) An interaction between the
expectations of the performance and the perceptions of that performance, from
which the patient evaluates the result. Eriksen (1995) further proposes there are
consequences that result from satisfaction, and delineates three of interest to
health care providers. These are: adherence to health care regime, increased
participation of the patient and positive influence to continue to use the service
again.

Eriksen (1995) further defines patient satisfaction with nurse caring as the
“patient’s subjective evaluation of the cognitive/emotional response that results
from the interaction of the patient’s expectations of nursing care and their

perception of actual nurse behaviors/characteristics”(p.7 1).

Dimensions of Patient Satisfaction

Pascoe (1983) delineated eight dimensions of patient satisfaction. These
eight dimensions are: service delivery, availability- accessibility- convenience,
financial- structural characteristics, provider-patient interaction, technical
competence, interpersonal skills, continuity of care, patient-provider fit and
clinical outcome.

Service delivery addresses the type of service received. Pascoe (1983)
reviewed the types of delivery of care, which range from primary care with a
family-centered style to tertiary, acute care such as an emergency department.
Pascoe (1983) found that patient satisfaction is consistent with improved
organization, but noted that this may be more a reflection of patient
idiosyncrasies, than the actual service provided. Patients develop a personal
definition of organized care by which they judge the organization of the service
delivery.

Availability, accessibility and convenience are a dimension of the eight
defined by Pascoe, 1983. Increased satisfaction has been demonstrated with
decreased travel time and waiting time in the office. Brief delays in obtaining
services also correlate positively with increased patient satisfaction. Kurata,
Nogawa, Phillips, Hoffman and Werblun (1992) reported a patient satisfaction
rating of 73-87%, in a study of a family practice residency program, identifying
waiting time for appointments as being a cause of dissatisfaction. This is an
important aspect of this study, since caring is being provided in the rural area in

close proximity to the patient’s home.

10

Financial and structural characteristics are a third dimension of patient
satisfaction (Pascoe, 1983). Quality of care and socioeconomic status are very
much interrelated. Findings indicate that the less costly the care, the more
satisfied the patient. Insurance status also affects satisfaction in that patients with
insurance generally preferred private practice, while patients without insurance
generally preferred or had been assigned to clinics.

Provider-patient interaction forms a fourth dimension of satisfaction, and
has been the most commonly investigated source of satisfaction. Woolley, Kane,
Hughes and Wright (1978) state the degree to which a patient believes the
physician cares about them may be the most important element in determining
compliance and satisfaction. DiMatteo et al. (1993) report that even with time
limited visits, physician job satisfaction positively affected patient satisfaction.
Weisman and Nathanson (1985) found that job satisfaction among family
planning and community health nurses positively effected satisfaction among
patients in county health department family planning clinics. Duffy (1992)
asserted that nurse caring is an important predictor of patient satisfaction. This
dimension of satisfaction is intimately involved with the present study as nurse
caring requires the establishment of a therapeutic interaction.

Technical competence, Pascoe (1983) continues, is the best predictor of
overall satisfaction. Kurata et al. (1992) reported a 97% satisfaction rate with the
technical competence of providers in a family practice residency program. Risser
(1975) found that patient perceptions of nurse behaviors in the knowledge and

technical expertise domains were the greatest predictor of patient satisfaction.

1 1
Fosbinder (1994) notes that patients value interpersonal skills in ‘bedside nursing’

as being important, and relates these skills as important toward technical
competence.

The question of whether a patient is an adequate judge of technical
expertise then arises. Can a lay person truly judge whether a provider is
technically expert? Perhaps the perception by the patient that their provider has
technical expertise is the important concept in operation. The issue is not whether
the patient is an adequate judge, but if the patient has a global perception of
expertise on the part of the provider, and how that global perception effects their
satisfaction. Although Risser (1975) identified knowledge and technical expertise
as predictors of satisfaction, intra/interpersonal functions and development of a
trusting relationship were also identified as being integral to patient satisfaction.
Ben-Sira (1982) concluded that satisfaction with a physician’s affective behavior
greatly influences the evaluation of professional competence. The global
perception of expertise Ben Sira (1982) proposes is linked to satisfaction, integral
to this process is the trust the patient develops for their provider. Therefore,
satisfying interpersonal interactions may positively influence the perception of
technical expertise.

Woolley et al. (1978) note that effective communication leads to a
perception of ‘being cared for.’ Interpersonal skills were seen as a fifth dimension
of patient satisfaction by Pascoe (1983). He reported that clear communication
and interest shown in the patient are part of the process of satisfaction. In a study

of APNs in a breast clinic in the United Kingdom; Hammond, Chase and Hogbin

12

(1993) found that patients were more satisfied with nurse practitioners over house
physicians, especially in terms of communication. In a marketing and managerial
targeted investigation, Bowers, Swan and Koehler (1994) determined that
communication is a significant determinant of patient satisfaction. Interestingly,
they also found that caring was a significant predictor of patient satisfaction. This
then is another dimension of patient satisfaction intimately involved with this
study.

Continuity of care is a sixth dimension of patient satisfaction. Having a
regular provider of care is directly associated with increased satisfaction
(Starfield, 1992). Weyrauch (1996) noted continuity of care in the HMO clinical
setting increases patient satisfaction.

Patient-provider fit are a seventh dimension of patient satisfaction
according to Pascoe (1983). Patient-provider fit examines the degree of
congruence between the socio-economic status of the physician and the socio-
economic status of the patient; the greater the degree of accord between the status
of the patient and the status of the provider, the greater the degree of satisfaction.
Extending this to the APN in primary practice, nurses may be seen as being more
on the level of the ‘common individual’ than the physician, and hence clients may
be inherently more satisfied with nurses, particularly middle and low income
clients.

Clinical outcome is the last dimension of patient satisfaction. The better
the clinical outcome, the greater the degree of satisfaction. The reverse does not

hold true, however, that is poor outcomes do not produce dissatisfied patients.

13
Woolley et al. (197 8) reported that 92 percent of all patients expressed

satisfaction with care received, even though a poor outcome was the result. This
may be a measure of the fact that the health care provider “tried his/her best” and
an acknowledgment of that.

The relationship of nurse caring and patient satisfaction is predicated by
these 8 dimensions of care. It is important for APNs providing nurse caring to be
cognizant of these dimensions, since failure to address those that the APN has
responsibility for may result in inappropriate utilization of services.

To summarize, 8 dimensions of care affect patient satisfaction. Although
APNs are not able to affect all 8 dimensions, such as financial-structural
characteristics and convenience, they are able to impact interpersonal interaction
and skills. APNs also may impact the fit between patient and provider, and most
assuredly impact outcome.

Measurement Issues

Some measurement issues related to patient satisfaction are the concepts
which may externally effect satisfaction, these being: 1) Macro versus micro
levels of satisfaction; 2) Satisfaction with life in general; and 3) Health status in
general. Roberts, Pascoe and Atkisson (1983) reported that macro measurement
of patient satisfaction of health care in general, and micro measurements of
patient satisfaction of a particular episode of health care provided to the particular
patient produce dissimilar results. That is, patients report their personal health
care (micro) is generally satisfactory, but considering health care globally

(macro), health care is not satisfactory. Roberts et al. (1983) related this

14
phenomenon to the quality of life satisfaction of the respondent. Patients with

general feelings of well-being and life satisfaction are satisfied with their health
care; patients unsatisfied with life may tend to blame external forces more,
resulting in dissatisfaction with health care. Hall, Milburn and Epstein (1993) also
observed that health status is a causal determinant of satisfaction in a sample of
HMO based older patients. This study will only attempt to investigate the micro
level of satisfaction, that is satisfaction with their personal health care.

Watson (1988) specifies qualitative means of measurement for the
investigation of caring. In a personal communication, March 10, 1996; Dr.
Watson expressed pragmatism about the necessity of measurement of caring, yet
felt that measurement of caring “takes away fiom caring”. Yet to document the
“hard science” effect of caring, one must attempt to measure it quantitatively.
Caring has been measured by the Q-sort technique (Von Essen et a1, 1991), as
well as by use of several tools developed, e. g., Duffy (1992) with the Caring
Assessment Tool, and Wolf, Giardino, Osborne and Ambrose (1994) with the
Caring Behaviors Inventory, both of which have limited generalizability related
to sampling technique. The sample utilized in Wolf et al. (1994) was a
convenience sample of 278 nurses and 263 patients in secondary and tertiary
setting. Duffy (1992) also utilized a tertiary care setting, however it was a
randomly selected sample of admissions to the hospital, with a new random
number generator reset every 24 hours.

