Which Of The Following Change Strategies Is Most Likely To Be Used By Nurse Managers

• Research article
• Open Access
• Published: 13 June 2014

How nurses and their piece of work environment impact patient experiences of the quality of intendance: a qualitative study

BMC Health Services Research volume 14, Article number:249 (2014) Cite this article

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Abstract

Background

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 accept a major impact on patient experiences. To improve patient experiences of the quality of intendance, 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.

Methods

A descriptive qualitative research pattern was used to collect data. Four focus groups were conducted, ane each with vi or vii registered nurses in mental wellness care, hospital care, home intendance and nursing home intendance. A total of 26 nurses were recruited through purposeful sampling. The interviews were audiotaped, transcribed and subjected to thematic analysis.

Results

The nurses mentioned essential elements that they believe would meliorate patient experiences of the quality of nursing care: clinically competent nurses, collaborative working relationships, autonomous nursing exercise, acceptable staffing, control over nursing practice, managerial support and patient-centred culture. They likewise 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 volition non ameliorate patient experiences of the quality of nursing care.

Conclusions

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 practise would outcome in more positive patient experiences. Notwithstanding, nurses work in a healthcare context in which they take to reconcile cost-efficiency and accountability with their want to provide nursing care that is based on patient needs and preferences, and they experience a conflict betwixt these two approaches. Nurses must proceeds autonomy over their own exercise in order to improve patient experiences.

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Background

In countries throughout the world, patient experiences are existence monitored in society to obtain information about the delivery and quality of healthcare [1]. Patient experiences can be defined as a reflection of what really happened during the intendance process and therefore provide information most the performance of healthcare workers [2]; it refers to the process of care provision [3]. In the United States [4] and many European countries [5], assessing patient experiences is office of a systematic survey program. In the Netherlands, the government has implemented a national performance framework for comparing the quality of healthcare. This framework contains a set of quality indicators that include patient experiences. The Consumer Quality Alphabetize (CQI) is used every bit the measurement standard [6].

Assessing patient experiences of the quality of care non simply provides information about the actual experiences, but besides reveals which quality aspects patients regard as most important [seven]. Many studies have been performed to analyse what patients consider essential within healthcare [eight–10]. For example, a study past the Picker Institute Europe [11] revealed eight general quality aspects:

1. 1.

   Involvement in decisions and respect for preferences

2. two.

   Clear, comprehensible information and support for self-care

3. iii.

   Emotional back up, empathy and respect

4. 4.

   Fast access to reliable wellness advice

5. v.

   Effective treatment

6. 6.

   Attending to concrete and environmental needs

7. 7.

   Involvement of, and support for, family and carers

8. viii.

   Continuity of intendance and smoothen transitions

The quality aspects are more often than not reflected in questionnaires used to monitor patient experiences, such equally the CQI [12] or the Consumer Cess of Healthcare Providers and Systems (CAHPS) [four]. Patients are asked which aspects in receiving care are of importance and most their actual experiences [xiii].

Patient experiences take been identified as an indicator for evaluating and improving the quality of care [three, 14]. When healthcare organisations assess patient experiences, professionals can use the results for internal quality improvements. Professionals apply patient experiences and preferences to suit their own practice and to make visible their contribution to patient outcomes [15].

Because nurses spend a lot of time with patients [sixteen], they bear on patient experiences of care [17]. Inquiry has shown that the nursing work environment is a determining factor. Information technology seems that when patients take positive experiences of nursing care, nurses also feel a good and healthy work environment [18–20]. A healthy work environment can exist defined as a piece of work setting in which nurses are able to both reach the goals of the organisation and derive personal satisfaction from their piece of work [21]. A healthy piece of work environment fosters a climate in which nurses are challenged to utilize their expertise, skills and clinical noesis. Furthermore, nurses who work in such an environment are encouraged to provide patients with first-class nursing care [21]. Enquiry by Kramer and Schmalenberg revealed that several aspects are related to the work environment [22]. The researchers used grounded theory to identify viii 'essentials of magnetism' that ascertain the nursing piece of work surroundings and influence the quality of nursing care. From the perspective of nurses, the following eight 'essentials' are crucial in a work environs to the provision of loftier quality nursing intendance [22]:

• Clinically competent nurses

• Adequate staffing

• Good nurse–md relationships

• Autonomous nursing practice

• Nurse manager support

• Control over nursing practise

• Support for education

• A culture that values concern for patients

Relation between nursing piece of work environs and patient experiences of the quality of care

The American Nurses Credentialing Center (ANCC) started the Magnet Recognition Program in the early 1990s. This program was built upon the study carried out in 1983 by McClure et al. [23]. It is focused on improving patient care, patient safety and patient experiences by creating a good and salubrious work environment for nurses. Research has shown that patient experiences in healthy work environments are significantly ameliorate [24–26].

The relationship between the nursing work surround and patient experiences was too investigated in a cross-sectional study carried out in 430 hospitals by Kutney-Lee et al. [18]. The researchers used data on patient experiences from the national CAHPS survey. The nursing work environment was measured with the Foot-NWI tool, which includes items on nursing leadership and nurse–physician relationships. Data on twenty,984 staff nurses were used in the study. The nursing piece of work environment had significant relations with all ten CAHPS measures, indicating that the quality of the work surroundings has an influence on patient experiences of the quality of care.

This finding corresponds with the cross-sectional study past McHugh et al. [nineteen] in which 428 hospitals and 95,499 registered nurses participated. The researchers used data from the Pes-NWI and the CAHPS. They concluded that nurses' dissatisfaction with their work environs was associated with a significantly lower quality of patient experiences.

In the RN4Cast project [20], 61,168 infirmary nurses and more than 131,000 patients in Europe and the The states were questioned in a cantankerous-exclusive survey. The aim of this immense study was to make up one's mind whether the nursing piece of work surround affected patient care. The PES-NWI was used to measure out the nurses' perceptions of their work environment. Patients' overall satisfaction was measured with the national CAHPS survey. The perceptions of nurses and those of patients were found to be consistent, indicating that both patients and nurses had more positive experiences in hospitals with better work environments.

Although at that place is a relationship between the nursing piece of work surround and patient experiences of the quality of care, it is not clear how this human relationship is formed and characterised from the perspective of Dutch nurses, and which aspects in daily practice influence patient experiences. Could these aspects somehow be linked to the 'essentials of magnetism'? Little is known near the underlying mechanisms and how these result in meliorate patient experiences. In 2006, the Dutch regime started to move towards a healthcare model of responsible consumer option and care services competition [27]. Considering of this entrepreneurial approach, healthcare organisations transformed their policy towards a toll-efficiency and productive intendance system (eastward.chiliad. a shorter length of stay per patient) [28]. Furthermore, today's patients tend to suffer from multiple disorders or illnesses, which results in a higher complexity of intendance and an increased nursing workload. The increasing complexity of patient intendance requires well-trained nurses who are capable of creating a safe and patient-centred surroundings [29]. In 2011, the Netherlands Institute for Wellness Services Research conducted a literature report to investigate the roles and positions of nurses in Belgium, Germany, the U.k., the U.s. and Canada, and found differences in levels of education and nursing job profile or job description in all five countries [xxx].

Given the circumstances and changes with which Dutch nurses are confronted, information technology is important and relevant to examine and comprehend their views on how their work and work environment contribute to positive patient experiences.

Methods

Aim of study

The aim of this written report was to understand from the perspective of nurses how the nursing work environment is related to positive patient experiences.

Research question

The cardinal research question was: According to nurses, which elements of their piece of work and work environment influence patient experiences of the quality of nursing care?

The sub-questions were:

• Are these elements related to the eight essentials of magnetism?

• What is the mechanism by which these elements pb to better patient experiences?

