The Research Article Critique Part 2 by Dey, 2016

Relationship of Hospitalized Elders’ Perceptions of Nurse Caring Behaviors, Type of Care Unit, Satisfaction With Nursing Care, and Health Outcome of Functional Status

Marlene Melchiorre Dey, PhD, APN, ACNP-BC, ANP-BC, Elite Medical Care

Abstract This study investigated relationships among hospitalized elders’ perceptions of nurse caring behaviors, the type of unit on which they received care, their satisfaction with nursing care, and their outcome of functional status. A predictive correlational nonexperimental design was used with a sample of 180 subjects, 90 from an acute care elder unit and 90 from a telemetry unit in an acute care medical center where new-nurse orientation included Nurses Improving Care for Health System Elders (NICHE) concepts of care. Elders’ perceptions of nurse caring behaviors were correlated with satisfaction with nursing care (r[178]¼ 0.555, p¼ .000). Only one of seven hypotheses was supported. Type of care unit had no effect on elders’ perceptions of nurse caring behaviors, satisfaction with care, or functional status outcome. Nurses who are taught how to care for acutely ill hospitalized elders are likely to demonstrate nurse caring behaviors that result in satisfaction with nursing care, better functional outcomes, and care quality. This study supports evidence that the NICHE model of care could be the answer to the Institute of Medicine’s (2001, 2010) charge to improve the delivery of health care and care quality to vulnerable population of elders.

Keywords: nurse caring behaviors, satisfaction with nursing care, hospitalized elders, NICHE, ACE unit, functional status

Background and Study Rationale Approximately 20% of the U.S. population will

be 65 years of age or older by the year 2030 (Centers for Disease Control and Prevention and Merck Company Foundation, 2007). As the number of elders increases, so will the demand for medical, nursing, and social services. Elders use more hospital care and have the highest average length of stay than any other age group (Hall, DeFrances, Williams, Golosinskiy, & Schwartzman, 2010).

Hospitalized elders are at risk for negative outcomes (Palmer, Counsell, & Landefeld, 2003). Chronic and acute illness superimposed upon elders can increase their frailty and compromise their ability to perform activities of daily living (ADL). Therefore, they require specialized nursing care during hospitalization (Touhy & Jett, 2010).

The anticipated increase in elders who need hospitalization is a societal concern, as more U.S. health care dollars are spent on elders than on any other age group. Those who are 85 and older use even more dollars because of increased frailty and nursing home placement (Hartman, Catlin, Lassman, Cylus, & Heffler, 2008). Therefore, it is important for elders’ health care to result in care quality and positive health outcomes. There is a link between patient satisfaction and care quality, and both of these are further linked to the care that nurses provide, such that patient satisfaction is most frequently referred to as an outcome of quality nursing care (Larrabee & Bolden, 2001).

Importance of Patient Satisfaction Risser (1975) defined patient satisfaction as a

subjective, emotional, and personal response by

a recipient of health care that what was expected, needed, and wanted when seeking health care was in fact delivered and received. Yellen, Davis, and Ricard (2002) reported that patient satisfaction should be measured by patients’ agreement that the nursing care given to them was what they expected, and was delivered with nurse caring behaviors.

Some elders reported not being satisfied with the care they received when hospitalized, and attributed this to nurses not knowing what elders want and need in their care (Turner, Lee, Gletcher, Hudson, & Barton, 2001). Patient satisfaction has been linked to the utilization of health services and compliance with treatment (Donabedian, 1980; Mahon, 1996). Elders’ nonutilization of health care could result in missed opportunities for health promotion and illness prevention, increased morbidity, and decreased function and lead to poor health outcomes and increased health costs. Placement of elders on units where nurses are educated to care for them might have a positive influence on elders’ perceptions of nurse caring, enhance their satisfaction with nursing care (Chang et al., 2003), and result in positive health outcomes (Cochran, 2005).

Importance of the Health Outcome of Functional Status

Health outcomes are the changes that occur in the patient’s health status after receiving health care (Donabedian, 1980). Physical function is the ability to manage the everyday function of life such as eating, bathing, ambulating, managing money, and keeping track of medications. It is a process influenced by motivation, physical and cognitive ability, illness, and support systems (Kresevic, 2008).

Covinsky et al. (2003) reported that nearly one third (33%) of acutely ill hospitalized elders

experienced functional decline. Palmer et al. (2003) explained functional decline as a conceptual model where there are ‘‘elements of hospitalization’’ that interact with the elder’s clinical features that results in ‘‘dysfunctional syndrome’’ or decline. Decline in functional status can negatively affect independence and quality of life in elders and signal compromise of safety. It is of special concern because it can increase the complexity of care and lengthen care time, which in turn escalates health care costs (Arora et al., 2007).

Importance of Cost-Effective, Quality Care The Institute of Medicine (IOM; 2001)

recommended reorganizing health care to provide care that is patient centered, respectful, and responsive to an individual’s personal needs and values, with these goals guiding clinical decision making. The IOM (2010) asserted that health care costs are straining federal and private sector budgets. Cost reduction might be achieved through the delivery of appropriate and effective care based on the application of evidence through scientific research findings. The IOM (2010) recommended the use of advanced-practice nurses; collaboration among nurses, physicians, and other health care team members; and models of care that meet patients’ needs and improve quality of care delivery to vulnerable populations.

Innovative Models of Care Delivery Nurses Improving Care for Health System

Elders (NICHE, 2016) is a system of providing care to hospitalized elders and encompasses two such models to which the IOM refers: the geriatric resource nurse (GRN) and the acute care elder (ACE) unit. The GRN is a staff nurse who is educated by a geriatric advanced-practice nurse to identify and address specific geriatric syndromes such as falls and confusion and to implement care strategies that provide high- quality nursing care specific to the needs of hospitalized elders. The ultimate goal of these care strategies is to maintain and even improve functional status and prevent functional decline. The GRN serves as the clinical resource person on geriatric issues to other nurses on a unit. The ACE unit is a systemized care unit that delivers interventions known to improve clinical outcomes. The aim is to treat the whole person, not simply the clinical condition. The ACE unit typically includes carpeted floors and a common area with a kitchen to which elders have access. Elders are encouraged to get out of bed, dress, and ambulate and function as though they were home for the purpose of preventing functional decline

International Journal for Human Caring134

(NICHE, 2015). A multidisciplinary team oversees and plans the care for each patient, and can include a geriatric physician; an advanced- practice geriatric nurse; a registered nurse and nursing assistant; a dietician; a social worker; occupational, speech, and physical therapists; a pharmacist; a geriatric psychiatrist, and a spiritual care provider (Haugh, 2004). In addition to providing a framework for the two models of care, the mission of NICHE (2015) is to provide support services such as materials, interventional programs, and care protocols to health care agencies to improve the health outcomes of hospitalized elders (NICHE, 2015).

