While it is vital to assess whether nurses follow professional codes and policies, it is equally important to consider patients’ perceptions of good nursing
Ann Gallagher, PhD, MA, PGCEA, BA (Hons), RMN, SRN, is reader in nursing ethics and director, International Centre for Nursing Ethics, Faculty of Health and Medical Sciences, University of Surrey, and was formerly senior research fellow, Kingston University and St George’s University of London; Khim Horton, PhD, BSc (Hons), RN, RCNT, RNT, PGCEA, is senior lecturer; Verena Tschudin, PhD, MA, BSc (Hons), DipCouns, RM, RN, is visiting senior fellow; both at Faculty of Health and Medical Sciences, University of Surrey; Sara Lister, RN, BSc Hons) MSc, PGCAE, Cert Christian Counselling, is assistant chief nurse/head of school of cancer nursing and rehabilitation, Royal Marsden Hospital, London and Surrey.
Gallagher, A. et al (2009) Exploring the views of patients with cancer on what makes a good nurse – a pilot study. Nursing Times; 105: 23, early online publication.
This article presents and discusses findings from a qualitative pilot study that surveyed patients with cancer to discover their views on what makes a good nurse. Ten outpatients at a UK specialist cancer hospital, who had received inpatient treatment for cancer, were interviewed. The interview data was analysed thematically, and four themes were identified: good nurse virtues, knowledge, skill and organisational culture.
Keywords: Cancer, Patient, Experience
- This article has been double-blind peer reviewed
There are many possible perspectives on what it means to be a good nurse. Professional codes state what nurses must do, and policies and protocols offer guidance regarding professional competencies and how to engage in good nursing practice. What this guidance fails to capture are the subtleties and nuances of patients’ views on good nursing and how it impacts on their well-being.
This pilot study replicates a study that has been underway in Asia since 2004 (Pang et al, 2009) that explores patient perspectives on the ‘good nurse’ (Box 1). Findings from the project, conducted in China, Hong Kong, Japan, Korea and Taiwan, were presented at a meeting in Hong Kong in August 2007. Two of the research team (Ann Gallagher and Khim Horton) who attended the Hong Kong meeting agreed to conduct a UK pilot study exploring the views of people with cancer on what makes a good nurse. Also present at the meeting was Dr Chris Gastmans, Centre for Biomedical Ethics and Law, Catholic University of Leuven, Belgium, who agreed to conduct a literature review (Rchaidia et al, 2009) on the same topic.
The Asian ‘good nurse’ study used a mixed-method approach: interviews were conducted with patients to gain their narratives regarding the good and bad nurse; and a questionnaire survey (n = 2,630) was conducted. The questionnaire was divided into four sections: good nurse virtues; good nurse works; good nurse impacts; and patient characteristics. A summary of the key findings from individual countries (presented at a public seminar in Hong Kong on 9 August 2007) is shown in Appendix 1.
The literature review on the views of people with cancer about what makes a good nurse (Rchaidia et al, 2009), identified and analysed 12 articles in which patients described a range of attitudes, skills and knowledge that good nurses possess. Regarding attitudes of good nurses, patients in studies in both the East and West identified the significance of nurses relating to patients as people, who appreciated their uniqueness and who knew the patients and their families. Good nurses were sincere and friendly and also respectful, treating people as individuals. They were concerned and interested in the care of patients and understood and responded to their vulnerability. They also contributed to healing by understanding patients’ needs and demonstrating compassion. Good nurses also provided emotional support to patients and offered encouragement and reassurance, which encouraged feelings of hope and optimism.
In some of the studies examined, good nurses were revealed as people who identified themselves by name and shared something of their own personality. This resulted in meaningful interpersonal relationships in which patients felt they were ‘bonded’ and ‘connected’ to nurses. Good nurses also kept promises and did not make mistakes or, if they did, they took responsibility for them. Other qualities included being cheerful, kind, gentle, sympathetic and compassionate. Having a sense of humour and being courteous and approachable were also highlighted as desirable qualities.
Although there was much common ground between findings from projects in the East and West, some differences were observed. Japanese and Chinese patients, for example, highlighted the importance of nurses greeting patients and families ‘in a gentle voice’ and there was also an expectation from Japanese patients that good nurses would have good manners and be courteous.