Inquiry blueprint

A phenomenological approach was applied to explore areas near which lilliputian is known or to gain an understanding of specific areas. Phenomenology is the study of subjective experience, feelings and behaviours of people [31, 32].

Sample size, limerick and data collection

To gain a deeper understanding of the influence of the nursing piece of work environs on patient experiences, we conducted iv focus groups. The purpose was to elicit ideas, thoughts and perceptions from nurses [31] about patient experiences and how nurses can improve those experiences. We recruited participants by purposeful sampling, using the following criteria:

• Participants must be employed as registered nurses or certified nursing assistants.

• Participants must have worked every bit nurses for at least ii years.

• Participants must be operative in mental health intendance, infirmary care, habitation care or nursing abode care.

Nurses are active in various settings and every setting has its specific dynamics. By gaining insight into their perspectives, we were able to compare mayhap different views. In addition, we obtained an overall view of the total healthcare system.

The organisations we recruited are participating in a Dutch program chosen Splendid Care. The program is based on the eight essentials of magnetism and focuses on creating a dynamic, inspiring and innovative nursing piece of work environment in order to meliorate the quality of care. We asked the programme manager 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 abode intendance, respectively. The nurses described their perceptions and views with respect to their ain areas of expertise.

Each focus group word was led past two researchers. I researcher facilitated the interview, and the other had an observing office and monitored the procedure. After each focus group, the researchers evaluated and critically reflected on the process in guild to examine the quality of the meetings. This investigator triangulation allowed the dissection of maybe different views.

The researchers used an interview guide with predefined topic areas (Table 1, topic list). The sequencing of questions depended on the process of the group and the responses of the informants.

Table 1 Topic list

Total size table

Each focus grouping lasted 2 hours. The researchers explained the procedures and introduced the topic to exist debated. When the informants were discussing certain topics, the researchers practical a not-directive arroyo considering of the dynamics of the group and the unlike perspectives that were being examined. When certain views were polarised, the researcher stimulated the discussion by introducing a new question or topic. All conversations were digitally recorded and then transcribed to meliorate transferability.

Upstanding considerations

This was a qualitative study in competent subjects without whatsoever intervention. It did not involve any course of invasion of the participant'southward integrity, and in such cases no approval by an ethics committee is required in the netherlands (according to the Medical Research Involving Human Subjects Human action; see ccmo-online.nl). All respondents received written and verbal information about the aim and content of the written report. Written report participation was voluntary. Data were analysed in an anonymous manner and the results were not-traceable to private participants.

Information analysis

The transcribed data were open coded and categorised. Several themes were extracted past organising and structuring the categories. During the analytical process, interview fragments were constantly compared. The literally transcribed interviews were reviewed several times to check whether elements might accept been disregarded. The final analysis was presented to the participants and they were asked to comment on the contents. This member bank check helped to determine whether we had adequately understood and interpreted the data. The analytical procedure and findings were discussed within the research team to improve the quality of analysis. MaxQDA software was used to support the coding ordering analyses.

Results

The sample consisted of 26 registered nurses (half-dozen male and 20 female person nurses). The hateful historic period of the participants and the hateful length of nursing experience varied per focus group, as shown in Table two below.

Table 2 Demographics of the participants

Full size table

Participants formulated several facilitating elements that they consider primal to improving patient experiences of the quality of care. They likewise mentioned such inhibiting factors every bit cost-effectiveness and transparency and accountability goals. These factors foreclose them from improving patient experiences (Table iii).

Table 3 Facilitating and inhibiting elements

Full size table

Both facilitating elements and inhibiting factors are elaborated below.

Facilitating elements

Clinically competent nurses

Participants stated that in social club to human action in a professional style, nurses need to have certain competencies, namely social skills, expertise & feel, and priority setting.

Social skills

Participants stated that social skills are an important competency to create a trustful intendance relationship. They indicated correct behaviour and attitude, sophistication, making time for patients, and listening and having empathy as essential nursing competencies. According to participants, these social skills convey a sense of delivery to the patient and play a major function in coming together patient expectations.