Caring Theory NICHE (2015), with the GRN and ACE models

of care, has attributes that are consistent with caring theory. Leininger (1993) defined caring as behaviors that assist, support, or enable individuals to lessen a burden or illness. Caring in nursing has also been defined as a nurse’s way of being that conveys a demeanor of interest and being present, and an attitude that the patient is important (Watson, 2008). These attributes of nurse caring could be present within the GRN model and ACE unit, and could be a significant factor contributing to patient satisfaction and positive health outcomes in hospitalized elders.

Knowledge of how to care, knowledge of how to express caring behaviors, knowledge of the patient and the patient’s individual preferences, and knowledge of the self are all important antecedents to caring (Watson, 2008). NICHE (2015) proposes that nurses who have knowledge of caring for elders will focus their care around the inherent frailties of acutely ill elders and will use best practices and scientific evidence when giving care so that outcomes will be positive. GRNs could improve the quality of care that leads to patient satisfaction and positive health outcomes.

A supportive environment is antecedent to caring. The concept of environment includes not only the physical layout, but a process of readjustment of the nurse–patient space, whereby the nurse modifies the environment to assure safety, comfort, dignity, privacy, autonomy, advocacy, social interaction, and a place for the patient’s emotional release within the physical place. The nurse–patient space can create the environment that is integral for caring and healing (Watson, 2008).

The ACE unit is an environment that is sensitive to the needs and vulnerabilities of elders. Nurse caring behaviors can be fostered in the ACE model of care as opposed to the general medical unit because nurses who work on ACE units receive specialized education in caring for elders. ACE units are organized to meet the needs and frailties of elders, and are focused on elder assessment and intervention and prevention of factors that can typically cause poor health

outcomes and functional decline in elders after acute illness and hospitalization. Some studies have shown ACE units to produce better clinical health outcomes and patient satisfaction than units providing more traditional care (Cochran, 2005; Landefeld, Palmer, Kresevec, Fortinsky, & Kowal, 1995). This translates into lower costs per patient.

Nurse caring in the NICHE (2015) model of care could be different from nurse caring on general hospital units. Elders might perceive more nurse caring behaviors on ACE units than in other areas of the hospital. If elders perceive more comfort, burden relief, and satisfaction and have positive health outcomes when cared for on an ACE unit under the NICHE (2015) model of care, then nurse caring and the attributes of caring could be responsible. As of yet, this has not been tested. Caring for elders in a controlled environment, specifically designed to cater to elders’ vulnerabilities where nurses have the knowledge to care for them, might lead to better quality of care for elders (Bogardus, Richardson, Maciejewski, Gahbauer, & Inouye, 2002). Quality of care could lead to patient satisfaction and positive health outcomes (Donabedian, 1980).

Theorists and researchers suggest that patient satisfaction could be in jeopardy in the hospital environment where nurses have little time to demonstrate caring behaviors (Duffy & Hoskins, 2003; Watson, 2008). Larrabee et al. (2004) asserted that the extent and quality of nursing care and nurse caring behaviors could determine the degree of patient satisfaction. The GRN and ACE models of care support the practice of nurse caring behaviors.

There has been little information about what aspects of nursing care or nurse caring behaviors might actually contribute to the health outcome of functional status, and if the nurse caring behaviors perceived by elders are satisfying to them. Aharony and Strasser (1993) suggested the importance of studying the relationships between patient satisfaction and clinical outcomes and the causal relationship of employee attitude to patient satisfaction. Mitchell, Ferketich, and Jennings (1998) asserted that further examination is needed related to the influences of teams or models of care within the hospital system and their effect on patient outcomes—not just medical outcomes, but the outcomes of nursing interventions, feeling cared for, and improved health and quality of life. The purpose of the study was to investigate seven hypotheses:

1. Hospitalized elders’ perceptions of nurse caring behaviors are positively related to satisfaction with nursing care.

2. Hospitalized elders’ perceptions of nurse caring behaviors are positively related to the health outcome of functional status.

3. Hospitalized elders on the ACE unit will report more nurse caring behaviors than hospitalized elders on the telemetry unit.

4. Hospitalized elders on the ACE unit will report more satisfaction with nursing care than hospitalized elders on the telemetry unit.

5. Hospitalized elders who were cared for on the ACE unit will have less functional status decline upon discharge than hospitalized elders who were cared for on the telemetry unit.

6. Type of care unit moderates the relationship between hospitalized elders’ perceptions of nurse caring behaviors and satisfaction with nursing care.

7. Type of care unit moderates the relationship between hospitalized elders’ perceptions of nurse caring behaviors and the health outcome of functional status.

Method A predictive correlational nonexperimental

design was employed in this study. A moderate relationship was anticipated between the independent variables elders’ perceptions of nurse caring behaviors and satisfaction with nursing care and elders’ perceptions of nurse caring and the health outcome of functional status. The comparison of two groups of subjects, a moderate effect, and a probability of .05 required 90 subjects from each group. Ninety subjects would yield a power of .80 (Munro, 2005). The final total sample size was 180 subjects, with 90 obtained from each unit.

Research Setting The research sample was drawn from a 40-

bed ACE unit and a 40-bed medical–surgical telemetry unit within a 321-bed acute care medical center in the northeastern United States. All nurses employed by the health system received a 2-hour orientation on the concept of NICHE and the topics of fall prevention and geriatric sensitivity. Specific topics included visual/ perceptual changes, hearing loss, communicating with hearing and cognitively impaired elders, and arthritic changes. The lecture content incorporated knowledge related to caring for elders using evidence-based practice guidelines.