Patients are reluctant to report negative feelings (Ventura, Fox, Corley &

Mercurio, 1982). Reluctance to report negative feelings causes a problem in the

15

measurement of satisfaction creating generally high ratings, with little variability.
In the Ventura et al. (1982) review of patient satisfaction as a criterion to evaluate
primary care, patients were reluctant to express negative feelings, especially if
care was needed in the future. Ventura further discussed that scales are frequently
distorted by the use of primarily positively worded items, which also skews
positively results.

Another reason for problems in measuring patient satisfaction is that of
dissatisfied patients may choose not to be patients. Satisfaction, or dissatisfaction,
with care results in decisions regarding care seeking, adherence behavior and
reactive behavior, according to Ware and Davies (1983). Care seeking includes
whether the patient seeks care for illness treatrnent, well-care appointments, or
numbers of visits during a specific time. Adherence includes cooperation with
health care recommendations established by a patient-provider collaborative
effort; for example, medication regimes or lifestyle changes. Reactive behavior
examines actions by consumers expressing satisfaction or dissatisfaction with
their health care. Reactive behavior may include patients speaking out publicly
about dissatisfaction, the filing of legal suits, or seeking new providers. Thus,
satisfied clients are more apt to seek care, adhere to recommendations and engage
in less negative reactive behavior.

Ware and Davies (1983) concluded that consumer behaviors, specifically
patient recommendations for or against specific providers, changing health plans,
filing formal complaints or malpractice suits are substantially related to

dissatisfaction with health care services. Ware and Davies (1983) concluded

16

further that patient dissatisfaction may account for delays in care seeking and
doctor shopping.

Fiesta (1991) cited patient dissatisfaction as a primary cause of
malpractice suits. Elgin (1990) reported 7 0 percent of malpractice suits were
related to patients’ dissatisfaction with communication patterns with their health
care provider. Elgin posited the pervasive use of ‘Mdeityspeak’ as being a prime
contributor to dissatisfaction with communication with health care providers.
‘Mdeityspeak,’ according to Elgin, is the mode of questioning used in the
interview that does not allow the patient more than 18 seconds to complete the
reply. This finding specifies communication as an area to be examined when
measuring patient satisfaction, although this will not be investigated in this study.

A final consideration of the inherent difficulties of measurement of patient
satisfaction is the limited potential percentage for improvement. Since the
literature indicates a high rate of satisfaction, there is little upon which to
improve. It must be considered that not all of the dimensions of satisfaction have
as yet been identified.

Therefore, this study examined patient satisfaction in the context not only
of satisfaction with Pascoe’s delineated dimensions, but also in relationship with
other concepts, such as caring. To review, the dimensions of patient satisfaction
specifically being examined in this study are: 1) Service delivery, primary care by
an OCNS; 2)Availability, accessibility and convenience in a rurally located clinic;
3) Provider-patient interaction between the OCNS and the patient; 4) Technical

competence as perceived by the patient; 5) Interpersonal skills, specifically

17
effective communication between the OCNS and the patient. Examination of the

relationship of nurse caring on patient satisfaction, although perhaps somewhat
“soft," may provide many opportunities. These being: 1) The opportunity of
APNs to document effectiveness; 2) The opportunity to decrease reactive
behaviors, such as filing of legal suits, “provider-shopping," improper utilization,
such as seeking care at after-hours clinics or emergency departments or failure to
seek care at all; 3) Nurse caring may also provide the opportunity for increased
satisfaction keeping patients in health plans, making the APN a valued team
member.

Relationship of Caring and Patient Satisfaction

What is the relationship between patient satisfaction and caring? Duffy
(1992) noted three consistent themes in a review of patient satisfaction studies
over the last thirty years. First, in general, patients are satisfied with hospital
services. Second, demographics do not seem to be a significant factor in patient
satisfaction. Third, satisfaction with nursing care is a consistent factor in overall
satisfaction with hospitalization. The third result indicates that nurses and caring
are in a prime place to effect patient satisfaction (Duffy, 1992).

Quality assurance is a method of measuring effectiveness of care. The
current health care system is in a crisis. Costs continue to rise with no end in
sight. Cost benefit and effectiveness are increasingly being examined by payors
and consumers (Hegyvary, 1991). Health care professionals must begin to view
their services as results and products. Patients are titled “guests” or “customers”.

Customer satisfaction is being sought to maintain “business.”

18
Quality assurance standards previously had examined delivered care from

the perspective of structure (Bauman, 1991). For example, highly organized
structures were able to provide quality care. Currently, the standard of quality
assessment and assurance has shifted to include goals of improved patient
outcome, which includes customer satisfaction. First, evaluation of care from a
patient perspective allows the patient to tell nursing if the care provided met their
needs. Second, analysis of patient outcomes measures if optimal care was
provided at optimal price. Third, a system that provides the highest quality
outcome of patient satisfaction due to nursing care, holds the most promise for
advancement of professional nursing (Bauman, 1991). A system holding the
highest quality patient outcomes would hold the most promise for the APN in
primary care practice, proving not only societal but monetary worth to employers,
such as managed care. A high quality system utilizing APNs to provide primary
care with satisfied clients is cost effective, has cost benefits and meets patient’s
needs. Patient outcomes present the opportunity to demonstrate effectiveness of
provided nursing care (Jones, 1993). Applying the concept of outcome
measurement to the practice of the APN would make evident the advantages of
care provision by the APN.

Outcome measures, specifically patient satisfaction, may be used to
measure practice, demonstrate effectiveness and justify continued expansion of
the APN role. Marketing of the practice of the APN may be accomplished by
using satisfaction measures. Current users of the APN practice will most likely

continue to utilize the practice, if they are satisfied. If these users are women,

19

they will tend to continue using the same providers over the lifetime of their
family (Naylor, Munro, & Brooten 1991). Consequently, the practice of the APN
will fuel expansion of the role of Clinical Nurse Specialist/Nurse Practitioner in
health care provision. Women proportionately seek health care in greater numbers
than men (Naylor et al., 1991). When the APN may provide greater satisfaction
with health care to these women, especially considering the perceived congruence
of socio-economic status as well as gender, the APN will be a sought-after
provider.

The APN whether in primary care, serving a managed care population or
in focused care of oncology patients, may use the documentation of his/her
advanced caring abilities as a tool to document worth to the employer.

riti Dis sion

In summary, there are several shortcomings in the available literature in
relation to the purpose of this study. First, the literature is mainly hospital based
and developed for the hospital setting. Measures of patient satisfaction developed
for in-patient settings are not necessarily transferable to outpatient, rural oncology
clinics. Second, the patient satisfaction literature indicates most patients, 92-97
percent, are satisfied with their care (Woolley et al., 1978; Kurata et al., 1992). In
review of satisfaction as a criterion to evaluate primary care, patients are
generally reluctant to report negative feelings, especially if they believe they may
need care in the future (Ventura, Fox, Corley & Mercurio, 1982).

There are few studies related to patient satisfaction with advanced practice

nursing as the focus. Safriet (1992) notes in a treatise on the role of advanced

20
practice nursing and health care regulation, that APNs have a higher overall

rating of patient satisfaction than physicians, related to conveyance of
information, reduction of professional mystique and the costs of care.

As previously noted, caring is a construct of nebulous definition. Caring
currently has no physical parameters by which it may be measured. Few tools
have been developed to measure caring. Despite much literature discussing
caring, no one author has given a clear, concise measurable definition of caring.
Von Essen and Sjoden (1991) using the CARE-Q method identifying which
behaviors were most important. Duffy (1992) developed the Caring Assessment
Tool, for use in measurement of nurse caring in the in-patient setting. The
encounters in this study have been designed to be of a nurse caring nature, and
will for that reason provide the means to measure caring by variation in numbers
of their encounters.

The study examined the correlation between the number of encounters of
nurse caring from a patient's perspective and their subsequent satisfaction with
nursing care. This study clarified the relationship between the caring provided by
the Oncology CNS (OCNS) and demonstrated that this caring is an integral part
of ultimate health care satisfaction. OCNSs in a rural setting positively impacted
the global satisfaction with health care and thereby documented the value of
OCNS nursing. Long term benefits obtained from ONCS caring will be cost -
effective for the insurers and managed care concerns overriding the short term

potential for increased costs by: 1) Increasing adherence behaviors; 2) Decreasing

21
reactive behaviors; and 3) Decreasing morbidity, and possibly mortality through

early identification of risk factors and increased patient participation.
Theoretical Framework

Watson’s (1988) Philosophy of Nursing as Human Science and Human Care was
developed originally as a textbook for a Baccalaureate nursing program. Watson is
heavily influenced by belief in the metaphysical aspects of our existence. She believes
the health/illness and human care process is too abstract to be limited to empirical science
and the physical-materialistic views. Society needs the caring professions, and nursing in
particular, to help restore humanity and nourish the human soul in an age of technology,
scientism, and stress. Nursing, according to Watson (1988) is “knowledge, thought,
values, philosophy, commitment and action with some degree of passion” (p.53). Each
person is the locus of their existence with three spheres of being: mind, body and soul.