Nurses must have the ability to develop and maintain good relationships with patients. For patients, nursing intendance is most being heard and seen. Knowing that you're in prophylactic hands. You allay their fear and doubtfulness. You give patients conviction and hope in return. You lot offer them several options from which they can choose. Someone who is dependent, and does not know what will happen, is more suspicious and anxious. (Respondent 21, hospital focus grouping)

Expertise & feel

Participants mentioned three key aspects related to expertise, namely knowledge, technical skills and communicative capabilities. According to participants, the first key aspect means that nurses must have substantive noesis related to the nursing profession. They indicated that nurses should maintain and follow both existing developments and new insights. According to participants, nurses must continually invest in nursing cognition and education. In their view, nurses ought to offering state-of-the-art interventions or activities that are in line with the agreed nursing policy.

Equally a second central aspect related to expertise, participants indicated that nurses must take technical skills in order to provide effective and safe care.

The third aspect mentioned by participants is that nurses must have communicative capabilities. Participants said that nurses serve as spokespersons for patients who are ofttimes in vulnerable positions. They stated that nurses are easily accessible and tin act as a link betwixt the patient and other professions. According to participants, nurses tin use the right substantive arguments on behalf of a patient'due south interests or needs. Participants mentioned that this expertise is important for patients because it is related to the quality of care.

If you can reply a care-related question, it gives the patient a certain peace of mind. It signals: she knows what she'due south talking about. I notice that patients actually appreciate information technology when I share knowledge and offer them information that at the time they don't nevertheless have. Just then can patients make decisions almost their own intendance. (Respondent 15, nursing dwelling house focus group)

In addition to substantive expertise, participants stated that nursing experience is also of influence. Co-ordinate to them, a junior nurse has too little experience to respond creatively to sometimes complex care situations. However, co-ordinate to participants, junior and senior nurses tin learn from each other: they should piece of work as a team and collectively pursue their common objectives. In their view, experience is gained through practice. According to participants, this tin exist characterised as 'expertise'.

When y'all suspect someone is contemplating suicide, y'all need to know how serious this is. Is it just a cry of "I'm non feeling well" or are these serious thoughts? Has the patient already made plans, does the patient have a death wish, or is information technology an impulsive thought? In that sense y'all demand to reflect on the signals very carefully. You tin can just larn this from practice. (Respondent 1, mental health care focus group)

Priority setting

As stated by participants, various activities can occur simultaneously during the daily intendance of patients. Co-ordinate to them, nurses should assess what care is needed so flexibly coordinate diverse actions with each other. In the view of participants, prioritisation is about the organisation of nursing intendance. Patients need nurses who have clinical experience in order to coordinate care. Nurses must determine what choices to brand, what is urgent and what is important. Those choices influence patient experiences.

Prioritisation is very of import. It means that you take to coordinate the daily care and decide which activities accept priority. Patients sometimes have to await for help. If you're in a hasty mood, you transmit that feeling to patients. Information technology shows immediately. The restlessness affects the other patients. (Respondent eighteen, nursing abode focus group)

Participants said that patients sometimes accept to look earlier they are taken care of, or that nurses are not immediately bachelor to reply questions or deal with problems. Co-ordinate to participants, patients do not ever obtain the right and needed care, especially when the nurses' workload is high.

Collaborative working relationships

According to participants, it is important to develop and maintain collaborative working relationships with professionals, including those in their own field. In the view of participants, collaborative working relationships exist when all the involved professionals interact and operate in a complementary manner, and show mutual respect that is based on knowledge and expertise. Participants stated that all professionals need to discuss and influence patient care on the basis of their own expertise. Participants believe that bug will be solved sooner when ideas and thoughts are exchanged. In their view, it is about sharing information and communication. Equally stated by participants, communication and aligning with each other is needed then that no conflicting data is given and uniformity in care or treatment is provided. This generates, according to the participants, composure and clarity towards patients.