Unit Characteristics The ACE unit and the telemetry unit were

chosen for this study because of the similarities of elders’ conditions and the distinct differences in approaches to nursing care and medical treatment goals of the hospitalized elder. Approximately 75% of patients admitted to the ACE unit were age 65 years and older. Approximately 68% of patients admitted to the telemetry unit were age 65 and older. The average length of stay in the ACE unit was 4.02

2016, Vol. 20, No. 3 135

Relationship of Hospitalized Elders’ Perceptions of Nurse Caring Behaviors, Type of Care Unit, Satisfaction With Nursing Care, and Health Outcome of Functional Status

days, and that in the telemetry unit was 3.5 days. Both units admitted patients with similar medical diagnoses.

The physical environment of both units was different. The ACE unit had a common sitting area and railings in the hallways. There was large-print signage, low-glare wax on the floor, up lighting, and soothing beige colors. Every room had a geriatric chair; bathrooms had showers. There were several nurses’ stations of wheelchair height positioned in the center and at the ends of the hallways. A nurse was present at each station. In contrast, the telemetry unit was painted blue and had a high standing-height nurses’ desk only at the center of the unit. Technical equipment was visible throughout the hallways, and there was no common area.

Nurses in both units worked 12-hour shifts. The nurse-to-patient ratios varied in both units; the ACE unit had a ratio of 1:6 on the 7 AM to 7 PM shift and 1:8 to 1:10 on the 7 PM to 7 AM shift; the medical telemetry unit had a ratio of 1:5 to 1:7 on both day and night shifts.

The knowledge requirements for nurses employed on each unit differed. All ACE unit nurses were given a 14-hour orientation class derived from various geriatric resources, including NICHE and evidence-based geriatric protocols. ACE unit nurses had to maintain annual competency in the assessment and nursing care of functional decline, delirium, and inappropriate use of medications for elders. In contrast, telemetry unit nurses received an orientation in the topics of electrocardiograph monitoring, cardiac drugs, chest tubes, ventilators, vascular access devices, patient-controlled analgesia pumps, blood products and transfusion, and peritoneal dialysis. These topics guided the content of nurses’ annual mandatory competencies. There was no additional orientation to elder care for the nurses in the medical telemetry unit other than that of the system-wide orientation that every newly employed nurse received.

In the ACE unit, a geriatrician led a multidisciplinary team who created care plans focused on the elders’ return to their preillness level of function or higher, and their preadmission place of residence. The focus was the whole patient. Daily rounds included the expertise of the GRN, dietitian, pharmacist, physical therapist, social worker, and case manager. In contrast, daily rounds in the telemetry unit included nursing and medicine with the focus of telemetry triage, to identify those patients who no longer required telemetry and could be discharged to another unit, rehabilitation center, or home. The focus of care in the telemetry unit was the cure of disease; the focus of care in the ACE unit was holistic care of the elder, of which the medical diagnosis was only one part.

Instruments The Caring Behaviors Inventory for Elders

(CBI-E) was used to measure the independent variable of elders’ perceptions of nurse caring behaviors, and was originally developed for elders who reside in assisted living and independent living facilities (Wolf, Zuzelo, Goldberg, Crothers, & Jacobson, 2006). Its use in the acute care setting was not previously documented. Items on the CBI-E were derived from caring literature in general and framed by Watson’s (2002) transpersonal caring theory. It provided supportive evidence for empirical validation of Watson’s transpersonal caring theory.

The CBI-E (Wolf et al., 2006) is the only instrument to measure elders’ perceptions of nurse caring; therefore, its use for this study was appropriate. The instrument was developed with elders in mind to measure both nurses’ and elders’ perceptions of nurse caring. The instrument has two parts: one for nurses’ perceptions, and another for elders’ perceptions. For the purpose of this study, the part of the instrument related to elders’ perceptions of nurse caring was used because nurses’ perceptions of their own caring behaviors were not being studied.

The CBI-E is criterion referenced and measures nurse caring as it is perceived by the individual answering the items. Construct validity of the convergent, factorial, and contrasted- groups types was established. Cronbach’s internal consistency reliability coefficient was .94 for the overall CBI-E (Wolf et al., 2006).

The Patient Satisfaction Scale (PSS) was used to measure the dependent variable of satisfaction with nursing care. The instrument measures three dimensions of satisfaction: technical and scientific care, provision of information, and interaction and support. The aim of the PSS is to elicit how a patient feels with regard to needs related to the technical ability of the nurse to give skilled care; the ability and manner in which the nurse communicates needed information; and support, such as being respected, listened to, and having emotional responses addressed. It was developed to measure nursing accessibility, nurse competency, and how the care led to the patient outcomes (Suhonen, Leino-Kilpi, Valimaki, & Kim, 2007). A Cronbach’s a of .93 was achieved for the whole 10-item PSS (Suhonen et al., 2007).

The Katz Index of Activities of Daily Living (Katz ADL Index) was used to measure the dependent variable of functional status. It was developed to study the outcomes of treatment and prognosis in the elderly and chronically ill on the activities of feeding, bathing, dressing, toileting, continence, and transferring (Katz, Ford, Moskowitz, Jackson, & Jaffee, (1963). Wallace and Shelkey (2007) noted that it is the most appropriate instrument to assess functional status

of a client’s ability to perform ADL independently. To determine the reliability of scales composed of dichotomously scored items such as the ADL scale used here, a special form of Cronbach’s alpha called the Kuder-Richardson 20 (KR-20) was used. The KR-20 is an estimate of the expected correlation between one test and a hypothetical alternative test that has the same number of items. The KR-20 is frequently used with Guttman’s analysis as a further indicator of reliability. Ciesla, Shi, Stoskopf, and Samuels (1993) reported an internal consistency reliability of .87.