The art of caring is expressed when the nurse “having realized or experienced the
feelings of another, detects and senses these feelings and creates a condition where the
other is able to experience these feelings more freely and release the feelings he/she has
been longing to express” (Watson, 1988, p. 68). An actual caring occasion involves
action and choice by both the nurse and patient and has the potential to influence both the
nurse and patient in the future (See Figure 1).

Watson’s philosophy of nursing has its basis in phenomenology and
existentialism. The belief is of nursing as a human science and human care process as a
significant humanitarian and epistemic act that contributes to the preservation of
humanity. Concepts integral to the understanding of this theory are: 1) caring- all factors

used by a nurse to deliver healthcare, including knowledge provision, and nurturance; 2)

22

congruence— an aspect of the helping/trusting relationship that involves being genuine,
authentic and honest; 3) empathy- an aspect of the helping/trusting relationship that
involves the ability to experience, understand and communicate understanding of
another’s perceptions and feelings; and 4) carative factors- structural components that
describe caring process, including mutual respect and how a client maintains, attains or
sustains a peacefiil death.

Transpersonal caring is a “special type of human care relationship” (Watson,
1988). This relationship is a union with another person dependent on: a)a moral
commitment to protect and enhance human dignity, b) nursing intent to affirm
personhood, c) nurses’ ability to realize and accurately detect feelings and inner
conditions of another, d) nurses’ ability to realize and feel a union with another - to be
expressed in some manner, e) nurses’ own sensitivity gathered through life experiences,
personal growth and identifications of personal values (Watson, 1988). Watson’s
construct of transpersonal caring melds the facets of caring as a human trait, moral
imperative, affect, interpersonal interaction and therapeutic intervention.

The concepts of knowledge provision, nurturance, mutual respect and the
congruence and empathy aspects of the helping/trusting relationship may be extracted
and supported by this theory as the previously noted conceptual definition of caring. The
following model of caring as being an essential supporting factor of patient satisfaction is
proposed (Figure 2).

Watson’s (1988) model depicts the overlap of experiences between the nurse and
patient. The dashed line represents the lived experience of the nurse, while the dotted line

the patient. The caring occasion takes place when the two come together during the

23
present, bringing their past experiences along. The proposed model of the study

constructs indicates where the caring occurs, and how the constructs of the study are

applicable. Patient satisfaction is measured in the future, after the caring occasion has

 

occurred.
\ /'*’T'—‘\."°'z‘i
.- . / ° Future \ . °
\..‘."/../ .. "'.\ \:!
\-./ - - .. :/
\.,,,../:... ,, \. \ ,1
\/ -. ’ - /
\. A.. \.
3'\/ Phenomenal F iel‘d. . "
.’ ..\._ ./ A". ,‘/
. . set. I; .
, \, . \../ V4 .
: 9/ ‘\._./°\-‘. ACTUAL
‘\/ /\ CARING
’) \. . / . - \. OCCASION
_, Present ' I . . oMoment\.
:7 V;
: \.
J .
7 \.
: CausalPast \'

l

.l
Nurse ... _ .. j i‘

Patient ------ i

i

Figure l. Watson’s Model of Nursing (1988, p.59)

24

  

' . I . . . I . .
l x .' - ' : .
- . . / . .' Patient Satisfaction

   

Causal Past

Figure 2: Watson’s Model of Nursing with Study Concepts

25

Rationale

The underlying rationale for this study is the lack of a clearly documented link
between nurse caring and patient satisfaction. When examining the rising cost of health
care, outcomes of nursing care must be measured and documented. The profession of
nursing must increase efforts to document effects of nurse caring on health care
outcomes. Outcome-based measures are a means to do so. Patient satisfaction is a
frequently measured outcome, and therefore nursing can begin to measure and document
it as an outcome. Documentation of the positive effects that caring nurses may have on
patient satisfaction, specifically by examining the benefit of care provision by rural
CN S’s, might encourage greater utilization of the CNS/APN. With caring provided by
the CNS/APN; increased satisfaction for the patient may ultimately translate into high
quality, accessible care, decreased costs, and better overall outcomes for patients

Methods

A secondary analysis will be done using data from a primary investigation by
Charles W. Given, PhD and Barbara A. Given, RN, PhD, FAAN, Principal Investigators.
The primary investigation was entitled the “Rural Partnership Linkage for Cancer Care, "
and was funded by the National Cancer Institute, Grant No. 1R0] CA56338-02. This was
an investigation into the treatment and supportive care of multiple types of canCer
patients living in three rural counties in southwestern Michigan. The quasi-experimental
study was funded for 5 years, and is currently beginning the fourth year. This study has
developed and implemented interventions of oncology clinical nurse specialists in rural
cancer clinics, and continues to measure the effectiveness of the OCNS/ rural cancer

clinics. The rural areas of the country must generally wait for progressive modalities of

26

treatment. By consciously bringing state of the art cancer care to the rural communities,
the intervention hopes to improve outcome of cancer treatment.

For the proposed study, secondary analysis of the data from wave 4, one year
afier entry into the study, was done. A OCNS, with a minimum of a Baccalaureate
degree in Nursing and advanced certification in oncology nursing performed the
intervention and was instructed in provision of care consistent with empathy, nurturance,
knowledge provision, mutual respect and congruence. Wave 4 included a measure of
patient satisfaction. From these data the relationship of number of encounters of nurse
caring on patient satisfaction was examined. The study was a correlational, cross-
sectional design. Justification of the design of this investigation was guided by several
factors. Selection was limited to patients who have already developed cancer. Under
study was the relationship of the effect of nurse caring as provided in frequency of
encounters and rural cancer patient satisfaction, making this a correlational study. Cross-
sectional studies collect data only at one point in time and therefore are meant to obtain
measurements of the moment. These types of studies describe what exists today, and
make no effort at prediction or causation. Measurement of patient satisfaction with
perceived nurse caring may help guide future practice, but satisfaction is only at one
point in time. The limitations of this method will be further discussed in the discussion
section. Convenience sampling was employed since random sampling of cancer patients
in the three specified counties did not provide a large enough sample size, and was too

expensive to do so.

27
Sample

The study sample was a convenience sample, composed of patients living in the
rural Southwestern Michigan counties of Allegan, Van Buren and Barry. Eligibility
criteria included referral by oncologist, community agencies, self-referral, family or
primary care physicians. There were 190 patients enrolled in the intervention at the time
of the study onset, of which 131 have reached Wave 4, 48 percent attrition. The patients'
ages range between 32 and 92. Sample size for this study was 47. (See Table 2).

Of 190 patients enrolled, 131 have reached Wave 4. The failures to complete
may be accounted for as follows: 45 have died, 7 were too ill to complete Wave 4; and
11 refused to complete. Sixty-eight patients remain of the original 131, of whom 49 have
returned the questionnaire, however, 2 were returned blank. The attrition rate is 21 or 38
percent related to refusal to complete.

The intervention in this study was designed to bring state of the art cancer care to
rural communities. Oncology Clinical Nurse Specialists providing this nurse caring
interaction are Baccalaureate, Masters candidates or Masters prepared nurses with
certification in Oncology Nursing, specially trained in state of the art caring. The special

training procedure will be further outlined in the next section.

Table 2:

Socioeconomic Distribution

 

Socio-Demographic
Variable Value Percent Number .

 

 

,.-. .V-._. «Ln -.,. “‘- ,. IV g—- .n.. —.‘. s..--. - .-.. ~W .. .- a. . -—,. L- -— .o- o-n *.-M.mM—-. --_. .-.~.‘-. -._. -._..-........ fl...._.--_.