Participants believe that collaboration and communication affect how patients experience the quality and effectiveness of care.

We have a patient who is very compulsive. We made agreements about how to approach and handle this patient. We continually need to communicate with each other, physicians, psychologists, nurses. Clear communication is so of import, and I miss that sometimes. When you take good relationships it is easier to review and hash out the handling administered. It will not only increment your cognition, merely too be helpful in the communication with the patient and his family. It'south easier to explain why the specific treatment is existence deployed. (Respondent five, mental health care focus grouping)

Autonomous nursing practice

Participants in all four focus groups stated that the telescopic of practice for which they are accountable influences patient experiences. The telescopic of exercise, co-ordinate to them, means that nurses can control their ain work related to patient intendance and tin brand contained decisions about patient outcomes based on clinical judgements. Participants therefore believe it is essential to monitor and measure out outcomes, as long every bit the monitoring is directly related to patient care. However, participants indicated that they did non have insight into care results obtained from assessments.

We participate in an annual national prevalence survey. We have to fill out a lot of forms. It's an authoritative burden and takes a lot of fourth dimension – fourth dimension we tin't spend on patient intendance. We get a pile of papers, screen patients and register them. Information technology doesn't contribute to the quality of care because we never go any feedback. And what does one measurement tell usa? It doesn't inform u.s.a. whether we are doing well or not. I do non believe that. (Respondent 12, home intendance focus grouping)

According to participants, in that location is no policy to meliorate patient experiences on the ground of the information derived from assessments. Participants could not bespeak whether the interventions deployed are actually leading to desired nursing intendance results, including patient experiences. Participants feel they have insufficient autonomy to influence this process.

Adequate staffing

Participants stated that the number of nurses available influences how patients feel the quality of care. Although they could not indicate what number they consider sufficient, they remember 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 ane 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 full general, increasingly developing in the direction of job-centred care in which different working methods are practical. According to them, this affects patient experiences of the quality and effectiveness of nursing care.

Nurses provide care inside sure theoretical frameworks that are designed to increase the self-reliance and self-management of the patient. Nurse assistants take a more practical focus and take over patient care at a indicate when they should non. These two ways of working are confusing for patients. And nosotros recall 'How come the patient is fabricated to feel then nervous?' and afterwards we find two contradictory ways of working. (Respondent 3, mental health care focus group)

Every bit stated by participants, a sufficient nurse staffing level determines whether patient wishes and needs are met. According to participants, an bereft deployment of nursing staff has a direct negative bear on on patient experience.

I work lonely in a group. For example, when I'm in the bath with a patient, the other patients are solitary. Then I have to keep my eyes and ears open up and must reply to what occurs. And that is not always easy. I constantly think: I must check if everything is all right. Because I'one thousand responsible for the other patients. I always go out the bathroom door partly open up, then I tin can meet and listen to what is going on in the living room. I provide patient care likewise hastily. My patients plain feel that. (Respondent 17, nursing habitation focus group)

Control over nursing practice

The participants stated that command over nursing practise means that nurses are involved in nursing policy or nursing problems. In their view, nurses are not always in charge and cannot always make their own decisions most nursing issues. Participants feel that this affects the quality of nursing care.

In the past, I ever made my ain schedule. Now we have planners and they don't have any feel with care. Efficient planning is more important than patient-centred planning. It doesn't affair whether information technology suits the patient. The patient should be scheduled later if it fits better in the planned route. (Respondent 9, habitation care focus group)

The participants stated that if nurses were more involved in the development of nursing policies, this would have a positive influence on patient care. Co-ordinate to them, they would be able to reverberate upon and discuss nursing bug related to the quality of patient care, which would improve the quality of care.

Managerial support

Participants indicated that a manager should pay attention to the team spirit and unity. In their view, a managing director must be able to handle conflicts, and also be visible and approachable. Participants said that they believe that a manager should ask the stance of nurses; therefore, in their stance, regular contact is of import.