Procedures for Data Collection The study was initiated at the end of October

2012 after institutional review board approval was obtained from the hospital system and the sponsoring university, and was completed in June 2013. Permission was granted to obtain verbal assent instead of a signed consent. The subjects were given written information about the study. Survey completion served as willingness to participate.

The criteria for inclusion in the study were limited to elders who were 70 years of age and older; had intact cognitive ability as documented in the medical record; were able to complete two surveys as determined by the primary nurse; did not experience acute delirium during their hospitalization; were able to see, speak, and hear; were scheduled to be discharged; and agreed to answer the CBI-E and the PSS surveys. In addition, subjects with the same medical diagnoses were recruited from each unit, matching subjects as closely as possible to lessen the confounding influence of severity of medical diagnoses on study results. Data for the variable of functional status were retrieved from the Katz ADL score in the subject’s medical record. The primary nurses on both units obtained the subject’s score upon admission and discharge. The interrater reliability was .89. Demographic data, including age, gender, ethnicity, marital status, religion, and education of the subjects, were obtained on the first page of the survey.

Results Sample Characteristics

Data were analyzed with SPSS version 21. The sample (n¼ 180) was between the ages of 70 and 99, had a mean age of 80, and was predominantly female, Caucasian, Catholic, and married. The most frequent level of education was high school graduate and some college, with a range of first- to fifth-grade education to doctoral degree. Sample characteristics are presented in Tables 1 and 2. Table 3 lists the frequencies and percentages of subjects’ medical diagnoses.

International Journal for Human Caring136

Relationship of Hospitalized Elders’ Perceptions of Nurse Caring Behaviors, Type of Care Unit, Satisfaction With Nursing Care, and Health Outcome of Functional Status

Instrument Scoring Caring behaviors inventory for elders. The 28- item CBI-E was administered. Subjects marked never, sometimes, or always according to the frequency with which they experienced each nurse caring behavior. Two instrument items, CBI- E 3, ‘‘Helping you and your family make decisions,’’ and CBI-E 6, ‘‘Assisting you to meet your religious or spiritual needs,’’ were removed because of high missing data counts and subject feedback of item irrelevance for the setting. The summed score was based upon 26 items, two less than the original 28-item instrument. The Cronbach’s a coefficient for the 26-item scale was .918. The revised total score range was 26–78. Scores closest to 78 indicated that elders perceived more nurse caring behaviors (Wolf et al., 2006). In this study, the summed CBI-E score (M¼ 72.07, SD¼ 6.78) indicated that the total population of subjects (elders; n¼ 180) perceived high levels of caring. The CBI-E scores were not normally distributed, as evidenced by homogeneous scores and a negative skew. Descriptive statistics are presented in Table 4.

Patient satisfaction scale. The 10-item PSS was administered. Subjects marked their choice of very dissatisfied, dissatisfied, satisfied, or very satisfied according to the degree with which they were satisfied with nursing care. Two instrument items, PSS 3, ‘‘The choices I had in getting specialized nursing care when I needed it,’’ and PSS 5, ‘‘The ways nurses prepared me for my discharge,’’ had high counts of missing data and were removed from analysis. Surveys were given to subjects at the point a discharge order was written, and subjects had not received discharge teaching at the point that they were completing the survey; therefore, they could not make a determination about satisfaction. The summed score was based upon eight items, two less than

the original 10-item instrument. The Cronbach’s a for the 8-item scale with PSS 3 and PSS 5 removed was .946. The revised total score range was 8–32. Scores closest to 32 signified very high levels of satisfaction with nursing care. The PSS score for the total subject population (n¼ 180; M ¼ 28.26, SD¼ 4.52) indicated that elders experienced high levels of satisfaction with nursing care. The PSS scores were not normally distributed, as evidenced by homogeneous scores and a negative skew. Descriptive statistics are presented in Table 4.

Katz ADL index. The health outcome of functional status was determined by whether a subject experienced decline or no decline. No decline or decline was determined by first obtaining the admission and discharge ADL scores from the electronic medical record for each subject. The scores on admission and discharge ranged from 0 to 6 for each unit and were recorded by the staff nurses. Independent in no ADLs was recorded as 0; independent in 1 ADL was recorded as 1; independent in 2 ADLs was recorded as 2; and so on up to independent in 6 ADLs, which was recorded as 6. Then the discharge score was subtracted from the admission score to determine if there was a decline or improvement in functional status. A decrease in score from admission to discharge was determined as decline; a score that stayed the same or increased was determined as no decline. Among total respondents (n¼ 180), 154 subjects (85.6%) experienced no decline; 26 (14.4%) experienced decline. The number and percentage of subjects with functional decline per unit are presented in Table 5.

Hypotheses Testing Hypothesis 1 was tested using the

Spearmans’s rho correlation coefficient. The

correlation between elders’ perceptions of nurse caring behaviors and satisfaction with nursing care was significant using the Spearman’s rho, r(178)¼ .555, p¼.000. Hypothesis 1 was supported.

Hypothesis 2 was tested using the Spearman’s rho correlation coefficient. The correlation between hospitalized elders’ perceptions of nurse caring behaviors and the health outcome of functional status was not significant, r(178)¼�.007, p¼ .924. Hypothesis 2 was rejected.

Hypothesis 3 was measured using the Mann– Whitney U test. The results of the test were not in the expected direction and were not significant, f ¼�1.230, p¼ .219. Elders on the ACE unit had an average rank of 85.74, whereas elders on the telemetry unit had an average rank of 95.26. Hospitalized elders cared for on the ACE unit did not report higher perceptions of nurse caring behaviors than elders on the telemetry unit. Hypothesis 3 was rejected.

Hypothesis 4 was measured using the Mann– Whitney U test. The results of the test were not in the expected direction, and were not significant (f ¼�.315, p¼ .753). Elders on the ACE unit had an average rank of 89.29, whereas elders on the telemetry unit had an average rank of 91.71. Hospitalized elders cared for on the ACE unit did not report more satisfaction with care than elders on the telemetry unit. Hypothesis 4 was rejected.