Gender Male 34 16
Female 66 3 l

28

 

Socio-Demographic

 

 

Variable Value
WMarital Status I--- M M” Single
Married
Divorced
Widowed
Race Caucasian

Educational Level

Household Income in US. Dollars

Diagnosis

African American
Native American
Refused

Grade School

Some High School
High School Graduate
Some College
College Graduate
Graduate Degree
Refused

O-4,999 ,

5,000-9,999

1 0,000- 14,999
15,000-19,999
20,000-24,999
25,000-29,999
30,000-34,999
3 5,000-39,999
40,000-44,999
45, GOO-49,999
50,000-59,999
70,000-79,999
Refused

Breast

Colon

Ovary
Lung/Respiratory
Prostate
Lymphoma
Cervical /Uterine
Larynx
Leukemia
Melanoma
Thymus/Heart
Esophagus

59.6
12.8
25.5
63.8
4.3

2.1

29.8

8.5
8.5
34.0
29.8
12.8
4.3
2.1

2.1
12.8
6.4
12.8
8.5
8.5
6.4
6.4
6.4
6.4
6.4
2.1
14.9

46.8
10.6
8.5
8.5
6.4
4.3
4.3
2.1
2.1
2.1
2.1
2.1

r—aNONI-‘i-‘A-b
&O\

\I—wwwwwabowCh—t

N

2

--~NNwAAm

 

29
Training Nurses to Provide “ aring” Interventions

The multiple goals of the intervention are to assist patients and their families with
acquiring the necessary knowledge, skills and support, to obtain the services and
resources necessary to live with cancer, manage their disease and treatment. Managing
their cancer was done with the least impact on their physical and psychosocial
functioning (Given, 1995). Care provided by nurses in an advanced practice role
complemented the medical care patients and their families receive from primary care
physicians and cancer specialists.

The contacts for the structured caring intervention included, but were not limited
to (Given, 1995):

1) Receipt of ongoing education, strategies, information and psychosocial support
about cancer as a disease. Information also included facts about cancer treatments and
problems they may or do experience. Knowledge provision is a crucial component of this
portion of the intervention.

2) Patients were aided in development of adaptational strategies to live with the
cancer, gain control of side effects of treatment or enhance rehabilitation during the first
months of adjuvant therapy. Anticipatory guidance was offered by the nurse, and patients
were encouraged to express needs based on their experiences. Empathy, nurturance and
congruence were keys to this section of the intervention.

3) Problem-solving approaches were used to help the patient make the necessary
life-style changes resulting from the disease and its treatment. This was an on-going

intervention with the patient and his/her family due to the ever-changing needs of the

30
illness. Knowledge provision, empathy and mutual respect are especially important in

problem solving approaches.

4) Networking skills were developed in response to patient needs. Mobilization of
formal and informal community resources was assisted through the development of these
skills. Patients and families were assisted to follow their prescribed therapeutic plan of
cancer care. Mutual respect of the competency of the patient to make decisions, and
utilize resources was critical.

5) Ongoing emotional support and counseling was provided to deal with
problems, issues and concerns related to the cancer diagnosis and treatment; to anticipate
the follow-up care that was needed and to complete the prescribed therapeutic regimen.
Referrals were used when other care providers were needed. Empathy and nurturance
were characteristics of a caring encounter that are very important for this portion of the
intervention.

6) The oncology clinical nurse specialist (OCNS) assumed a case manager role of
advocacy, counseling and support, service coordination and collaboration and
consultation with the primary and specialty care health professionals (physicians, nurses,
etc.) to ensure that the therapeutic plan and follow-up care was followed and received.
Mutual respect was important, especially respect of the nurse for the inherent abilities
and capabilities of the patient.

7) Health and symptom status, and the psychosocial, physical and functional level
of the patients were assessed at each encounter. An initial intake assessment was
completed and each subsequent visit included a follow-up assessment. A plan of care was

completed at each visit based on problems identified. The ability to empathize with and

 

31
nurture the patient through this difficult time was an important component in this

intervention.

8) Referrals were made to the appropriate home care and hospice agencies as
needed. Knowledge of available resources and provision of this knowledge to the patients
and their families was an aspect of caring.

The intervention described above is directed toward patients to provide
continuing and supportive care in the immediate period following cancer diagnosis. This
period included a minimum of ten to twelve contacts: there were two visits months one
and two following diagnosis; one visit months three through six following diagnosis, and
two telephone contacts per month. Additional contacts were available as needed.

The interventions operationalize the identified components of caring in several
ways. Ongoing guidance of the patient and family, being supportive, counseling,
providing anticipatory guidance all involve the components of empathy, congruence,
mutual respect and nurturance. Knowledge provision involves the teaching aspects of the
role; and outright knowledge provision, anticipatory guidance, and networking skills
were all items of learning. Congruence again is the ability to be genuine and honest,
making it a critical component of the entire intervention.

The oncology clinic nurse provided nursing care that was accountable,
responsible, comprehensive, continuous and coordinated. The oncology clinic nurse was
in a collaborative relationship with the specialty physician as well as the primary care
physician. The patient and family were at the center of the plan of care and were

members of this collaboration. The aspects of caring: knowledge provision, empathy,

32
congruence, mutual respect and nurturance, are integral to the collaborative effort of

oncology patient care, as well as to the provision of nurse caring.
W

This secondary analysis used data collected from Wave 4: evaluation of
effectiveness of the intervention and the extent to which the clinic services meet the
continuing needs of patients and their families. Wave 4 measurement was done of
patients who completed 15 visits with the oncology clinical nurse specialists,
approximately 1 year after intake into the study. Wave 4 consisted of (among other
things) a modified LaMonica-Oberst Patient Satisfaction Scale (LOPSS), Appendix A.

The measure of caring is the number of caring encounters with the OCNS. Since
this intervention is designed to be of a caring nature, so all encounters are presumed to
caring encounters and therefore, adequate measures of caring as provided by OCNSs.

The Wave 4 data was collected by telephone interview. Interviewers were
graduate assistants employed by Michigan State University, Department of Family
Practice, College of Human Medicine, and were specially trained by detailed interviewer
training, including a procedure manual for protocols, mock interviews and regular
follow-up by monthly taped interviews.

The subjects were interviewed at entry into study (Wave 1), 3 months from initial
contact (Wave 2), 6 months (Wave 3), 9 months and 1 year (Wave 4) from initial entry
into the study. The medical intervention may be surgery, radio- or chemotherapy, or
palliative care. Nursing interventions were based on patient needs. After each interview
the subjects were sent a Self-Administered Booklet with questions to complete. Wave 4

was at 1 year from initial entry into the study and was not related to phase in the

33

treatment, but from phase in the nursing intervention. The satisfaction survey proposed
for use in this secondary analysis is from the mailed self-administered questionnaires,
consisting of 32 items. It was administered during Wave 4, i.e., 12 months after entry
into the study. The basic statement of the survey is, “The nurse in the rural clinic...”, to
which the patient responded on a 5 point Likert Scale from Strongly Agree to Strongly
Disagree.
Protection of HM

Human subjects protection was sought from UCRIHS and obtained for the
primary study, # 91-27 7. Subjects were informed that their participation was optional and
would not affect the quality of their care from other settings and providers. Subjects were
assigned a case number and all contacts for data 'collection are by telephone, thus
ensuring privacy. Since this is a secondary analysis, an exempt from full review human
subjects approval was sought for this investigation. UCRIHS approval # 96-066 was
granted for this study. (See Appendix B).
ngational definitions

The operational definition of caring will be the number of caring encounters with
the OCNS to include office visits as well as telephone contacts. Since these encounters
all have caring as the basis of the intervention, every encounter will be considered to a be
a caring encounter.

The operational definition of patient satisfaction will be the score on the
LaMonica-Oberst Patient Satisfaction Scale (LOPSS). A mean score of at least 4.00 or
better was considered to be a satisfied patient, since they are at minimum agreeing on

average with most items.

34
Instrumentation

For the purposes of this study, a modified LOPSS was used (Appendix A).
Patient satisfaction is notoriously difficult to measure. Typically, patients respond with
positive reports of satisfaction. This scale used negatively worded items to avoid this
pitfall. In previous uses, the LOPSS reported positively skewed findings. In development
of the LOPSS, La Monica et al. (1986) attempted to develop a tool free of positive
skewing. Coefficient alpha for the entire scale was reported to be .95 (La Monica et al.,
1986). Three subscales were identified by LaMonica et al., dissatisfaction, interpersonal
support and good impression. The subscale factors reported high internal consistency,
(coefficient alpha = .91, .92 & .89). Subscale to subscale intercorrelations support
dissatisfaction as separate from other factors. COrrelations are: dissatisfaction with
interpersonal support r = .59; dissatisfaction with good impression r = .58; and
interpersonal support with good impression r = .74. Psychometric testing of the LOPSS
by Munro et al. (1994) demonstrated construct validity. Construct validity is the degree
of actuality with which the instrument actually measures what it is supposed to measure
(Brink & Wood, 1994), and may be asserted by several approaches: contrasted groups,
experimental manipulation, and multitrait-multivariate method. Munro et al. (1994), in
using three contrasted groups, tested the LOPSS with Cesarean section patients, women
with gestational diabetes, and nononcologic hysterectomy. The findings reported this
scale to be useful in measurement of patient satisfaction across these groups. Cronbach’s
alpha was recomputed for the proposed study, since this was a different sample and using

revised scale.