The knowledge of the good nurse relates to the knowledge of disease, treatment and symptoms. Good nurses are those who assess needs and respond to difficulties, pain and discomfort and who are able to pick up changes in patients’ condition. In addition to being responsive, good nurses communicate information clearly to patients, give advice and respond to patients’ questions.
The skills of good nurses relate to technical competence, for example, in drawing blood and managing intravenous infusions. It is reported that, as a result of the good nurses’ knowledge and skills, patients feel better, have less depression and pain, and feel more comfortable. This contributed to nurse-patient relationships where trust, hope and optimism were important features.
Grounded theory, informed by a symbolic interactionist perspective (based on the theory that the way people behave towards things is based on what those things mean to them) was considered the most appropriate approach as it allows themes and concepts to emerge from an analysis of qualitative data collected independently (Horton and Arber 2004). Letters of invitation and information sheets were sent to a sample of patients with cancer one week before their attendance of an outpatients appointment in 2008. Only patients who had a confirmed diagnosis of cancer, who were told of their diagnosis and had received medical treatment as an inpatient in the past 12 months, were invited to participate.
Five patients, aged between 43 and 86, agreed to participate: two men and three women. Three participants were of British origin, one was from India and one from Ghana. They were interviewed in a private room during their outpatient appointment at a specialist hospital in England (Box 2). In one case the patient was accompanied by his wife who also contributed to the interview. Interviews were transcribed and analysed thematically by two researchers who read, coded, compared and agreed codes for the analysis.
Results of the interviews
Four themes emerged: good nurse virtues; knowledge; skills; and organisational features.
Good nurse virtues
Participants referred to the good nurse as having particular qualities or virtues, meaning dispositions to feel, think and act in certain ways. A wide range of virtues or qualities of character were identified, such as flexibility, helpfulness, courage, respectfulness, reliability, care, sense of humour, honesty, kindness, fidelity, friendliness, empathy and patience, as illustrated by the following response:
She treated [me] as if I was known to her for a long time […] she was very friendly and very eager to help you out in any problems […] You even feel rotten to come to the hospital while you are suffering. So it is good that people laugh and have got that sense of humour.
[The nurse] was very caring but she was very normal and ordinary, you know, in her conversation. She was almost like a sort of friend, if you like, and I had confidence in her [Interviewer: tell me about being caring] It means being there if I need something, if I called a nurse in the middle of the night because I’m feeling bad, they want to do something about it […] and […] giving you confidence that they understand how you feel.
Good nurses are, therefore, caring (‘being there if I need something’). They respond appropriately during situations considered significant and anxiety-provoking for patients (‘easy and normal, no big deal’). They are in a state of readiness and willing to go the extra mile (‘ready to assist’, going ‘out of the way to help everybody’). They are conscientious (‘doing duty’) and welcome family involvement. Good nurses are also sensitive, understanding and honest when sharing information (‘it’s going to be a bit uncomfortable’). Good nurses are also respectful, polite and courteous (‘he regards you well’). They are friendly, meeting and greeting appropriately and have a sense of humour. Good nurses are also trustworthy, which is related to fidelity, reliability and punctuality.
Good nurses can make time and make patients feel that they have time for them. Good nurses are also reliable and not forgetful:
The nurses here are always wanting to help. But it goes a lot beyond that, they’re always able to although they don’t have time, but they’re always able to give you time and make you feel that you’ve got all the time in the world.
If they said they were going to do something they always did it, instead of rushing off and forgetting.
There were examples of nurses who lacked virtues or who were ‘bad nurses’ from other hospital experiences: nurses who were arrogant and ‘not helpful’ and who were uncooperative. An example of a bad nurse related to not welcoming or including family. In this case, the patient’s wife reported:
The nurse said: ‘I’m sorry Mrs R, if you’re going to keep butting in I’m going to have to ask you to leave.’
