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An exploratory descriptive study : orthopedic patients' perceptions of satisfaction with nursing care… Rohrer, Irene Reiko 1991

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EXPLORATORY DESCRIPTIVE STUDY: ORTHOPEDIC PATIENTS' PERCEPTIONS OF SATISFACTION WITH NURSING CARE IN THE EMERGENCY ROOM by IRENE REIKO ROHRER BSN., The U n i v e r s i t y of B r i t i s h C o l u m b i a , 1987 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES SCHOOL OF NURSING We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1991 (c) I r e n e R e i k o R o h r e r , 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of [\^( j f S \ a, The University of British Columbia Vancouver, Canada DE-6 (2/88) i i A b s t r a c t The purpose o£ t h i s e x p l o r a t o r y d e s c r i p t i v e s t u d y was t o d etermine o r t h o p e d i c p a t i e n t s ' p e r c e p t i o n s of s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s d u r i n g t h e i r emergency room e x p e r i e n c e . The c o n c e p t u a l framework s e l e c t e d f o r t h i s s t u d y was based on R i s s e r ' s (1975) c r i t e r i o n t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . R i s s e r ' s e v a l u a t i v e c r i t e r i o n c o n s i s t s of f o u r d i m e n s i o n s which i n c l u d e : t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r , t r u s t i n g r e l a t i o n s h i p , i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p , and e d u c a t i o n a l r e l a t i o n s h i p . The s t u d y was conducted i n a l a r g e m e t r o p o l i t a n h o s p i t a l i n the Vancouver a r e a . The sample c o n s i s t e d of seven men and t h r e e women. T h e i r ages ranged from 23 t o 81 y e a r s . A l l s u b j e c t s were a d m i t t e d t o the emergency room and s u b s e q u e n t l y t r a n s f e r r e d t o an o r t h o p e d i c ward as a r e s u l t of an o r t h o p e d i c i n j u r y and/or i l l n e s s . An i n t e r v i e w guide was d e s i g n e d by the r e s e a r c h e r t o c o l l e c t r e t r o s p e c t i v e d a t a of s u b j e c t s ' p e r c e p t i o n s of t h e i r emergency room e x p e r i e n c e . Data were c o l l e c t e d t h r o u g h taped s e m i - s t r u c t u r e d i n t e r v i e w s w i t h a l l the s u b j e c t s d u r i n g t h e i r s t a y on the o r t h o p e d i c ward. Data were a n a l y z e d by c a t e g o r i z i n g the i d e n t i f i e d n u r s i n g c a r e b e h a v i o u r s under the f o u r d i m e n s i o n s of R i s s e r ' s (1975) e v a l u a t i v e c r i t e r i o n . The f i n d i n g s i n d i c a t e d t h a t s u b j e c t s were a b l e t o i i i r e c a l l s a t i s f y i n g or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s . They a p p r a i s e d and/or commented on the n u r s i n g c a r e b e h a v i o u r s which met t h e i r b a s i c p h y s i c a l and p s y c h o s o c i a l needs. The n u r s i n g c a r e b e h a v i o u r s r e l a t e d t o the t r u s t i n g r e l a t i o n s h i p d i m e n s i o n were an i n t e g r a l component of p a t i e n t s a t i s f a c t i o n . The r o l e of the t r i a g e nurse was s i g n i f i c a n t i n i n f l u e n c i n g s u b j e c t s ' p e r c e p t i o n s of s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h n u r s i n g c a r e . O v e r a l l , s u b j e c t s e x p r e s s e d s a t i s f a c t i o n w i t h the n u r s i n g c a r e b e h a v i o u r s i n each of the f o u r d i m e n s i o n s . i v TABLE OF CONTENTS i i i v v i v i i CHAPTER ONE I n t r o d u c t i o n Background t o the Study 1 C o n c e p t u a l Framework 4 Problem Statement - 5 Purpose 6 D e f i n i t i o n of