A director, according to the participants, must exist able to create the right conditions and accept the logistical power to ensure continuity of intendance. In their view, this means arranging sufficient personnel, replacement staff and succession planning.

Participants find that managers critically examine the deployment of personnel. Co-ordinate 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 arrangement that is dominated by controlling costs. Thus in their view, nurses may desire to provide a patient with a specific form of care, while management limits care to a maximum number of minutes based on budgetary considerations. Co-ordinate to participants, nurses regularly experience a tension with direction in shaping care that meets patient expectations.

We desire to provide certain care, but that'southward at the expense of something else. If we do one affair, we tin't do another. For instance, we programme 30 minutes for patient care. When a patient wants to go outside for a walk, this volition cost him 10 minutes of this total fourth dimension. And then we really take to negotiate with the patient or his family. This leads, of class, to lots of misunderstandings. I sympathize that feeling. (Respondent 13, nursing home focus group)

Patient-centred care

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 increment patient self-management and encourage improved health and recovery.

As participants stated, nurses are the first points of contact for patients. In the participants' view, they are frequently with the patient for 24 hours/7 days a calendar week (except for habitation intendance) and gather large amounts of information nigh them. They call up that direct contact with patients is crucial to building and maintaining a relationship of trust. The participants believe that high quality nursing care is achieved when patients feel heard and understood, consider themselves to be in safe hands and know that their care bug have been noticed. This, according to the participants, results in positive patient experiences.

We listen to the patient and talk to him. We immerse ourselves in his background. What is important, how he copes and handles care issues. Based on this knowledge, we present the patient with a number of options and so that he can decide upon a solution for his care issues. (Respondent 8, home care focus grouping)

Inhibiting factors

The participants talked about 2 inhibiting factors that preclude them from improving patient experiences: cost-effectiveness and transparency & accountability goals.

Cost-effectiveness

Participants stated that system policy is focused on the efficient and effective deployment of people and resources. They mentioned the transfer of tasks to less well qualified nurses in order to work as efficiently as possible and to achieve college productivity. In their view, care is more and more standardised. At the same time, they noted that care has go increasingly complex. According to them, patients are generally older and have multiple age-related comorbidities. The participants feel an increasing workload and piece of work-associated pressure level.

In recent years, patient turnover has increased. It ways that patients are discharged quicker. Equally before long as they recover, they're sent domicile. Nevertheless, patients sometimes too have chronic disorders. I sometimes think it is irresponsible [to transport these patients home so quickly]. Patients go less attention because the work pressure is loftier. (Respondent 22, hospital focus group)

Transparency & accountability goals

Participants reported an increasing authoritative workload to account for the quality and costs of care.

So many forms. Entering the data means a double administrative workload. We use different programs. We showtime have to register in programme X. And so we accept to register our measurements and enter all kinds of codes in another plan. Log in and log out. The registrations and coding are needed for the regime and health insurers. It is not e'er patient related and does not inform us about the health status of patients. (Respondent 23, hospital focus group)

The authoritative workload is, according to participants, out of remainder. They said that this ways that monitoring and registration is aimed not at improving nursing care, but at serving an external accountability goal to inform health insurers and the regime.

The participants stated that they have niggling autonomy to change this policy. According to them, monitoring care results should help nurses to better their own practice. For them, it means that nurses can reflect upon and talk over nursing issues related to quality of patient care, including the results of patient experiences.

Give-and-take

We interviewed 26 nurses working in various Dutch healthcare settings in social club to ascertain their views on how their work and their work surroundings contribute to positive patient experiences. Using an open arroyo, nosotros 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 exercise, the participants look it will consequence in more than positive patient experiences of nursing care. The elements are: clinically competent nurses, collaborative relationships, autonomous nursing do, acceptable staffing, control over nursing do, managerial support and patient-centred care.