Although participants were not asked directly about the impact of the good or bad nurse, the data suggested that this is important to patients:
When you meet somebody who was nice and polite and courteous and helping things out, you don’t moan and groan and worry about it. You know she’s going to be on duty, that’s fine, you’re going to stay here for two days and she’s going to look after you […] The main thing is the personality of the nurse. Doesn’t matter what colour, caste, a smile wins hearts and when you’re dealing with a sick person one smile can make a lot of difference. His misery can turn into happiness. That’s very important.
The virtues or qualities of character may be moral or non-moral. Moral virtues would include care, courage, honesty, empathy, trustworthiness and patience. Non-moral virtues would include flexibility and sense of humour. The quality of ‘being ordinary’ and making things feel normal in circumstances that were not ordinary for patients is identified as important. The fact that nurses would go out of their way to help patients suggests perhaps that good nurses act in a way that goes beyond just doing their duty. The data suggest that participants’ experience of good nurses was that they cared, demonstrated respectfulness and were friendly and courteous.
Two types of knowledge featured in the data: knowledge relating to professional competence, and knowledge of the patient. The presence or absence of knowledge for practice inspired confidence or anxiety in patients:
She [the nurse] knew her job well and she was there to sort things out.
They [nurses] have the expertise to give you confidence, that what they are telling you is OK. If you ask them ‘Can I take these three tablets together?’ ‘Yes you can’. Total confidence that you can. I don’t have that confidence (chuckles) in other hospitals I’ve been in […] I was in the other hospital having a blood top-up. And I was just so, so concerned that the nurse who’s hanging this thing up, you know, to continue feeding me with the blood or the drip or whatever it was… it was a worry for me… it concerned me that I was getting the right stuff pumped into me.
Good nurses are competent and ‘know their job well’. Feeling confident and trusting nurses and other professionals is important but can lead to patients not questioning treatment offered:
If I was messed around with having suffered something like this I would feel very vulnerable and anxious. But you know, I do feel reassured here. I do feel that I’m in the best hands and that I’m sure that […] any treatment they give me is the best treatment. And I don’t ever question what they say, their recommendations.
The importance of being recognised, remembered and known by the good nurse was highlighted as important:
She’d sussed me out, sussed us out, that, you know, we’re pretty cheerful people and love a joke […] They know, you know, the nurses know ‘Oh, you’re the guy who lives in […], don’t you?’ and that makes you so comfortable.
She’ll always say to me ‘How’s your son?’ and ‘I bet he’s getting a big boy now’.
She just makes you feel completely at ease. She’s incredibly friendly, she always remembers who you are […], if you meet her in the corridor she always stops to speak to you, she knows your name […] I’ve always felt that I could phone her if I needed help or advice or anything else.
The theme of knowledge in relation to nurses’ practice (knowing what they were doing and having expertise) and in relation to the patient as a person (‘sussed us out’ and remembering who they are) is closely related to participants’ views of competence and to having or lacking confidence in the nurses and in the organisation. A recent publication from the Department of Health (2008) emphasised the importance of patients having confidence in care and identified five ‘confidence creators’: environment, culture, good teamworking and good relationships, well-managed care delivery and ‘personalised care for and about every patient’. Our data also suggests the importance of personal relationships, of being acknowledged and remembered.
Three areas emerged from the data: skill in relation to care tasks, skill in relation to greeting, and skill in relation to advocacy and communication. One participant talked about the challenge and anxiety of having a bath after surgery and of the skill of the nurse:
[The nurse] makes it so easy and normal just to, you know, to be naked and for her to lower you into the bath. She makes it no big deal.
The cultural significance of greetings was identified by one participant:
In my country like this when someone greets you that means he regards you, he regards you well.
One participant gave an example of a good nurse advocating on his behalf:
And she was prepared to confront the doctor on that and say ‘Look’ and I remember her words: ‘I have to look after the whole patient.’ And she discussed it with him and talked him through it and made him understand it was a problem […] She represented me when I was probably not in a position to represent myself.