Hypothesis 5 was tested using the chi-square. A two-way cross-tabulation analysis was conducted to evaluate if there was less functional status decline on the ACE unit than on the telemetry unit. The percentage of elders who declined on the ACE unit was slightly but not significantly higher than the percentage of elders who declined on the telemetry unit and is presented in Table 5. The chi-square analysis indicated no significant association between decline and the type of unit on which the elder received care (Pearson v2[1, 179]¼ .719, p¼ .396). Hypothesis 5 was rejected.

A cross-tabulation and chi-square analysis were done to see the actual number and percentage of subjects’ level of function per unit upon admission and at discharge, and to determine the level of significance. The analysis is presented in Table 6. Mean admission and discharge scores were computed according to unit and are presented in Table 7. Katz ADL scores were higher for subjects admitted and discharged on the telemetry unit versus the ACE unit. A chi-square (with Yates continuity correction) indicated that there was no significant unit difference between subjects’ admission Katz ADL scores, v2(1, n¼ 180)¼ .209, p¼ .225; however, there was a significant unit difference between subjects’ discharge Katz ADL scores (v2[1, n¼ 180]¼ .277, p¼ .020). Subjects who were discharged from the telemetry unit had less

Table 1

Sample Characteristics (Age; n¼ 180)

Age ACE Unit Telemetry Unit Total Sample

n % n % n %

70–74 27 30 16 17.8 43 23.9

75–79 15 16.7 20 22.2 35 19.4

80–84 25 50 25 50 50 27.8

85–89 18 20 15 16.7 33 18.3

90–94 4 4.4 8 8.9 12 6.7

95–99 1 1.1 6 6.7 7 4

Note: M¼ 80.55, SD¼ 7.041, range¼ 70–99, skew¼ 0.371, kurtosis¼�0.450.

2016, Vol. 20, No. 3 137

Relationship of Hospitalized Elders’ Perceptions of Nurse Caring Behaviors, Type of Care Unit, Satisfaction With Nursing Care, and Health Outcome of Functional Status

functional decline than those who were discharged from the ACE unit.

Hypothesis 6 was tested using multiple regression analysis to determine if the interaction of the two variables together, type of unit and nurse caring behaviors, and separately, type of unit and nurse caring behaviors, was predictive of elders’ satisfaction with care. The regression model was significant (R2¼ .24, adjusted R2¼ .229, F[3, 176]¼ 18.737, p¼ .000), explaining 24% of the variance in elders’ satisfaction with care, but only with the variable nurse caring

behaviors as a significant predictor of elders’ satisfaction with care (B¼ .421, p¼ .013). Type of unit was not a predictor of satisfaction (B¼ 1.088, p¼ .891); and the interaction variable type of unit and nurse caring behaviors were not predictors of elders’ satisfaction with care (B¼ �.020, p¼ .849). Hypothesis 6 was rejected.

Hypothesis 7 was tested using multiple regression analysis to determine if the interaction of the two variables type of unit and nurse caring behaviors together and type of unit and nurse caring behaviors separately was predictive of elders’ functional status. The model was not a predictor of functional status decline (v2[3, n¼ 180]¼ 1.78, p¼ .618). The interaction variable of type of unit and nurse caring behaviors had no significant effect on functional status decline (B¼ .059, p¼ .335). The variable type of unit had no significant effect on functional decline (B¼ 4.888, p¼ .301); and the variable nurse caring behaviors had no effect on functional decline (B¼�.076, p ¼ .392). Hypothesis 7 was rejected.

Discussion The evidence found in this study is consistent

with previous research conducted on the relationship between nurse caring behaviors and satisfaction with nursing care using the populations of medical surgical patients (Wolf et

Table 2

Sample Characteristics (Gender, Ethnicity, Reli- gion, and Marital Status)

Variable n %

Gender

Male 77 42.8

Female 103 57.2

Ethnicity

African American 1 0.6

Asian 1 0.6

Caucasian 176 97.8

Latino 1 0.6

Other 1 0.6

Religion

Catholic 120 66.7

Jewish 4 2.2

Protestant 41 22.8

Other 15 8.3

Marital status

Married 80 44.3

Single 10 5.6

Separated 3 1.7

Divorced 13 7.2

Widowed 73 40.6

Partnered 1 0.6

Education

Grade 1–5 1 0.6

Grade 6–8 10 5.6

Grade 9–12 22 12.2

High school graduate 53 29.4

Some college 53 29.4

(Table 2 continued)

Table 3

Sample Characteristics (Medical Diagnoses)

Diagnosis ACE Unit Telemetry Unit Total

n % n % n %

Cardiac 10 11.1 43 47.8 53 29.4

Respiratory 23 25.6 14 15.6 37 20.6

Gastrointestinal 21 23.3 7 7.8 28 15.6

Syncope 2 2.2 11 12.2 13 7.2

Skin infection 8 8.9 1 1.1 9 5

Musculoskeletal 1 1.1 6 6.7 7 3.9

Anemia 5 5.6 0 0 5 2.8

Malaise 2 2.2 1 1.1 3 1.7

Vascular 2 2.2 1 1.1 3 1.7

DMII 1 1.1 0 0 1 0.6

UTI 8 8.9 4 4.4 12 6.7

Kidney 7 7.8 2 2.2 9 5

Note: DMII¼ Diabetes Mellitus Type 2; UTI¼ Urinary Tract Infection.

Table 2 (continued)

Sample Characteristics (Gender, Ethnicity, Reli- gion, and Marital Status)

Variable n %

Associates 6 3.3

Bachelors 27 15

Master’s 5 2.8

Doctorate 1 0.6

Missing 2 1.1

International Journal for Human Caring138

Relationship of Hospitalized Elders’ Perceptions of Nurse Caring Behaviors, Type of Care Unit, Satisfaction With Nursing Care, and Health Outcome of Functional Status

al., 1998), cardiac patients (Wolf, Miller, & Devine, 2003), patients on medical, surgical, and intensive-care step-down units (Larrabee et al. 2004), and surgical patients (Palese et al., 2011). This study strengthens the theory of caring and supports the theoretical proposition that nurse caring behaviors are satisfying to patients (Watson, 2008). In this study, elders 70 and older were satisfied with nursing care when they perceived nurse caring behaviors. This is an important finding because satisfaction with care is an indicator of care quality (Vuori, 1991).