One of the sub-questions was whether the identified elements are related to the eight essentials of magnetism defined by Kramer and Schmalenberg [22]. We found that they are. The essential of magnetism 'nurse–md relationships' is, in our opinion, non totally applicable in a modern healthcare organization. Although physicians are represented in all settings, also other professionals, such as psychologists, social workers or physical therapists, are part of a healthcare squad. The participants stated that a skilful human relationship must be based on collaboration and clear advice not only with physicians, but with all involved healthcare workers. The participants stated that patient wellbeing must be the common aim of all the involved professionals and that advice and collaboration must back up this shared goal. We therefore replaced 'nurse–physician relationships' with 'collaborative working relationships'.

Competing policies in the nursing setting

The other sub-question concerned mechanisms by which these elements lead to amend patient experiences. By analysing the data information technology became clear that nurses operate in a circuitous healthcare context. These different views control the fashion in which nurses can exercise their profession. We noticed that nurses are confronted with organization policies that are focussed on cost-efficiency, transparency and accountability goals. According to participants, this has led to a more productive care system. It likewise became clear that nurses flourish inside a patient-centred care system. Such a system supports private patients in their need to brand decisions and participate in their own care. This ways that organisations should facilitate a culture where nurses can professionally support patients by practising high-quality nursing care [33].

Each view is defendable on its own, but collectively they contradict each other. The context in which nurses work is almost paradoxical: they accept to offer patient-centred intendance in a standardised and productive care organization.

In the Dutch context, healthcare insurers, the government and healthcare providers are responsible and accountable for providing good quality intendance. However, these parties have different foci. Each year, healthcare insurers make agreements with healthcare providers almost which care volition be delivered. These agreements are defined in a healthcare procurement contract [28]. Individuals who legally live in kingdom of the netherlands are obliged to have out individual wellness insurance [27]. In order to make well-considered choices, individuals need to be informed near the quality of care provided by healthcare workers. Healthcare insurers are therefore driven by accountability goals, because they demand to determine whether healthcare organisations or professionals run across the minimum standard of performance, as agreed upon in the healthcare procurement contract [34]. The government is the supervisory dominance that ensures the proper performance of the healthcare system and is therefore responsible for the transparency process [35]. In the netherlands, a national operation framework for comparing the quality of healthcare is implemented nether the supervision of the government [36]. This framework contains a fix of quality indicators and related measures, including patient experiences [6, 37]. Healthcare insurers and the government collect data for external accountability goals [38]. Healthcare providers and professionals themselves are also responsible for the quality of care. Their aim is more internally driven, namely to improve the quality of intendance and to make visible their contribution to patient outcomes [39, 40]. However, our research showed that nurses do not receive feedback on their scores and they are not aware that they could – and even should – use these data to monitor and amend the quality of their piece of work.

It could exist argued that the dominance of toll-effective policy and transparency determines the style in which nurses tin can practise their profession and that this influences patient experiences of intendance. Ancarani [41] showed that patient satisfaction was negatively associated with direction-controlled wards that are nether pressure to produce. Open, collaborative, innovative wards and wards that are focused on the welfare and interest 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 enquiry, in which participants stated that the dominance of policies focussed on cost-effectiveness and transparency lead to more than pressure to produce and a loftier authoritative workload. The participants experience that they have bereft autonomy to influence this policy.

Strong nursing practice

To contain the identified elements into nursing practice, toll-effectiveness, transparency and patient-centred care policy demand to be connected. For instance, the registration and monitoring of outcomes should be used not only to quantify achievements against transparency goals, merely too for overall nursing quality improvement. Nurses should be able to decide which bug are of importance to amend patient care.

Connecting the different policies requires the participation and delivery of both nurses and nursing management. Nurses need to be challenged to shape their own environment and create a potent nursing practice [42], which will result in more positive patient experiences [43].

Limitations of this report

We conducted four focus groups, one each with nurses in mental health care, hospital care, home care and nursing dwelling house intendance. Although we gained a broader insight into the perspectives of nurses, every sector has its specific dynamics and context. Therefore, ane focus grouping per sector might have been bereft. However, nosotros reached data saturation as new information did not announced and similar themes emerged within the focus groups.