In another instance, a patient reported how bad news was given in an insensitive manner during a ward round at another hospital where the nurse did not intervene. The patient refers also to the emotional consequences of her treatment:
[I was] told immediately that he could see a growth and that I had cancer […] pretty distressing […] very uncomfortable […] the nurse who had been in the consultation came out and started giving me bits of paper to distribute round the [local, non-specialist] hospital to book in for scans […] a specialist nurse happened to walk past […] but she was very rushed… I said, I was told that she’d keep in touch, and she didn’t…
Time was a recurrent theme in the data and might be thought of in terms of virtues or skills – having the disposition to prioritise the needs and individuality of patients and the skill to make them feel valued when there are conflicting pressures:
I think a good nurse is, again, someone who you have some sort of personal connection with, and who you feel comfortable with, and who you have confidence in really. And just spending the time, taking the time… to make you feel that way is important, instead of just sort of rushing in and rushing out.
The data highlights the importance for participants of nurses having skills in relation to care tasks, to greeting, and to advocacy and communication. What also seems evident is the relationship between skills and virtues or qualities of character. The nurse who helped the patient to have a bath in a manner that was easy and normal, making it ‘no big deal’, was demonstrating respect for the patient’s dignity. Similarly, greeting patients demonstrates regard or respect and, in some instances, advocacy demonstrates courage. When nurses do not intervene, as in the ward round example, patients’ vulnerability is increased and sensitivity and compassion may be lacking. The significance of spending time with patients is also a nursing response that contributes to patients feeling valued and respected.
The fourth theme concerned the importance of the organisational culture or climate, suggesting a relationship between the good nurse and the good organisation:
There’s a culture here… I certainly feel that it doesn’t matter whether it’s the nurse or whether it’s the cleaner, or it’s the person who’s making you a cup of tea, they all treat you the same with respect and a sort of caring and listening approach […] in this hospital there’s a culture […] It feels like a team, well, it just feels like a family […] there seems to be the flexibility for people to be able to overlap, just for the patient’s sake.
This is an example of the ward housekeeper who returned from days off to find a scuff on the ward floor. The housekeeper ‘disappears’ and returns with one of the cleaners to ‘sort it out’:
It was very much pride in her [the housekeeper’s] ward, you know, that was her ward […] So there must be standards, they must be spelt out when people start working here.
I think it probably is the organisation as well. I think because the [specialist hospital] is so geared up to giving such wonderful care to people. I just, I just can’t quite understand why the experience here could be so different from, from the NHS elsewhere.
Good nurses are good nurses in a particular context and in relation to a particular disease trajectory with particular patients and their families. Some of these patients may not survive. One participant said:
With cancer, in some cases of cancer, they know it’s the end of the road of life for them and because of that you have to, the nurses have to think from that angle, that this patient will try her best to survive. Sometimes it’s not possible […] if you are in a cancer hospital they have the experience and they are aware how many patients do come back and how many patients have gone, they’ll go in a black bag from here.
It seems important, therefore, to consider both the special nature of cancer in relation to the good nurse and the role of specialist hospitals in providing a context for good nursing.
Findings from the pilot study revealed much that is in accord with the literature review undertaken by Rchaidia et al (2009). The qualities, knowledge and skills of good nurses identified from the literature also emerged from our study. We were particularly struck by the inter-relationship between technical and ethical dimensions of practice, for example the presence or absence of trust, respectfulness and confidence in relation to tasks such as blood transfusion and bathing. The virtues or moral qualities discussed by participants and the non-moral virtues are types of excellence that make a thing good for its purpose (Banks and Gallagher 2009).
Most of the virtues identified in the Asian study were seen in our pilot study (for example, cheerfulness, friendliness, patience, trust and competence), although some were less obvious in the UK data. It might be that acknowledging, being caring and remembering patients suggest sincerity, but this would require further exploration. There was evidence in most categories of good nurse work in the UK data. The categories ‘knowing the patient’, ‘comfort work, ‘communication work’, ‘presence’, ‘respect work’ and ‘personalised caring work’ are suggested in our data. It did seem that UK study participants felt that good nurses made a positive contribution to their well-being and that bad nurses detracted from this. This would also be worthy of exploration in a larger study.
One area that has received less attention, and which was a strong theme in our data, relates to the context in which good nurses work. Organisational culture or climate was considered important and suggests that positive patient experiences do not depend on relationships with individuals alone, but also the environment in which they receive care. These findings are supported by recent work by the Department of Health (2007) and also by work commissioned by the Royal College of Nursing (2008) regarding dignity in care.