There was no association between hospitalized elders’ perceptions of nurse caring behaviors and the health outcome of functional status. Elders’ decline might be a physiological phenomenon over which nurse caring behaviors have little control. King (2006) proposed that there are numerous factors that contribute to functional decline in hospitalized elders, some of which include the illness itself and its deconditioning effects; complications of therapies, procedures, and medications; and complications of bed rest.

The lack of significant difference between the ACE and telemetry units on the variables of nurse caring and satisfaction with care might be related to the system-wide orientation of new nurses to the NICHE model of care and care of elders. The knowledge and sensitivity of elder care gained in the orientation could have influenced nursing care delivery in both units.

Different staffing ratios on the ACE and telemetry units might have influenced the lack of significant difference between units on elders’ perceptions of nurse caring behaviors and satisfaction with nursing care. Better staffing ratios on the telemetry unit could have resulted in more nursing availability and nursing presence, which might have confounded the positive effects of the ACE unit environment. Siegler, Glick, and Lee (2002) concluded from their survey of ACE unit staffing ratios that when combining registered nurses and practical nurses, staffing ratios average 1:5 on days, 1:6 on evenings, and 1:7 on nights. Curtin (2003) recommended a ratio of 1:4 to 1:6 in most acute care settings. Staffing should be adjusted to patients’ characteristics with no more than 1:2 in settings where patients are debilitated. Hall et al. (2003) reported that a staff mix of registered nurses with practical nurses resulted in better patient health outcomes upon discharge.

The significantly higher Katz ADL discharge scores from the telemetry unit compared to the ACE unit could be due to the fact that subjects had higher Katz ADL scores on admission to the telemetry unit. The higher admission Katz ADL scores could have confounded the lack of significant difference of subjects’ decline between units. The literature on the positive outcomes of hospitalized elders who are cared for on ACE units is conflicting. Saltvedt et al. (2006) found no difference in function, depression, or general well- being of elders cared for in a geriatric evaluation and management unit when compared to those cared for in a general medical ward. Cochran (2005) reported that elders showed more improvement than decline when cared for on an ACE unit. Palmer et al. (2003) stressed the importance of adhering to the ACE unit concept as a model for improvement of health care. The lack of difference in the health outcome of functional status between the ACE unit and the telemetry units could have been due to a weakness in adhering to the ACE unit concept, as Palmer et al. suggest. It is possible that the implementation of these processes was not consistently applied.

The interaction of nurse caring behaviors (predictor variable) and type of unit (moderator) was neither associated with nor did it predict satisfaction with nursing care. In addition, the interaction of nurse caring behaviors and type of unit into an interaction variable was not associated with nor did it predict the health outcome of functional status. It is possible that the confounding variables of frailty, functional status upon admission, comorbidities, and nurse characteristics could have affected the lack of associations between type of unit, nurse caring behaviors, and functional status.

High total scores on the CBI-E and the PSS reflected that elders were satisfied with nursing care on two units in a hospital where NICHE

concepts are taught as part of new-nurse orientation. Early researchers reported that elders did not believe that nurses knew how to care for them with their inherent frailties, and they were not satisfied with nursing care (Turner et al., 2001).

Although there was no unit difference in subjects’ functional status decline, the overall rate of functional decline, 14.4%, was lower than the 33% in previous studies (Covinsky et al., 2003). The NICHE model and the philosophy of care might have been so pervasive throughout this medical center that a culture of elder care was inherent in care delivery and contributed to positive health outcomes of acutely ill elders in both units equally.

Limitations There are several limitations to this study. The

sample lacked cultural and racial diversity; therefore, the study outcomes are limited to Caucasian and Catholic individuals and are not generalizable to other groups. The instrument CBI-E had not been previously tested in the hospital setting. Elders in this study had difficulty with two items: CBI-E 3, ‘‘Helping you and your family make decisions,’’ and CBI-E 6, ‘‘Assisting you to meet your religious/spiritual needs.’’ These items had high missing values. The PSS use had not been documented in an acute care telemetry/ medical surgical unit limited to elders. Elders in this study had difficulty with two items: PSS 3, ‘‘The choices I had in getting specialized nursing care when I needed it,’’ and PSS 5, ‘‘The ways nurses prepared me for my discharge.’’ Further testing would strengthen the validity of the CBI-E and the PSS for use in the acute care setting with elders.

Conclusions and Nursing Implications The number of elders will continue to increase

in this century, and will tax the health care system financially. Teaching elder care in new-nurse orientation might improve nurse caring behaviors that lead to satisfaction and care quality. Further research is necessary using a NICHE and non- NICHE hospital to test the model of care. It might not be where the care is delivered but how it is delivered. It might not be the environmental model of NICHE but the nurse education that produces the positive outcome. A true experimental study

Table 4

Instrument Total Scores and Descriptive Statistics

Variable n M SD Minimum Maximum Skew Kurtosis

Summed CBI-E 180 72.07 6.78 39 78 �1.59 3.07

Summed PSS 180 28.26 4.52 8 32 �1.56 3.30

Table 5

Number (Percentage) of Subjects With Functional Decline According to Unit

ACE Unit Telemetry Unit Totals

Decline 15 (16.7) 11 (12.2) 26 (14.4)

No decline 75 (83.3) 79 (87.8) 154 (85.6)

2016, Vol. 20, No. 3 139

Relationship of Hospitalized Elders’ Perceptions of Nurse Caring Behaviors, Type of Care Unit, Satisfaction With Nursing Care, and Health Outcome of Functional Status

whereby confounding variables are identified and controlled would be desirable.

Additional research is needed to determine the factors that contribute to functional decline of hospitalized elders. Older elders and those who are frail may need more assessment and intervention to prevent new disability and decline in ADLs. Assessment of elders’ relationship status can identify those at risk for decline and negative health outcomes. There might be a mind–body interplay related to decline.