terms 6 Assumptions 7 L i m i t a t i o n s 7 S i g n i f i c a n c e of the Study 8 O r g a n i z a t i o n of the Repo r t 9 CHAPTER TWO Review of R e l a t e d L i t e r a t u r e I n t r o d u c t i o n 10 P a t i e n t S a t i s f a c t i o n w i t h i n the H e a l t h Care F i e l d 10 P a t i e n t S a t i s f a c t i o n w i t h i n the C o n t e x t of N u r s i n g 16 P a t i e n t S a t i s f a c t i o n R e l a t e d t o N u r s i n g Care 16 P a t i e n t s as I n f o r m a n t s of P a t i e n t S a t i s f a c t i o n 18 P a t i e n t S a t i s f a c t i o n R e l a t e d t o the A s p e c t s 20 of N u r s i n g Care Emergency N u r s i n g Care Standards i n R e l a t i o n t o 25 R i s s e r ' s C r i t e r i o n t o E v a l u a t e P a t i e n t S a t i s f a c t i o n w i t h N u r s i n g Care Summary 31 CHAPTER THREE Methodology I n t r o d u c t i o n 32 Re s e a r c h Design 32 Research S e t t i n g 32 Sample S e l e c t i o n 33 S e l e c t i o n P rocedure 33 Data C o l l e c t i o n 34 Data C o l l e c t i o n I nstrument 35 P i l o t T e s t 38 Data A n a l y s i s P r o c e d u r e ' 39 E t h i c a l C o n s i d e r a t i o n s 40 Summary 41 A b s t r a c t T a b l e of c o n t e n t s L i s t of T a b l e s Acknowledgements V CHAPTER FOUR P r e s e n t a t i o n of F i n d i n g s and D i s c u s s i o n I n t r o d u c t i o n 42 C h a r a c t e r i s t i c s of the S u b j e c t s 42 P r e s e n t a t i o n of the F i n d i n g s 43 T e c h n i c a l - p r o f e s s i o n a l B e h a v i o u r Dimension 43 T r u s t i n g R e l a t i o n s h i p Dimension 47 I n t e r - i n t r a p e r s o n a l R e l a t i o n s h i p Dimension 50 E d u c a t i o n a l R e l a t i o n s h i p Dimension 54 P r e s e n t a t i o n of D i s c u s s i o n 57 T e c h n i c a l - p r o f e s s i o n a l B ehaviour Dimension 57 T r u s t i n g R e l a t i o n s h i p Dimension 61 I n t e r - i n t r a p e r s o n a l R e l a t i o n s h i p Dimension 65 E d u c a t i o n a l R e l a t i o n s h i p Dimension 69 Summary 72 CHAPTER FIVE Summary, C o n c l u s i o n s , and I m p l i c a t i o n s f o r N u r s i n g Summary 74 C o n c l u s i o n s 77 I m p l i c a t i o n s f o r N u r s i n g 78 I m p l i c a t i o n s f o r N u r s i n g E d u c a t i o n 78 I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e 81 I m p l i c a t i o n s f o r N u r s i n g R esearch 82 R e f e r e n c e s 84 Appendices A L e t t e r t o Agency 90 B I n f o r m a t i o n L e t t e r 91 C Consent Form 92 D I n t e v i e w Guide P a r t A 93 P a r t B 94 v i LIST OF TABLES Tab l e 1 Congruency Between the T e c h n i c a l - p r o f e s s i o n a l 27 B e h a v i o u r Dimension and S t a n d a r d of Emergency N u r s i n g P r a c t i c e 2 Congruency Between the T r u s t i n g R e l a t i o n s h i p 28 Dimension and S t a n d a r d of Emergency N u r s i n g P r a c t i c e 3 Congruency Between the I n t e r - i n t r a p e r s o n a l 29 Dimension and S t a n d a r d of Emergency N u r s i n g P r a c t i c e 4 Congruency Between the E d u c a t i o n a l Dimension 30 and S t a n d a r d of Emergency N u r s i n g P r a c t i c e 5 T e c h n i c a l - p r o f e s s i o n a l B e h a v i o u r Dimension: 44 S u b j e c t s ' P e r c e p t i o n s of N u r s i n g Care B e h a v i o u r s 6 T r u s t i n g R e l a t i o n s h i p Dimension: 48 S u b j e c t s ' P e r c e p t i o n s of N u r s i n g Care B e h a v i o u r s 7 I n t e r - i n t r a p e r s o n a l R e l a t i o n s h i p Dimension: 51 S u b j e c t s ' P e r c e p t i o n s of N u r s i n g Care B e h a v i o u r s 8 E d u c a t i o n a l R e l a t i o n s h i p Dimension: 54 S u b j e c t s ' P e r c e p t i o n s of N u r s i n g Care B e h a v i