This written report was express to nurses, but to fully sympathize the nuances of this relation, it might be interesting to analyse patients' views.

Conclusion

The knowledge obtained from this inquiry has resulted in a better understanding of how nurses regard their role in achieving positive patient experiences. From the viewpoint of the interviewed nurses, several elements are essential in relation to patient experiences of the quality of nursing intendance: clinically competent nurses, collaborative working relationships, autonomous nursing practice, adequate staffing, command over nursing practise, managerial back up and patient-centred culture. These elements correspond to the viii 'essentials of magnetism'. If these elements are incorporated into the nursing practice, it will most likely result in more than positive patient experiences of nursing intendance.

This research revealed several factors that nurses find inhibiting when it comes to improving patient experiences of the quality of nursing care. Electric current nursing policy is heavily focussed on cost-effectiveness and transparency for external accountability, which creates a high administrative workload and pressure to increase productivity. However, despite all the registrations that accept place for external accountability, the participating nurses stated that they exercise not monitor care results to better their ain practice. They felt they insufficient autonomy to influence this. They believe it is important to reverberate upon and hash out nursing issues related to the quality of patient intendance, including patient experiences.

Recommendation

Farther research is recommended to examine whether the elements of a healthy work environment are statistically related to patient experiences in the Dutch healthcare setting. In the Netherlands, patient experiences are measured with the Consumer Quality Index (CQI) [6].

Nurses' perceptions of their work surround are measured using the Essentials of Magnetism Tool 2 (EOMII) questionnaire [44]. Further research should focus on the statistical relations betwixt CQI and EOMII.

Abbreviations

ANCC:

American Nurses Credentialing Center

Pes-NWI:

Practice environs calibration of the nursing piece of work alphabetize

EOMII:

Essential of magnetism tool Two

CQI:

Consumer quality index

CAHPS:

Consumer cess of healthcare providers and systems.

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Acknowledgements

The authors should like to thank all the nurses who participated in the focus groups. We also desire to give thanks the programme directors who helped to recruit the participants and who facilitated the interviews by providing an interview room. This paper represents contained research that was not funded by a grant.

Author information

Affiliations

1. Dutch Nurses' Clan, PO Box 8212, 3503, RE, Utrecht, The Netherlands

   Renate AMM Kieft & Brigitte BJM de Brouwer

2. ane/ NIVEL, Netherlands Plant for Health Services Research, PO Box 1568, 3500, BN, Utrecht, The Netherlands

   Anneke Fifty Francke

3. 2/ EMGO+/VU medical center, Van der Boechorststraat seven, 1081, BT, Amsterdam, The Netherlands

   Anneke 50 Francke

4. Professor of Transparency in Healthcare from the Patient'southward Perspective, Tranzo, Tilburg Academy, PO Box 90153, 5000, LE, Tilburg, The Netherlands

   Diana MJ Delnoij

Respective author

Correspondence to Renate AMM Kieft.

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Competing interests

The authors declare that they have no competing interests.

Authors' contributions

RK participated in the pattern of the study, conducted the focus groups and analyses, and drafted the manuscript. BdB participated in the data drove (two focus groups) and revised the manuscript. DD participated in formulating the enquiry questions, designing the study, and collecting and analysing the data (two focus groups), and helped to draft the manuscript. ALF participated in the design of the written report and helped to draft the manuscript. All authors read and approved the final manuscript.

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Kieft, R.A., de Brouwer, B.B., Francke, A.Fifty. et al. How nurses and their piece of work environment affect patient experiences of the quality of care: a qualitative study. BMC Health Serv Res 14, 249 (2014). https://doi.org/x.1186/1472-6963-14-249

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• Received: 06 November 2013

• Accepted: 06 June 2014

• Published: 13 June 2014

• DOI : https://doi.org/10.1186/1472-6963-14-249

Keywords

• Patient experiences
• Quality improvement
• Nurses
• Nursing work surround

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