35

Scorin

Values are assigned to each response: 1= Strongly Agree, 2= Agree, 3= No
Opinion, 4= Disagree, 5= Strongly Disagree. Positively worded items were reversed
scored, and then a mean score for the entire scale was obtained. A score of 4.00 was
considered to be indicative of satisfaction since that indicated agreement with positively
worded items and disagreement with negatively worded items.
W

Patient satisfaction was measured and compared to the number of caring
encounters made. The null hypothesis is that patients having fewer caring encounters will
be equally satisfied as the patients having a greater number of caring encounters. The
alternative hypothesis is that patients receiving the greatest number of caring encounters
will show the greatest satisfaction with their care. Correlation coefficient (Pearson’s r)
were employed to determine if there was a relationship between the number of caring
encounters and patient satisfaction.

Data

Of the 68 patients eligible for this analysis, 19 did not return their survey. Of the
remaining 49, the satisfaction data was not available for 2, leaving an n= 47 (Attrition
rate of 38 percent). Cronbach’s alpha for the modified LOPSS was 0.9627 for this
sample, indicating high internal reliability.

Respondents were asked to rate their satisfaction on a 1 through 5 scale. Since
some of the items were positively worded and some negatively worded, positive items
were reversed scored. For the positively worded items, items # 1-13 and 28- 32, the

response of the patient was recoded to be a consistent value. 1= 5, 2=4, 4=2 and 5=1.

36

From this recoding a mean patient satisfaction score was obtained for each patient. The
total possible mean to indicate complete satisfaction would be 5.00. Satisfaction was
assumed when mean scores were at least 4.00 or better, since that indicated disagreement
with negatively worded items and agreement with positively worded items (See Table 3).
Table 3

Central Tendencies

 

 

 

ladable .. IrMflrMsdmL Mode
Mean Satisfaction 4.592 4.813 5.00
Caring Encounters 10.511 11.000 7.00/ 13.00

 

The mean number of encounters of caring was 10.51], with an SD of 4.413 and a
range of 19 encounters (1-20), n=47. The median number of visits was 10, and the
sample was bimodal at 7 and 13 visits. There was good variation in number of
encounters.

The mean satisfaction score was 4.592, SD = .486, range of mean individual
scores of 3.25 to 5.00, with 12 perfect 5.00 scores (n =47). There was no data available
for 2 cases of the 49 surveys obtained for mean satisfaction, and little variation in scores
of satisfaction. The surveys for the 2 cases for which no data was available were returned
blank, these patients saw the OCNSs only 1 and 4 times. It is possible these patients
experienced no satisfaction or they did not feel qualified to evaluate the caring

intervention.

37

A correlation coefficient (r) was then computed for mean satisfaction and the
number of encounters of caring (r =.2985, df = 46, p < .05, p = .021). This was
statistically significant. This signifies a moderate correlation between the number of
caring encounters and the patient satisfaction. Data indicates that as the number of caring
encounters increased, patient satisfaction was moderately positively effected.

Upon examination of raw scores of satisfaction of 10 patients scoring less than a
mean of 4.00, several items showed a higher incidence of less than complete satisfaction.
Items number 31 and 32, communication with family members and collaboration with
other health care services and providers, had the highest incidence of no opinion/ no
response, or no information. The number of no opinion responses for 31 and 32 were 9
and 7 respectively, each item was left blank two times. The OCNSs may not have
communicated with the family well enough. Perhaps this is related to lack of family
involvement, no family to involve, or other health care services were not needed. It must
also be remembered that some individuals may not be satisfied by any intervention. For
caring to be effective there must be communication. Perhaps these patients who indicated
less than perfect satisfaction did not communicate their needs to the nurse providing the
caring intervention.

Items 14, 15 and 16 also had a higher incidence of less than complete satisfaction.
These items were negatively worded, sanctioning a negative response. Item 14 examines
whether there was a perception of individuality; 2 no opinion and 3 agree. Apparently,
patients felt more often like a case, than an individual. Again, any rationale behind this
would be speculation, since we have no qualitative data regarding this response. Items 15

and 16 examine the perception of speed of follow-up and thoroughness. There were 3

38

responses of agreement, 1 response of strong agreement for each. Item 16 also had 2 no
opinion responses, where item 15 did not. Patients responded that they felt things should
have been handled more thoroughly, and speedily. Perhaps the patients had too many
needs for everything to be handled.

Items 20, 21 and 24 are a third group of items that show less than perfect
satisfaction. Again, these items are negatively worded, sanctioning negative response.
Item 20, “is impatient with me”, was the one item that received the most negative
scoring, with 3 patients expressing no Opinion, 1 patient agreeing, and 4 patients strongly
agreeing. Items 21 and 24 are “acts like I cannot understand the medical explanation of
my illness”, and “fails to consider my opinions and preferences ...” . Item 21 had 4 no
opinion responses; item 24 had 5 no opinion responses. These may be areas of
communication nonsuccess.

No significant demographic trend could be identified from the 10 patients whose
mean satisfaction was less than 4.00. Patients with a mean score of less than 4.00 tended
to be primarily women, 80 percent; married (6/ 10), widowed (3/ 10) and divorced (1/10);
cancer sites were breast (5/10), colon (3/ 10), ovarian (1/10) and prostate (1/ 10).

A point of consideration; the patients received the caring intervention in 3
different clinics, by 4 different providers. The scores were not categorized or analyzed by
the clinic in which caring took place. Nor were the clinic personnel, and accessibility of
that clinic equal throughout the intervention. It could also be possible that the clients
indicating less than 4.00 as a mean satisfaction were provided with caring that
encouraged them to comment on areas needing improvement. This may be a strong

indicator of effectiveness of communication and support by the OCNSS. “Differing levels

39

of satisfaction may, therefore, indicate different perspectives on nursing care quality
rather than different amounts of satisfaction with the same thing” (Bond and Thomas,
1992). It is possible that the differing levels of satisfaction then may indicate a trend in
the willingness of the patients to indicate not so much satisfaction or dissatisfaction, but
areas needing improvement and areas meeting expectations.

It must be emphasized that by far, patients agreed or strongly agreed with the
positively worded items and strongly disagreed or disagreed with the negatively worded
items. The vast majority of responses were therefore indicative of patient satisfaction.
The hypothesis of this study is supported; that nurse caring would have a positive
relationship with patient satisfaction.

Discussion

The hypothesis proposed by this investigation was supported. OCNS caring
moderately related to (r = 0.2985, p=.042) patient satisfaction. Considering the results, it
is apparent that specially designed caring interventions provided by OCNSs are
moderately positively related to patient satisfaction. The act of caring through knowledge
provision, mutual respect, congruence, empathy and nurturance provided a moderate
positive relationship towards gratification of health care needs.

The findings of this study would accentuate APN practice to be an asset to health
care. Since patient satisfaction has been linked to greater adherence, increased patient
participation and increased likelihood of continued use of the provider, the advantage of
using an OCNS’s to provide care to rural cancer patients becomes clear. Decisions

regarding care seeking, reactive behavior, proper utilization of health care resources may

40

be made with more information and less emotion with patients satisfied with the caring
provided by nurses.

Health care, and nurse caring, is not provided in a vacuum. It is a business, a
major part of the country’s Gross National Product in fact. In order to remain viable, this
business must encourage “repeat customers”. Providing caring, the OCNS’s have
demonstrated that they are a valuable asset to the “company," since their caring is related
to increased satisfaction and return visits.

Again, as in previous patient satisfaction studies, little variation in satisfaction
scores is noted. With satisfaction rates in the literature ranging from 92-97 percent
(Kurata et al., 1992; Woolley et al., 1978), there is little room to improve. Patients are
infinitely diverse individuals, with infinite factors that affect perception of satisfaction. It
is foolhardy to expect to develop an intervention that will satisfy completely everyone.
This is not to say satisfaction is not a significant outcome to measure, since it does have a
significant effect on patient behaviors, such as adherence, utilization and participation.