o u r s v i i Acknowledgements I would l i k e t o e x p r e s s my a p p r e c i a t i o n t o a number of people w i t h o u t whose h e l p t h i s s t u d y would not have been p o s s i b l e . I would l i k e t o thank S h e i l a S t a n t o n f o r her a s s i s t a n c e i n g u i d i n g me t h r o u g h the p r o p o s a l s t a g e of the r e s e a r c h p r o c e s s . My thanks and a p p r e c i a t i o n e x t e n d t o E t h e l Warbinek who took over as c h a i r p e r s o n and t o Anne Wyness f o r a c c e p t i n g the t a s k of committee member d u r i n g the r e s e a r c h p r o c e s s . T h e i r g u i d a n c e , s u p p o r t , and encouragement has e n r i c h e d by l e a r n i n g t h r o u g h o u t t h i s s t u d y . A s p e c i a l thanks i s extended t o my c o l l e a g u e s and f r i e n d s who have been so t h o u g h t f u l and s u p p o r t i v e i n t h e i r e f f o r t t o have me complete t h i s s t u d y . F i n a l l y , I am i n d e b t e d t o my husband, P a u l who has always g i v e n me e n d l e s s s u p p o r t and encouragement. 1 CHAPTER ONE I n t r o d u c t i o n Background t o the Study In t o d a y ' s consumer o r i e n t e d s o c i e t y i t i s i m p o r t a n t t o convey t o the consumers t h a t t h e i r feedback on h e a l t h c a r e p r o v i d e s i n f o r m a t i o n on p a t i e n t s ' c o n c e r n s , needs, and p e r c e p t i o n s of t r e a t m e n t t o h e l p improve the o v e r a l l q u a l i t y of h e a l t h c a r e ( D a v i s & Hobbs, 1989). Donabedian (1988) s t a t e d t h a t p a t i e n t i n f o r m a t i o n which i s r e c e i v e d t h r o u g h i n t e r v i e w s and q u e s t i o n n a i r e s i s i n d i s p e n s i b l e when com p l i a n c e and s a t i s f a c t i o n a r e used as measures t o a s s e s s the q u a l i t y of h e a l t h c a r e . Measurement of p a t i e n t s a t i s f a c t i o n i s now r e c o g n i z e d as a l e g i t i m a t e c o n c e r n of q u a l i t y a s s u r a n c e (QA) programs. A c c o r d i n g t o the Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n (CCHA), p a t i e n t s a t i s f a c t i o n i s one of the key f a c t o r s i n a s s e s s i n g h o s p i t a l q u a l i t y a s s u r a n c e programs ( H e f f r i n g , N e i l s e n , S z k l a r z , & Dobson, 1986). E v a l u a t i v e h e a l t h c a r e l i t e r a t u r e r e p o r t s t h a t p a t i e n t s ' p e r c e p t i o n s of h e a l t h c a r e s e r v i c e s are an i n t e g r a l p a r t of a s s e s s i n g the q u a l i t y of c a r e (Donabedian, 1988; Lemke, 1987; M c M i l l a n , 1987; O ' S u l l i v a n , 1983; P r e h n , Mayo & Weisman, 1989). D o e r i n g (1983) d e f i n e d p a t i e n t s a t i s f a c t i o n as "a measure of the degree t o which h e a l t h c a r e p r o v i d e r s have been s u c c e s s f u l i n meeting p a t i e n t - d e f i n e d needs and e x p e c t a t i o n s " (p.291). S p i t z e r (1988) s t a t e d t h a t n u r s e s need t o look a t whether t h e y a r e r e a l l y s e n s i t i v e t o the 2 n u r s i n g c a r e needs and e x p e c t a t i o n s of t h e i r p a t i e n t s . She c l a i m e d t h a t p a t i e n t s ' needs and e x p e c t a t i o n s of n u r s i n g s e r v i c e depend on many f a c t o r s . One i m p o r t a n t f a c t o r i s the p a r t i c u l a r c l i n i c a l s e t t i n g i n which the p a t i e n t r e c e i v e s n u r s i n g c a r e . O ' S u l l i v a n (1983) a l s o p o i n t e d out t h a t p a t i e n t s a t i s f a c t i o n has d i f f e r e n t i m p l i c a t i o n s depending on the s e t t i n g i n which the n u r s i n g c a r e i s d e l i v e r e d and the a s p e c t s of c