The RCN report detailed the views of UK nurses, student nurses and HCAs, and concluded that dignity in care was maintained or diminished by people (staff and others), places (organisational culture and the physical environment) and processes (care activities). The relationship between the virtues of individuals and institutions has also been discussed by MacIntyre (1985), who argues that the virtues are ‘fostered by certain types of social institution and endangered by others’.
The role of the specialist hospital is worthy of more exploration. Participants highlighted the special nature of cancer and the importance of appropriate individual and organisational responses to patients who are likely to be anxious and to fear the worst outcome. References to confidence, trust and respectfulness were made in relation to individuals and organisations, and participants were both appreciative and curious as to how this positive culture was maintained and why it was not always present elsewhere.
Although this was a small study, the resulting data was rich in terms of patient insights and perspectives. Participants talked positively about good nurses in the context of the specialist hospital and negatively of experiences of care elsewhere. We do not claim that the sample is representative, but rather that the insights revealed have truth and meaning in relation to the experiences of this sample. The perspectives offered were from a small but diverse group of patients with a wide range of experiences and patient expertise. To undertake a meaningful comparison with the Asian Good Nurse study would require a much larger sample, and there are plans to construct a much larger study comparing patients’ and nurses’ views of the good nurse in several specialties.
Implications for practice, education and research
- Be aware of the impact of individual nurses on patients.
- Appreciate that good nurses are supported by positive organisational cultures.
- Consider how to balance the ethical and technical dimensions of nursing practice.
- Learn from examples drawn from patients and be aware of their anxieties, fears and expectations.
- Incorporate findings from studies such as this into education and training.
Box 1. Aim and objectives of the pilot study
- Explore the views of people with cancer on what makes a good nurse.
- Compare and contrast findings in England with findings from the study in Asia.
- Develop a larger study, informed by findings from the pilot, relating to patient views on what makes a good nurse.
Box 2. Interview questions
- Please recall incidents where you found the nurse was a good nurse.
- Please recall incidents where you found the nurse was a bad nurse.
- Describe the incident(s) as fully as possible.
- What was the nurse doing?
- How did you feel about the nurse at the time?
Appendix 1. Views of countries on good nurse virtues – web only
|4||Understanding patient’s mind||Responsibility||Kindness||Skill/competence||Care|
Good Nurse Work
Good Nurse Impacts
|Cognitive work: thinking like a nurse||Optimising the patient’s relational well-being|
|Cognitive work: knowing the patient||Relieving the patient from negative emotion and discomfort|
|Comfort work||Empowering the patient in dealing with life positively|
|Personal greeting work|
|Personalised caring work|
(Pang et al 2007, unpublished]
We would like to thank: research participants for their time and for sharing their experience; specialist hospital staff who granted access to patients and helped with recruitment; the Faculty of Health and Social Care Sciences, Kingston University & St George’s University of London who funded the pilot study; Professor Paul Wainwright , who supported the project and who commented helpfully on drafts of the project report; and Professors Samantha Pang and Chris Gastmans for permission to refer to unpublished work.
Banks, S., Gallagher, A. (2008) Ethics in Professional Life: Virtues for Health and Social Care. Basingstoke: Palgrave/MacMillan.
Department of Health (2008) Confidence in Caring: A framework for best practice. Leeds: DH.
Department of Health (2007) Healthcare environment: privacy and dignity. London: DH. Accessed 09/06/09.
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MacIntyre, A. (1985) After Virtue: A Study in Moral Theory. London: Duckworth.
Pang, S. et al (2009) Knowing the patient and being a good nurse. In: Locsin, R.C., Purnell, M.J. (eds) AContemporary Nursing Process: The (Un)Bearable Weight of Knowing Persons. New York, NY: Springer Publications.
Rchaidia, L., et al (2009 in press) Cancer patients’ perceptions of the good nurse: a literature review. Nursing Ethics 16.4
Royal College of Nursing (2008) Defending Dignity – Challenges and Opportunities for Nursing. London: RCN