Communication is again an area where satisfaction is less than optimal. This area
did not meet the patients' expectations. Communications must be clear, and APNs are
traditionally strong in this facet of practice. Again, the infinite diversity of the patients
may account for the lack of complete satisfaction with the communications skills of the
APNs. Conversely, it may also be that the APNs in this intervention communicated
information to the patients that was not desired. For example, some patients in this
investigation may have just wanted to know the bare minimum, in the patriarchal mode
of treatment. It is possible that these patients were dissatisfied by the amount of

communication, that is to say, they may have wanted the professional mystique to

41
continue. Being kept informed by the APN may have required the patient to take a

responsibility for themselves that they did not wish.

The components of caring in this investigation were not exhaustive, nor can they
be carefully measured or controlled between providers. Additionally, the question arises,
is caring an irreducible concept; unable to be measured in parts, because the whole of
caring is greater than the sum of parts. Again, caring’s indistinct definition makes it
difficult to measure.

Since health status is a causal determinant of satisfaction with medical care (Hall,
Milburn & Epstein, 1993), it can be extrapolated that health status may also affect the
patient satisfaction with OCNS caring. With the findings of this investigation, that OCNS
caring was positively related to satisfaction in light of a life-threatening illness, the value
of OCNS caring is documented. That is to say, since most persons would not consider
themselves healthy when they are diagnosed with cancer, it is a negative health status.
These patients, although experiencing negative health, continued to rate their satisfaction
with OCNS caring highly, in spite of the negative health status.

The lack of significant effect of income and education level may be due to several
factors. Data is lacking regarding the number of respondents who indicated their income
(11 = 39), and education (n = 46). This may have been too small a sample to adequately
measure any differences. There was little variability; therefore for an effect to be
significant, the numbers would have had to be much greater.

Admuag of Theoretical Model
The model of Watson’s (1988) theory with satisfaction was an adequate

representation of the proposed relationship. However, it was difficult to accurately depict

42
the relationship of caring with satisfaction, as it appears in the model as a sequela of

caring. Through this investigation a moderate, not causal, relationship occurred. The
model (Figure 2) does depict the caring occasion occurring with knowledge provision,
mutual respect, empathy, congruence and nurturance during the encounter, with
satisfaction measured after the encounter. This demonstrates patient satisfaction as a
phenomenon that is measurable following a caring encounter. The model was effective in
it’s application to advanced practice nursing.
Limitations

There are several limitations to the design of this study. A major limitation is the
difficulty associated with measurement of patient satisfaction. The lack of a tool that is
not positively skewed in measurement of the satisfaction limits this investigation. This,
however is a global problem in measurement of patient satisfaction. Sources of error in
measurement of patient satisfaction lie in social desirability and acquiescent response set
(Brink & Wood, 1992; Pascoe, 1983; Ventura et al., 1982). Social desirability is defined
as the subject response is what they believe is the positive social response (Brink et al.,
1992). Acquiescent response set is defined as consistent agreement or disagreement with
the questions (Brink et al., 1992). Munro et al. (1994) recommends development of more
sensitive items to avoid acquiescence response set. To date, no more sensitive instrument
has been developed. The modified LOPSS distributed by this investigation attempts to
reduce the bias of social desirability, as well as acquiescence response by balancing the
positively worded items with negatively worded items. Negatively worded items
acknowledge the possibility of dissatisfaction and therefore sanction negative responses.

Patients being surveyed then feel it is acceptable to respond negatively. Munro et al.

43

(1994) recommend input from patients for the development of a more sensitive pool of
items. This investigation did not attempt this, however.

The use of non-probability sampling to obtain participants also allows for bias.
The sample used may not be truly representative of all rural cancer patients and this
limits generalizability. The participants in this investigation have the opportunity to self
select themselves into the study. This allows for participants who are open and possibly
eager to experience the care of a OCNS that may bias their perceptions. Lack of a control
group is also a limitation, however it is not ethical to withhold treatment from cancer
patients, so an experimentally pure control group is not ethically possible. It would be
possible to provide “regular care” in the community, as a control group, but this
investigation did not attempt this. This study does not include a limited caring control
group. Extraneous variables of race, social support, previous health status, previous
negative health care encounters and general life satisfaction were not included in this
investigation. Minorities are not excluded; however the demographics of the area
residents do not include a high minority population. This will limit generalizability to
rural minority groups.

Since cancer is a disease that sometimes causes death, attrition is somewhat of a
limitation. Some participants did not survive a year to participate in Wave 4, and hence,
were unable to evaluate the caring of the nurse and how it affected their satisfaction.
Conversely, some of the subjects were diagnosed and completed treatment early in the
disease process. These patients are discharged from the intervention early, and do not
require 15 visits; so have fewer encounters of caring by which to evaluate their

satisfaction. These clients were included in the study.

44

Requiring participants to mail the surveys back accounted for some attrition in
data collection. Participants may have chosen not to complete the survey, forgotten, been
too ill, or too close to death. Efforts were made to collect this data through reminder
letters and telephone calls, but some data were still lost.

Secondary analysis of data limits investigation due to the inability to collect the
exact information desired. The researcher must use what is available and measures used
by the primary researcher. The attempt is made to fit the question to the available data, as
opposed to designing the data collection to fit the question.

A final limitation of this investigation is the aforementioned indistinct concept of
caring. Although this investigation defines caring, each practitioner will interpret and
perform the caring intervention in a personal manner. It may be a limitation by assuming
each encounter was a caring encounter, since each encounter was not observed

Implications
Practice Implications

Implications for practice of the APN abound. Satisfaction is a useful and
valid tool to measure the concurrence between the patient’s expectation of nurse
caring and their perception of the actual nurse behaviors/characteristics. The
consequences resulting from satisfaction; adherence to health care regimen,
increased participation of the patient and positive influence to continued use of
health care again may be extrapolated from this study. These characteristics may
make the population utilizing APNs proactive in their health care, increasing the
overall health of the population. Additionally, there may be a greater demand for

caring as provided by APNs.

45

Adherence to health care regime may result in more appropriate use of the
health care system. For example, the patient who because the APN was able to
communicate the importance of continued regular use of anti-emetics may not
need to seek care in an emergency department related to dehydration from
chemotherapy. In lack of understanding and adherence, this patient will over
utilize, the system leading to increased costs. Another example, a patient educated
about the side effects of the medication may be aware of what to expect and
choose to continue therapy, knowing this is expected. This patient would then not
under utilize services, which may lead to potential for increased failure to cure
rate. This ultimately would cost the system more in time spent on cure at a later
stage of the disease process, and work force in attempt to effect that cure.

Increased patient participation in the cure process may result from the
APN caring intervention which provides psychological support. The post-
mastectomy woman, experiencing limitations in arm movement, who due to the
APN caring, does her arm exercises outside of the physical therapy session will
most likely return to full range of motion sooner than the patient who faithfully
goes to physical therapy, but only does her range of motion at physical therapy.

Managed care relies on the ability to continue to keep patients in the
system. Although they may ultimately cost the system more than they have
contributed by the payment of premiums, there are intangibles involved. The
intangible factor of goodwill developed by the patient whose participating APN
who aids them through the crisis of acute cancer treatment. Not all cancer patients

die, and as in this study, some are quite young and may remain vital and part of

46

the system for some time. These patients may, after acute treatment, become once
again become less costly to the system. Another area of goodwill may develop
from the family members who are not and may not be consumers of the health
care system at the moment the patient is. The patient who is provided with caring
by the HMO participating APN probably has family. These family members are
going to remember the caring from the APN and the HMO who allowed them to
utilize her services. If those services eased the death of the loved one, and
consequently satisfied the family, there will be the intangible goodwill of desire
to stay with that HMO because “they really took care of Nana well”, with the
unspoken thought that “I want them to take care of me that well”.

Areas identified as having less than optimal satisfaction in this study,
reiterate areas where satisfaction traditionally is less than optimal. These areas
being: communication and; thorough and speedy follow-up (Kurata et al., 1992;
Bowers et al., 1994; Elgin, 1990; Pascoe, 1983; Wooley et al., 1978). For the
APN in practice, this means attention must be paid to communication style and
practical items, such as, waiting time. Recognition of the individuality of each
patient’s situation is a critical strength of the APN. The site and staging of the
cancer is important, as well as family situation, presence of caregiver, social
resources and age. This is where APNs are most suited to the primary care of the
patient. The holistic focus of caring allows the APN to evaluate for the effect of
the myriad of factors influencing the response to the actual or potential health
problems. Although in this investigation, the APNs did not score complete

satisfaction with all patients, their caring was moderately related to satisfaction

 

47
experienced by the majority of the patients. APNs must be cognizant of and

continually honing the holistic focus of their caring. APNs may use the
documentation of increased satisfaction with care as a marketing tool,
documenting the value of the APN to any health care practice, or corporation.