a r e b e i n g e v a l u a t e d . The emergency room i n the h o s p i t a l i s one of the c l i n i c a l a r e a s where n u r s i n g c a r e i s g i v e n . The emergency room i s o f t e n the e n t r y p o i n t i n t o the h e a l t h c a r e system f o r many p a t i e n t s ( M i l l e r , 1983). In the emergency room, one i s l i k e l y t o f i n d a wide v a r i e t y of p a t i e n t s , some h a r d l y i l l , o t h e r s m a n i f e s t i n g l i f e - t h r e a t e n i n g emergencies (Donabedian, 1988). D u r i n g the i n i t i a l hour of c a r e , b e f o r e a d i a g n o s i s i s made, most n u r s i n g i n t e r v e n t i o n s respond t o problems a s s o c i a t e d w i t h the n a t u r e and s e v e r i t y of the f u n c t i o n a l d i s t u r b a n c e . T h e r e f o r e , n u r s i n g c a r e i n the emergency room o f t e n i n v o l v e s complex, u n p r e d i c t a b l e , and emergent n u r s i n g d e c i s i o n s ( S i d e s , 1986). Nurses w o r k i n g i n the emergency room a r e i n v o l v e d i n the c a r e of p a t i e n t s who p e r c e i v e t h a t t h e i r h e a l t h problems a re s u f f i c i e n t l y a c u t e t o w a r r a n t s e e k i n g emergency c a r e . P a t i e n t s who a r e a d m i t t e d t o t h e emergency room a r e f r e q u e n t l y f a c e d w i t h a sudden and unexpected h e a l t h r e l a t e d e x p e r i e n c e ( C l u t t e r , 1988). O f t e n t i m e s , the p a t i e n t ' s a n x i e t y l e v e l i s h i g h , not o n l y because of an 3 i n j u r y or i l l n e s s but a l s o as the r e s u l t of b e i n g i n an u n f a m i l i a r environment ( D a n i s , 1984). I f n u r s e s a r e meeting p a t i e n t s ' n u r s i n g c a r e needs and e x p e c t a t i o n s , the i n i t i a l p e r i o d of p a t i e n t s ' h o s p i t a l i z a t i o n may be l e s s a n x i e t y p r o d u c i n g . Emergency room n u r s e s work i n a c l i n i c a l l y s p e c i a l i z e d a r e a , and emergency n u r s i n g d i f f e r s from o t h e r t y p e s of n u r s i n g c a r e d e l i v e r y . The main d i f f e r e n c e s a r e t h a t n u r s e - p a t i e n t i n t e r a c t i o n s a r e u s u a l l y of s h o r t d u r a t i o n , the c l i m a t e i s o f t e n s t r e s s f u l , and p a t i e n t s e x p e c t immediate a t t e n t i o n . A l s o , the number of p a t i e n t s t o be c a r e d f o r a t any g i v e n time i s h i g h l y u n p r e d i c t a b l e (Sheehy & B a r b e r , 1985). Nurses must be aware t h a t t h e i r a t t i t u d e s and b e h a v i o u r s s i g n i f i c a n t l y impact on p a t i e n t s a t i s f a c t i o n w i t h t h e n u r s i n g c a r e t h a t p a t i e n t s r e c e i v e . Nurses p l a y a v i t a l r o l e i n r e d u c i n g the a n x i e t y l e v e l of many p a t i e n t s coming i n t o the emergency room. T h e r e f o r e , i t i s i m p o r t a n t t h a t n u r s e s w o r k i n g i n the emergency room be knowledgeable about how p a t i e n t s p e r c e i v e them and the n u r s i n g c a r e t h e y p r o v i d e i n t h i s type of c l i n i c a l s e t t i n g . Through an e x p l o r a t o r y d e s c r i p t i v e s t u d y , the r e s e a r c h e r a n t i c i p a t e s g a i n i n g i n s i g h t i n t o what p a t i e n t s p e r c e i v e as s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s of n u r s e s w o r k i n g i n the emergency room. C o n c e p t u a l Framework P a t i e n t s ' p e r c e p t i o n s of n u r s i n g c a r e can be a r i c h s o u r c e of i n f o r m a t i o n f o r g e n e r a t i n g improvement i n the q u a l i t y of p a t i e n t c a r e . The c o n c e p t u a l framework f o r t h i s s t u d y i s based on R i s s e r ' s (1975) e v a l u a t i v e c r i t e r i o n w hich i s a measure of p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . R i s s e r (1975) s t a t e d t h a t p a t i e n t s a t i s f a c t i o n may be c o n c e p t u a l i z e d as the "degree of congruency between a p a t i e n t ' s e x p e c t a t i o n of i d e a l n u r s i n g c a r e and h i s p e r c e p t i o n of the r e a l n u r s i n g c a r e which he r e c e i v e s " ( p . 