Elder care is complex, a specialty that requires specialized education. The care needs and wants of present-day elders may be different from those of previous generations of elders. Friedrich (2001) proposed five definitions of aging, one of which is historical or contextual age. This refers to the elderly individual’s lifespan related to the time period or century within which the elder has lived. It includes the differences in

lifestyles that occur from past to present time. Qualitative studies should be done on an ongoing basis to identify if what is truly wanted and needed by elders has changed over time.

In this study, acutely ill hospitalized elders reported that nurses demonstrated caring behaviors, and they were satisfied with nursing care. In the past, this was not always the case. Nurses who are taught how to care for acutely ill hospitalized elders are likely to demonstrate nurse caring behaviors that result in satisfaction with nursing care and better functional outcomes and care quality. This study supports evidence that the NICHE model of care could be the answer to the IOM’s (2001, 2010) charge to improve the delivery of health care and care quality to the vulnerable population of elders.

References Aharony, L., & Strasser, S. (1993). Patient

satisfaction: What we know about and what we still need to explore. Medical Care Research and Review, 50, 49–79. Retrieved from: http://mcr.sagepub.com

Arora, V. M, Johnson, M., Olson, J., Podrazik, P. M., Levine, S., DuBeau, C. E., . . . Meltzer, D. O. (2007). Using assessing care of vulnerable elders quality indicators to measure quality of hospital care for vulnerable elders. Journal of the American Geriatrics Society, 55, 1705–1711.

Bogardus, S. T., Richardson, E., Maciejewski, P. K., Gahbauer, E., & Inouye, S. K. (2002). Evaluation of a guided protocol for quality improvement in identifying common geriatric problems. Journal of the American Geriatrics Society, 50, 328–335.

Centers for Disease Control and Prevention and Merck Company Foundation. (2007). The

state of health and aging in America 2007. Whitehouse Station, NJ: Merck Company Foundation. Retrieved from: www.cdc.gov/ aging/pdf/saha_2007.pdf

Chang, E., Hancock, K., Chenoweth, L., Heon, Y. H., Glasson, J., Gradidge, K., & Graham, E. (2003). The influence of demographic variables and ward type on elderly patient’ perceptions of needs and satisfaction during acute hospitalization. International Journal of Nursing Practice, 9, 191–201.

Ciesla, J. R., Shi, L., Stoskopf, C. H., & Samuels, M. E. (1993). Reliability of Katz’s Activities of Daily Living Scale when used in telephone interviews. Evaluation and the Health Professions, 16, 190–203. doi:10.1177/ 01632787930600204

Cochran, P. A. (2005). Acute care for elders prevents functional decline. Nursing, 35(10), 70–71.

Covinsky, K. E., Palmer, R. M., Fortinsky, R. H., Counsell, S. R., Stewart, A. L., Kresevic, D., . . . Landefeld, S. (2003). Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. Journal of the American Geriatrics Society, 51, 451–458.

Curtin, L. L. (2003, September). An integrated analysis of nurse staffing and related variables: Effects on patient outcomes. Online Journal of Issues in Nursing, 8(3). Retrieved from: http://www.nursingworld.org/ MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/Columns/ KeynotesofNote/StaffingandVariablesAnalysis. html

Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press.

Duffy, J., & Hoskins, L. (2003). The Quality-Caring Model� blending dual paradigms. Advances in Nursing Science, 26, 77–88.

Friedrich, D. D. (2001). Successful aging: Integrating contemporary ideas, research findings, and intervention strategies. Springfield, IL: Charles C. Thomas.

Hall, L. M., Doran, D., Baker, G. R., Pink, G. H., Sidani, S., Pallas, L. O., & Donner, G. (2003). Nurse staffing models as predictors of patient outcomes. Medical Care, 41, 1096–1109.

Hall, M. J., DeFrances, C. J., Williams, S. N., Golosinskiy, A., & Schwartzman, A. (2010). National hospital discharge survey: 2007 summary. Retrieved from U.S. Department of Health and Human Services Centers for Disease Control and Prevention website: http://www.cdc.gov/nchs/data/nhsr/nhsr029.pdf

Hartman, M., Catlin, A., Lassman, D., Cylus, J., & Heffler, S. (2008). U.S. health spending by age, selected years through 2004. Health Affairs, 27(1). doi:10.1377/hlthaff.27.l.wl

Table 6

Crosstabulation and Frequencies of Subjects’ Katz ADL Scores Upon Admission and Discharge by Unit, n (%)

ACE Unit (n ¼ 90) Telemetry Unit (n ¼ 90)

Admission Discharge Admission Discharge

Independent in 6 ADLs 35 (38.9) 45 (50) 39 (43.3) 57 (63.3)

Independent in 5 ADLs 2 (2.2) 3 (3.3) 4 (4.4) 6 (6.7)

Independent in 4 ADLs 14 (15.6) 13 (14.4) 13 (14.4) 11 (12.2)

Independent in 3 ADLs 6 (6.7) 4 (4.4) 9 (10) 6 (6.7)

Independent in 2 ADLs 17 (18.9) 8 (8.9) 20 (22.2) 8 (8.9)

Independent in 1 ADL 9 (10) 14 (15.6) 4 (4.4) 2 (2.2)

Independent no ADLs 7 (7.8) 3 (3.3) 1 (1.1) 0 (0.0)

Table 7

Katz ADL Mean Functional Status Scores Upon Admission and Discharge by Unit

Type of Unit n M SD

Score on admission

ACE 90 3.74 2.13

Telemetry 90 4.12 1.82

Score on discharge

ACE 90 4.21 2.09

Telemetry 90 5.02 1.48

International Journal for Human Caring140

Relationship of Hospitalized Elders’ Perceptions of Nurse Caring Behaviors, Type of Care Unit, Satisfaction With Nursing Care, and Health Outcome of Functional Status

Haugh, R. (2004, March). A fresh model for gerontology. Hospitals & Health Networks, 52–56. Retrieved from: http://www.hhnmag. com

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st Century. Retrieved from: http://books.nap.edu/ catalog.php?record_id¼10027#toc

Institute of Medicine. (2010). The healthcare imperative: Lowering costs and improving outcomes. Retrieved from: http://www.nap. edu.catalog/12750.html

Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffee, M. W. (1963). Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. JAMA, 185, 914–919. doi:10.1001/jama.1963.03060120024016

King, B. D. (2006). Functional decline in hospitalized elderly. MEDSURG Nursing, 15, 265–271.