The documentation of caring as a valuable, indeed integral part of patient
satisfaction, an outcome measurement, articulates the need for a paradigm shift in
the education of nurses. Bevis and Watson (1989) suggest a shift towards a caring
cuniculum. Bevis (1989) believes the current nursing curriculum operates in a
masculine, behaviorist paradigm. She states this is appropriate for memorization
and skills learning, however, nursing is much more than memorization and skills.
Bevis (1989) declares “nursing and education are feminine fields” (pg. 4) and as
nontraditional, human sciences the fields of nursing and education require open,
flexible, whole theories which allow for multiple realities, and encourage intuitive
learning.

Watson (1989) advocates that the development of a human caring
curricula “requires a personal, social, moral, scientific and spiritual engagement
of the nurse educator and a commitment to self and other” (p. 42). She promotes
the development of a framework accommodating of “an evolving personal
consciousness” allowing for “methods that attend to moral ideals and values that
are relational, subjective inner experiences while honoring intuition, personal,
spiritual, cognitive and physical senses alike” (p. 53). Watson (1989) further

describes a human caring-human science perspective to curriculum development,

 

48
combining and integrating cognitive with beauty, art, esthetics, intuition and

spiritual awareness of the human caring process.

To teach caring Watson (1989) makes the following recommendations:
1) Modeling- educators who encourage self-affirmation and self-discovery model
caring. Teaching moments become caring occasions; 2) Dialog- genuine dialog
opportunities between faculty and students must be created; 3) Practice- caring
theory can first be applied in the educational setting and then moved to the
clinical setting; 4) Confirmation- in the educational caring occasions, nursing lays
the foundation for human caring in health care.

Bevis (1989) proposes the following goals of a paradigm shift and projects
the anticipated impact should this shift occur: A

1) Nursing graduates would be more responsive to societal needs.
“Nursing has a unique societal mission: to care for the vulnerable and to provide
caring services in prevention, cure and maintenance” (p. 350). To meet this goal,
nurses must become politically effective in shaping health care policy. The
finding of this study of patient satisfaction being moderately positively related to
nurse caring would be an area where APNs may demonstrate and seek a voice in
health care policy. Obtaining third party reimbursement for the “caring” service
would be a first step.

2) Critical thinking skills form the second goal of the paradigm shift
(Bevis, 1989). Using a scholarly approach to client and societal problems and
issues is another part of caring. Too often nurses are ‘trained’ on what to do, but

not educated how to think. Educating nurses how to provide caring will again

49

provide the reinforcement of the relationship of caring and satisfaction,
potentiating the adherence to health care recommendations, increasing the
likelihood of return visits, and increasing patient participation, thus paving the
way for increased health on the part of the population served by caring nurses.

3) Humanization of the complex and technological health care milieu is
the third shift to take place. Bevis (1989) proposes increasing the exposure to arts
and humanities as a means to do so. The caring received by patients in this study
took place in a ‘human’ manner.

4) The fourth goal of the paradigm shift is to increase the nurses insight
into ethical and moral issues, so that they may become better patient advocates
for these issues. Caring “cannot be a means, but must be an end in itself“ declares
Bevis (1989). This study does not specifically increase the insight into these
issues, but does suggest caring as a valued process in nursing.

Implications for Educating Caring

The study accentuates how nurses must be educated in caring. That
nursing currently operates in a behaviorist mode, with outcome criteria in each
course, which must be met and demonstrated before one is able to progress in the
curriculum is evidence of this. In fact, outcome measures, one of which is patient
satisfaction are also masculine and behaviorist. The development of a paradigm
shift in health care which examines the wholeness of theories accommodating a
personal consciousness may negate the need for such measurements. Caring

would become the standard by which all nursing is applied.

 

50
All of nursing must shift to that of a caring paradigm, for by doing so, it

will not only relate to patient satisfaction, but also to the valuation of caring in
society. For this, nursing must be educated, to practice and model caring. Nursing
must also educate and create an awareness in society of the absolute value of
caring, creating the necessary policy shifts.

Research Implications

Further research for Clinical Nurse Specialists/Nurse Practitioners lies in several
areas. First, although measurement of caring “takes away” from the caring encounter
(Watson, personal communication, March 10, 1996), we continue to work in a
behaviorist milieu, therefore a means to define and measure the concept must be
developed. Caring is that entity which is central to nursing. To define ourselves and that
“commodity” which we nurses are bringing to society, we must document its existence
and the outcome it has on patients. By definition of this “commodity, " APN practice may
be brought to the forefront of the health care system; which at this time emphasizes cure
over care (Watson, 1988).

Williams (1994) proposes patient satisfaction is artificially constructed by forcing
service users into evaluating service with unfamiliar terms. He further suggests that
providers need to identify the perception of patient satisfaction from the patient
perspective, and develop tools from this direction. Munro, et al. (1994) make a similar
recommendation to involve the patient. Areas of examination might include qualitative
and quantitative work to include the patient in development of a tool to measure caring
and subsequent satisfaction with caring provided by APNs. Investigating satisfaction and

the effectiveness of other APN practices (Jones, 1993) would further document

.37

51

effectiveness, and build a greater research underpinning to nursing practice (Rettig,
1991)

Hence, a second recommendation is development of a tool, free of skewing, by
which to adequately measure patient satisfaction with nurse caring. Although this seems
to contradict earlier statements by this author, we again must recall that nursing currently
practices in a behaviorist milieu, which requires documentation of phenomena. To
develop this tool, APNs must involve the patient and develop qualitatively a set of
themes which are truly evaluative of advanced practice nursing. From these themes, a
tool maybe developed that will accurately measure patient satisfaction with advanced
practice caring.

A third recommendation for further research in patient satisfaction with OCNS
caring might relate overall health and life satisfaction. Since not all health care is
received by healthy people identifying the factors that lead to satisfaction and
dissatisfaction that are within the realm of nurse caring would be worth investigating.
Considering the findings of Roberts et al (1983) and Hall et al (1993), that patients with
generalized feelings of well-being and life satisfaction and had greater overall feelings of
satisfaction with health care, it would be interesting to examine the relationship between
prior health status, general life satisfaction and patient satisfaction with nurse caring. A
much larger sample size would also be needed to develop relationships between the
extraneous variables of income, education level, site and staging of cancer. Insurance,
social support, previous negative health care encounters are also variables which could
also be examined in light of satisfaction with OCNS caring. A replication of this

investigation, controlling for the additional variables mentioned.

 

52
Fourth, Ben Sira’s (1982) finding that satisfaction with a physician’s affective

behavior greatly influences the evaluation of professional competence must be examined
in light of Fosbinder’s (1994) finding that patients value nurses’ interpersonal skills
highly and relate these skills toward technical competence. Does the conclusion of Ben
Sira extrapolate to nursing, and will patients evaluate APN’s as being more, or less
competent as a result of the evaluation of their affective (caring) behavior? Does this
mean that since nurses are experts in caring, which is often perceived affectively, they
will be accorded higher competence ratings? Will this matter to the patient utilizing an
APN? Will it make the patient seek out the services of an APN over a physician perhaps,
given all other variables being equal? It would be very interesting to determine what
effect the Clinical Nurse Specialist/ Nurse Practitioner would have on patient
satisfaction.

Advance practice nurses, be they Oncology Clinical Nurse Specialists; Pediatric,
Adult or Family Nurse Practitioners, Nurse Midwives, or Clinical Nurse Specialists, by
virtue of their advanced education should be experts in caring. They must document and
market this facet of their practice. They must also share this caring expertise with other

nurses .