4 6 ) . In t h i s s t u d y , as p a t i e n t s d e s c r i b e i n t e r a c t i o n s w i t h n u r s e s d u r i n g t h e i r emergency room e x p e r i e n c e , p a t i e n t s a t i s f a c t i o n and/or d i s s a t i s f a c t i o n w i t h n u r s i n g c a r e w i l l be c a t e g o r i z e d a c c o r d i n g t o R i s s e r ' s f o u r d i m e n s i o n s of t h e c r i t e r i o n : 1. t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r 2. t r u s t i n g r e l a t i o n s h i p 3. i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p 4. e d u c a t i o n a l r e l a t i o n s h i p . The f i r s t d i m e n s i o n , t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r , i n c l u d e s the t e c h n i c a l a c t i v i t i e s and knowledge base r e q u i r e d by n u r s e s t o c o m p e t e n t l y p e r f o r m n u r s i n g c a r e t a s k s . The second d i m e n s i o n , t r u s t i n g r e l a t i o n s h i p , r e l a t e s t o how n u r s e s f o s t e r c o n s t r u c t i v e and c o m f o r t a b l e n u r s e - p a t i e n t i n t e r a c t i o n and communication. Examples of t r u s t i n g r e l a t i o n s h i p b e h a v i o u r s i n c l u d e communication measures such as d e m o n s t r a t i n g an i n t e r e s t i n , s e n s i t i v i t y 5 t o , and/or l i s t e n i n g t o p a t i e n t s ' problems. The t h i r d d i m e n s i o n , i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p , , i s the e x p r e s s i v e f u n c t i o n of the n u r s e . The i n t e r p e r s o n a l q u a l i t y , demonstrated by v e r b a l b e h a v i o u r , r e l a t e s t o how n u r s e s s u c c e s s f u l l y i n i t i a t e , m a i n t a i n , and d i r e c t s o c i a l i n t e r a c t i o n w i t h the p a t i e n t . The i n t r a p e r s o n a l q u a l i t y , d emonstrated by n o n - v e r b a l b e h a v i o u r , r e l a t e s t o p e r s o n a l i t y c h a r a c t e r i s t i c s of n u r s e s such as appearance, f r i e n d l i n e s s , and c o n f i d e n c e . The f o u r t h d i m e n s i o n , e d u c a t i o n a l r e l a t i o n s h l . p . , i s the i n f o r m a t i o n exchange between nurse and p a t i e n t . These n u r s i n g c a r e b e h a v i o u r s r e l a t e t o n u r s e s ' a b i l i t y t o p r o v i d e i n f o r m a t i o n f o r p a t i e n t s such as a n s w e r i n g p a t i e n t s ' q u e s t i o n s , a s k i n g a p p r o p r i a t e q u e s t i o n s , and e x p l a i n i n g p r o c e d u r e s (Hinshaw & Atwood, 1982; R i s s e r 1975). R i s s e r ' s (1975) e v a l u a t i v e c r i t e r i o n w i l l be used t o p r o v i d e d i r e c t i o n f o r d e v e l o p i n g i n t e r v i e w q u e s t i o n s and c a t e g o r i z i n g p a t i e n t s ' p e r c e p t i o n s of s a t i s f y i n g and d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s . Problem Statement Emergency room nu r s e s must be c o g n i z a n t of t h e p e r c e p t i o n s of p a t i e n t s when e v a l u a t i n g the q u a l i t y of n u r s i n g c a r e d e l i v e r e d . C u r r e n t l y , t h e r e e x i s t s a p a u c i t y of p u b l i s h e d r e s e a r c h c o n c e r n i n g p a t i e n t s ' p e r c e p t i o n s of