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Healthcare organisations monitor patient experiences in order to evaluate and improve the quality of care. Because nurses spend a lot of time with patients, they have a major impact on patient experiences. To improve patient experiences of the quality of care, nurses need to know what factors within the nursing work environment are of influence. The main focus of this research was to comprehend the views of Dutch nurses on how their work and their work environment contribute to positive patient experiences.
A descriptive qualitative research design was used to collect data. Four focus groups were conducted, one each with 6 or 7 registered nurses in mental health care, hospital care, home care and nursing home care. A total of 26 nurses were recruited through purposeful sampling. The interviews were audiotaped, transcribed and subjected to thematic analysis.
The nurses mentioned essential elements that they believe would improve patient experiences of the quality of nursing care: clinically competent nurses, collaborative working relationships, autonomous nursing practice, adequate staffing, control over nursing practice, managerial support and patient-centred culture. They also mentioned several inhibiting factors, such as cost-effectiveness policy and transparency goals for external accountability. Nurses feel pressured to increase productivity and report a high administrative workload. They stated that these factors will not improve patient experiences of the quality of nursing care.
According to participants, a diverse range of elements affect patient experiences of the quality of nursing care. They believe that incorporating these elements into daily nursing practice would result in more positive patient experiences. However, nurses work in a healthcare context in which they have to reconcile cost-efficiency and accountability with their desire to provide nursing care that is based on patient needs and preferences, and they experience a conflict between these two approaches. Nurses must gain autonomy over their own practice in order to improve patient experiences.
The organisations we recruited are participating in a Dutch programme called Excellent Care. The programme is based on the eight essentials of magnetism and focuses on creating a dynamic, inspiring and innovative nursing work environment in order to improve the quality of care. We asked the programme director of each organisation to recruit nurses for the focus groups. A total of 26 registered nurses participated. Each focus group consisted of 6 or 7 registered nurses in mental health care, hospital care, home care and nursing home care, respectively. The nurses described their perceptions and views with respect to their own areas of expertise.
Participants stated that social skills are an important competency to create a trustful care relationship. They indicated correct behaviour and attitude, composure, making time for patients, and listening and having empathy as essential nursing competencies. According to participants, these social skills convey a sense of commitment to the patient and play a major role in meeting patient expectations.
In addition to substantive expertise, participants stated that nursing experience is also of influence. According to them, a junior nurse has too little experience to respond creatively to sometimes complex care situations. However, according to participants, junior and senior nurses can learn from each other: they should work as a team and collectively pursue their common objectives. In their view, experience is gained through practice. According to participants, this can be characterised as 'expertise'.
As stated by participants, various activities can occur simultaneously during the daily care of patients. According to them, nurses should assess what care is needed and then flexibly coordinate diverse actions with each other. In the view of participants, prioritisation is about the organisation of nursing care. Patients need nurses who have clinical experience in order to coordinate care. Nurses must decide what choices to make, what is urgent and what is important. Those choices influence patient experiences.
According to participants, there is no policy to improve patient experiences on the basis of the information derived from assessments. Participants could not indicate whether the interventions deployed are actually leading to desired nursing care results, including patient experiences. Participants feel they have insufficient autonomy to influence this process.
Participants stated that the number of nurses available influences how patients experience the quality of care. Although they could not indicate what number they consider sufficient, they think that a sufficient nurse staffing level is linked to team composition or staff mix. For instance, participants indicated the proportion of registered nurses to student nurses, or the number of different nurse qualification levels in one team. Participants stated that several tasks and assignments have been transferred to nurses with a lower qualification in order to work as efficiently as possible and to achieve higher productivity. As a result, participants believe that nursing care is, in general, increasingly developing in the direction of task-centred care in which different working methods are applied. According to them, this affects patient experiences of the quality and effectiveness of nursing care.
The participants stated that control over nursing practice means that nurses are involved in nursing policy or nursing issues. In their view, nurses are not always in charge and cannot always make their own decisions about nursing issues. Participants feel that this affects the quality of nursing care.
The participants stated that if nurses were more involved in the development of nursing policies, this would have a positive influence on patient care. According to them, they would be able to reflect upon and discuss nursing issues related to the quality of patient care, which would improve the quality of care.
A manager, according to the participants, must be able to create the right conditions and have the logistical ability to ensure continuity of care. In their view, this means arranging sufficient personnel, replacement staff and succession planning.
Participants find that managers critically examine the deployment of personnel. According to them, the nursing staff mix has drifted towards a model whereby higher-educated nurses are replaced with lower-educated ones. They noted that management is tied to a system that is dominated by controlling costs. Thus in their view, nurses may want to provide a patient with a specific form of care, while management limits care to a maximum number of minutes based on budgetary considerations. According to participants, nurses regularly experience a tension with management in shaping care that meets patient expectations.
According to participants, the focus of nurses is the provision of patient-centred care. They define this as nursing care that is focussed on patient needs and preferences and is intended to increase patient self-management and encourage improved health and recovery.
The administrative workload is, according to participants, out of balance. They said that this means that monitoring and registration is aimed not at improving nursing care, but at serving an external accountability goal to inform health insurers and the government.
The participants stated that they have little autonomy to change this policy. According to them, monitoring care results should help nurses to improve their own practice. For them, it means that nurses can reflect upon and discuss nursing issues related to quality of patient care, including the results of patient experiences.
We interviewed 26 nurses working in various Dutch healthcare settings in order to ascertain their views on how their work and their work environment contribute to positive patient experiences. Using an open approach, we obtained insights into their perceptions and noted what they said. Participants stated that a diverse range of elements are essential to providing high-quality nursing care. When these elements are incorporated into daily nursing practice, the participants expect it will result in more positive patient experiences of nursing care. The elements are: clinically competent nurses, collaborative relationships, autonomous nursing practice, adequate staffing, control over nursing practice, managerial support and patient-centred care.
The other sub-question concerned mechanisms by which these elements lead to better patient experiences. By analysing the data it became clear that nurses operate in a complex healthcare context. These different views control the manner in which nurses can practise their profession. We noticed that nurses are confronted with organisation policies that are focussed on cost-efficiency, transparency and accountability goals. According to participants, this has led to a more productive care system. It also became clear that nurses flourish within a patient-centred care system. Such a system supports individual patients in their need to make decisions and participate in their own care. This means that organisations should facilitate a culture where nurses can professionally support patients by practising high-quality nursing care .
It could be argued that the dominance of cost-effective policy and transparency determines the manner in which nurses can practise their profession and that this influences patient experiences of care. Ancarani  showed that patient satisfaction was negatively associated with management-controlled wards that are under pressure to produce. Open, collaborative, innovative wards and wards that are focused on the welfare and involvement of nurses and that provide supervisory support and training were positively associated with patient satisfaction. This confirms that the environment in which nurses operate influences patient experiences of the quality of care. This corresponds with the findings of our research, in which participants stated that the dominance of policies focussed on cost-effectiveness and transparency lead to more pressure to produce and a high administrative workload. The participants feel that they have insufficient autonomy to influence this policy. 2b1af7f3a8