APPENDIX A

SATISFACTION wr'rrr CARE FROM RURAL CLINIC

 

.(Check one response for each of the following:)

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. $51.". {:1 .. ' "1w .- _ :11.” _.‘ ,w’l
mamrnz RURALCLINICA ‘-,;~" ' j ' Agree":
., - Q ~_‘,.,.’,'.:.‘. p."_' :3”. “v ‘, - .' .. . .1 {v ;,-_ ' g

..
.
Agree "

Neither
Agree nor,
Disagree

Disagree

Strongly .
Disagree

 

ls gentle in caring for me

 

Helps me to understand my illnas and treatment

 

Understands me when [share my problems

 

ls available when 1 need support

 

Giva the imprssion my care is top priority

 

Make me feel secure

 

Give complete explanations and information

 

Giver irutruetions and information

 

Appers to enjoy caring for me

 

Malta me feel like 1 can share my feelings

 

Does things to make me more comfortable

 

Makes me feel better by jmt talking

 

Service provided by nurse was helpful

 

Makes me feel like a 'ase." not an individual

 

Do: not follow through quickly enough

 

Should be more thorough

 

lsnotasfriendlyassheeouldbe

 

Sea-n: more intersted in completing tasks than listening to my concerns

 

 

Negleets to be sure I understand the ‘u-nportance of my treatments

 

 

 

 

 

 

53

 

54

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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hnetuethntlveasshuheuldhe

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hint-amide! my ”Hound's-I’m regaring plan for my

core

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unhelpful

 

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prul

 

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problmertrmtmmt

 

Mymbeuwhoassindmewltbcarefomdthsmvlsluend
“conduit-l ‘

 

 

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h-lthmpnviden

 

 

 

 

 

 

 

APPENDIX B

 

MICHIGAN STATE

ll ft l \f E It Si l 1' Y

Aprll 25. tset

1o: luria uctvo
use Karen r.
Nowell. l" 40“!

.. : se-eee
“‘° }§¥:.; rat nttarroosnrv or'ocus nurse canxuc rucouurrns

AID PATIENT SATISMTCN
WISH)! RWY“): NIA

cartoon“ l-I
APPROVAL DATE: 02/15/96

the Univerait Co-iittee on teaearch Involvi Iii-nan sub ecto' menus)
review of thlz project in cowlete. x are planed to adviae that the
right. and unaltere ot the hu-ao euhjecta appear to be adequately
protected and cathode to obtain infer-ed conaent are appropriate.

retore. the UCRIHS approved thia project and any rewiaioua listed
above. ~

am: DCIUIS approval is valid (or one calendar year. beginning with
the approval date ahovm above. Inventigatora planning to
continue a proyect he cl one year mat uae the green reneuat
for- (enclosed with t original gproval letter or when a.
pro'ect la reneved) to seek t certification. Thereus a
ax”. at four such upedlit renewals aaihle. Investigators
a a

rag to continue a reject beyond the time need to out-it it
again or coqalete re ew.

 

arvraronaa venues aunt. review an

changea in, .a' i 1 ° hum:
mhjecta. ior to inztiation of tamer-.3: ?:°thi:gia 4.3... hr
the time o renewal. please use the eon eneual (ore. ‘I'o

reviae an ground protocol at an 0 her I; on during the year,

and yo tten request to the ms Chair, regueating rcvraed

approval and referencing the project's In I and irle. lnclcde

in request a deacription o! the clung. and any revised

in: ru-ento. cooeent (cm or advertlaenenta that are applicable.
eamml
We

Should either of the E ll ' 1 d..,_-- h
Bork, lmoti atora “2‘ gm ar ea "'9 t e course of the

nus roaptly: (ll rohleao
tune cred a de ettecta atnt , . '
m5?“ at he?” a ere l involving noon

‘2) reaearch environment or new
information ndicatlng greater tie); to the human nub ecta than
existed when the protocol was preVioualy reviewed an approved.

If we can be of any future help lease do not: hesitate to contact in
at (517)355-2100 or en: t51vie i- 171.

sincerely.

, ‘,..‘4...;..€.} 51 (J,

David I. lright. 911.0.
ucuus Chair

DIN : bed

  

cc: Charlel Gives"
Barbara 3. Given
Linda Beth Tiedje

55

56

MICHIGAN STATE
UNIVERSITY

Rarch s. 1996

To: Charles'civen
8100 Clinical Center

RE: IRBH: $2.277
TITLE: - ETEAL PARTNERSHIP LINKAGE FOR CANCER CARE
REVISION REQUESTED: N A
CATEGORY: F722 REVIEW
APPROVAL DATE: 03'04/96

The University Committee on Research Involving Human Subjects'(UCRIHS)
review of this prOJect is cor;.ete. I am pleased to adVise that the
rights and welfare of the harsh subjects appear to be adequatel

rotected and methods to obtain informed consent are appropriate.
gggrefore. the UCRIHS approve: this project and any reVisions listed
a V8.

RENEHAL: UCRIHS approval is valid for one calendar year. beginning with.
the approval date shown above. Investigators planning to
continue a project heyond one year must use the green renewal
form (enclosed with tne original agproval letter or when a
project is renewed to seek u date certification. There_is a
maximum of four strh expedite renewals possible. Investigatzri
wishing to continue a project beyond that time need to submit -1
again or complete rsView.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects. rior tt.initiation of t e change. If this.is done a:
the time o renewa-. please use the green renewalDform. To
revise an approved trotocol at any other time during the year.
send your written reruest to the CRIHS Chair. requesting revise:
approval and refershCing the project's Inn 3 and title.. Include
in your request a description of the change and any revised
instruments. consent forms or advertisements that are applicahle.

PROBLEfiS/ '

CHANGES: Should either of the followin‘ arise during the course of the
work. investigators oust noti UCRIHS promptly: (l) roblecu
(unexpected side effects comp aints. etc.) involving uman
subjects.or 52) thingss in the research environment or new
information indicating greater risk to the human sub ects than
existed when the ;r::ocol was previously reviewed an approve:

If we can be of any future heir. lease do not hesitate to contaCt us
at (517)355-2180 or FAX (517 6:2- 171.

\1 w

avid E. Wright. Ph.D.
UCRIHS Chair

DEH:bed

  

cc: Barbara A. Given

LIST OF REFERENCES

LIST OF REFERENCES

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Baer, E.D. & Gordon, S. (1994). Money Managers are unraveling the tapestry of
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Bauman, MK. (1991). The importance of outcome measurement in quality
assurance. Holistic Nurse Practitioner, 5(3), 8-13.

 

Benner, P. & Wrubel, J. (1989) Primacy of CaringReading, MA: Addison-
Wesley Publications.

Bevis, E0. (1989) Introduction. In Bevis, E.O. & Watson, J. (Eds) Toward a
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Bevis, ED. (1989) Making a difference. In Bevis, E.O. & Watson, J. (Eds)
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Bond, S. & Thomas, LR (1992) Measuring patients’ satisfaction with nursing
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Bowers, M.R., Swan, J .E. & Koehler, W.F. (1994). What attributes determine
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Boykin, A. & Schoenhofer, S. (1993). Nursing as caring. New York: National
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Brink, P.J. & Wood, M.J. (1994) Basic steps in planning nursimesearch: From
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Burfitt, S.N., Greiner, D.S., Miers, L.J., Kinney M.R., & Branyon, ME. (1993).
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Cohen, J .A. (1991). Two portraits of caring: A comparison of the artists,
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Costello, R.B. (Ed) et al. (1992). Random-House Webster’s college dictiongy.
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DiMatteo, M.R., Sherboume, C.D., Hays, RD. Orway, L., Kravitz, RL.,
McGlynn, E.A., Kaplan, S. & Rogers, W.H. (1993). Physicians’ characteristics influence
patients’ adherence to medical treatment: Results from the medical outcomes study.

Healfl; Psychology, 12(2), 93-102.

Duffy, J .R. (1992). The impact of nurse caring on patient outcomes. In D.Gaut
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Nursing Press #15-2465

Elgin, SH. (1990). Staying well with the gentle art of verbal self-defense.
Englewood Cliffs, NJ. Prentice Hall. '

Eriksen, LR. (1995). Patient satisfaction with nursing care: Concept clarification.
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Fiesta, J. (1991). QA and risk management: Reducing liability exposure. Nursing
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Fosbinder, D. (1994). Patient perceptions of nursing care: An emerging theory of
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Given, B. A. & Given, C .W. (1995) Description of interventions. Unpublished
Manuscript.

Hall, J .A., Milburn, M.A. & Epstein AM. (1993) A causal model of health status
and satisfaction with medical care. Medical Care 31(1), 84-94.

 

Hammond, C., Chase, J. & Hogbin, B. (1993). A unique service? Nursing Times
July 26, 91(30), 28-9.

Hegyvary, ST. (1991). Issues in outcome research. Journal of Nursing Quality
Asaurance, 5(2), 1-6.

Hill, J. (1993). Healthworld theory: A universal language of caring. In:
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Nursing Press #15-2514.

59
Hinshaw, AS, and Atwood, J .R ( 1982). A patient satisfaction
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Huggins, K.N., Gandy, W.M. & Kohut, CD. (1993). Emergency department
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Jacono, B]. (1993) Caring is loving. Journal of Advanced Nursing, 18(2), 192-
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