Kresevic, D. M. (2008). Assessment of function. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.), Evidence-based geriatric nursing protocols for best practice (pp. 23–40). New York, NY: Springer.

Landefeld, C. S., Palmer, R. M., Kresevec, D. M., Fortinsky, R. H., & Kowal, J. (1995). A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. New England Journal of Medicine, 332, 1338–1344.

Larrabee, J. H., & Bolden, L. B. (2001). Defining patient-perceived quality of nursing care. Journal of Nursing Care Quality, 16, 34–60.

Larrabee, J. H., Ostrow, C. L., Withrow, M. L., Janney, M. A., Hobbs, G. R., & Burant, C. (2004). Predictors of patient satisfaction with inpatient hospital nursing care. Research in Nursing & Health, 27, 254–268.

Leininger, M. (1993). Cultural care diversity and universality theory. Newbury Park, CA: Sage.

Mahon, P. Y. (1996). An analysis of the concept ‘‘patient satisfaction’’ as it relates to contemporary nursing care. Journal of Advanced Nursing, 24, 1241–1248.

Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality health outcomes model. Image Journal of Nursing Scholarship, 30, 43–46.

Munro, B. H. (2005). Statistical methods for healthcare research. Philadelphia, PA: Lippincott Williams & Wilkins.

NICHE Hartford Institute for Geriatric Nursing, New York University College of Nursing. (2016). NICHE mission and history. Retrieved from: http://www.nicheprogram.org/mission_ history

Palese, A., Tomietto, M., Suhonen, R., Efstathiou, G., Tsangari, H., Merkouis, A., . . . Papastavrou, E. (2011). Surgical patient satisfaction as an outcome of nurses’ caring

behaviors: A descriptive and correlational study in six European countries. Journal of Nursing Scholarship, 43, 341–350.

Palmer, R. M., Counsell, S. R., & Landefeld, S. C. (2003). Acute care for elders units: Practical considerations for optimizing health outcomes. Disease Management Health Outcomes, 11, 507–517.

Risser, N. (1975). Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nursing Research, 24, 45–52.

Saltvedt, I., Jordhøy, M., Mo, E. O., Fayer, P., Kaasa, S., & Sletvold, O. (2006). Randomized trial of in-hospital geriatric intervention: Impact on function and morale. Gerontology, 52, 223–230. doi:10.1159/000093654

Siegler, E. L., Glick, D., & Lee, J. (2002). Optimal staffing for acute care of the elderly (ACE) units. Geriatric Nursing, 23, 152–155. doi:10. 1067/mgn.2002.125411

Suhonen, R., Leino-Kilpi, H., Valimaki, M., & Kim, H. S. (2007). The patient satisfaction scale— An empirical investigation into the Finnish adaptation. Journal of Evaluation in Clinical Practice, 13, 31–38.

Touhy, T. A., & Jett, K. F. (2010). Ebersole and Hess’ gerontological nursing healthy aging. St. Louis, MO: Mosby Elsevier.

Turner, J. T., Lee, V. Gletcher, K., Hudson, K., & Barton, D. (2001). Measuring quality of care with an inpatient elderly population: The geriatric resource nurse model. Journal of Gerontological Nursing, 27(3), 8–18.

Vuori, H. (1991). Patient satisfaction—Does it really matter? Quality Assurance in Health Care, 3, 183–189.

Wallace, M., & Shelkey, M. (2007). Katz Index of Independence in Activities of Daily Living (ADL). Try this: Best practices in in nursing care to older adults. Retrieved from Hartford Institute for Geriatric Nursing, New York University, College of Nursing website: www. ConsultGeriRN.org.

Watson, J. (2002). Assessing and measuring caring in nursing and health science. New York, NY: Springer.

Watson, J. (2008). Nursing the philosophy and science of caring. Boulder, CO: University Press of Colorado.

Wolf, Z. R., Colahan, M., Costello, A., Warwick, R., Ambrose, M. S., & Giardinao, E. R. (1998). Relationship between nurse caring and patient satisfaction. MEDSURG Nursing, 7, 99–110.

Wolf, Z. R., Miller, P. A., & Devine, M. (2003). Relationship between nurse caring and patient satisfaction in patients undergoing invasive cardiac procedures. MEDSURG Nursing, 12, 391–396.

Wolf, Z. R., Zuzelo, P. R., Goldberg, E., Crothers, R., & Jacobson, N. (2006). The Caring Behaviors Inventory for Elders: Development

and psychometric characteristics. International Journal for Human Caring, 10(1), 49–59.

Yellen, E., Davis, G. C., & Ricard, R. (2002). The measurement of patient satisfaction. Journal of Nursing Care Quality, 16, 23–29.

Author Note Marlene Melchiorre Dey, PhD, APN, ACNP-

BC, ANP-BC was Associate Professor, Essex County College, Newark, NJ, USA.

Marlene Melchiorre Dey, PhD, APN, ACNP- BC, ANP-BC is now an Acute Care and Adult Nurse Practitioner at Elite Medical Care, Freehold, NJ, USA.

The author wishes to thank Claudia Anderson Beckmann, PhD, WHNP-BC, CNM, RN; Lucille Sanzero Eller, PhD, RN; Jeanne Ruggiero, PhD, RN; Zane Robinson Wolf, PhD, RN, FAAN; John Kolassa, PhD; and Linda Hassler, RN, MS, GCNS-BC, FNGNA for their guidance throughout the process of this research.

Correspondence regarding this article may be sent to Dr. Marlene Dey, 1 West Chaucer Lane, Farmingdale, NJ 07727 USA. Electronic mail may be sent via the Internet to [email protected].

2016, Vol. 20, No. 3 141

Relationship of Hospitalized Elders’ Perceptions of Nurse Caring Behaviors, Type of Care Unit, Satisfaction With Nursing Care, and Health Outcome of Functional Status

Copyright of International Journal for Human Caring is the property of International Association for Human Caring and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.