s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s of n u r s e s i n the emergency room. O r t h o p e d i c p a t i e n t s a r e f r e q u e n t l y seen i n emergency rooms and a r e o f t e n a d m i t t e d t o h o s p i t a l f o r f u r t h e r 6 t r e a t m e n t and c a r e . T h i s group o£ p a t i e n t s tends t o e x p e r i e n c e common problems and r e q u i r e s s i m i l a r n u r s i n g i n t e r v e n t i o n s . As t h e i r i n j u r i e s are g e n e r a l l y not l i f e - t h r e a t e n i n g , t h e y s h o u l d be a b l e t o r e c a l l t h e i r p e r c e p t i o n s of n u r s i n g c a r e b e h a v i o u r s w h i l e i n the emergency room. Purpose The purpose of t h i s s t u d y was t o d e t e r m i n e , t h r o u g h an e x p l o r a t o r y d e s c r i p t i v e s t u d y , o r t h o p e d i c p a t i e n t s ' p e r c e p t i o n s of s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s d u r i n g t h e i r emergency room e x p e r i e n c e . D e f i n i t i o n of Terms P a t i e n t s a t i s f a c t i o n - "the degree of congruency between a p a t i e n t ' s e x p e c t a t i o n of the i d e a l n u r s i n g c a r e and h i s [or h e r ] p e r c e p t i o n of the r e a l n u r s i n g c a r e which he [or she] r e c e i v e s " ( R i s s e r , 1975, p.46). P a t i e n t d i s s a t i s f a c t i o n - d i s c o n t e n t w i t h n u r s i n g c a r e or the l a c k of congruency between a p a t i e n t ' s e x p e c t a t i o n of the i d e a l n u r s i n g c a r e and h i s p e r c e p t i o n of the a c t u a l n u r s i n g c a r e which he r e c e i v e s . Emergency room - a h e a l t h c a r e department w i t h i n a h o s p i t a l p r o v i d i n g a 24 hour s e r v i c e t o p a t i e n t s e x p e r i e n c i n g an u n f o r s e e n h e a l t h c a r e event r e q u i r i n g u r g e n t assessment and t r e a t m e n t . The emergency room s e r v e s as an e n t r y p o i n t t o the h e a l t h c a r e f a c i l i t y . 7 Emergency n u r s i n g - the n u r s i n g c a r e which i s p r o v i d e d t o i n d i v i d u a l s of a l l ages by n u r s e s w o r k i n g i n an emergency room. O r t h o p e d i c p a t i e n t s i n the emergency room - t h o s e p e r s o n ( s ) who a r e a s s e s s e d and t r e a t e d i n the emergency department f o r i n j u r i e s i n v o l v i n g any a s p e c t of the m u s c u l o s k e l e t a l system, which i n c l u d e s the m u s c l e s , tendons, bones, and j o i n t s . Assumptions T h i s s t u d y was based on the f o l l o w i n g a s s u m p t i o n : P a t i e n t s a t i s f a c t i o n was an i n d i c a t o r of how the p a t i e n t had p e r c e i v e d the q u a l i t a t i v e a s p e c t s of n u r s i n g c a r e ( V u o r i , 1 9 8 7 ) L i m i t a t i o n s T h i s s t u d y had the f o l l o w i n g l i m i t a t i o n s : 1. The f i n d i n g s of t h i s s t u d y were based on the r e t r o s p e c t i v e p e r c e p t i o n s of the p a r t i c i p a n t s . T h e r e f o r e , a l l n u r s i n g c a r e b e h a v i o u r s which p a t i e n t s p e r c e i v e d as s a t i s f y i n g or d i s s a t i s f y i n g may not be r e c a l l e d . 2. The s t u d y was l i m i t e d t o o r t h o p e d i c p a t i e n t s . S i n c e t h i s s t u d y d i d not encompass a l l t y p e s of p a t i e n t s who p r e s e n t e d i n the emergency room, the g e n e r a l i z a b i l i t y of the f i n d i n g s was l i m i t e d . 8 S i g n i f i c a n c e of the Study V u o r i (1987) s t a t e d t h a t , " p a t i e n t s a t i s f a c t i o n i s an a t t r i b u t e of q u a l i t y per s e : Without i t t h e r e cannot be good c a r e " (p.108). Harper P e t e r s e n (1989) s t r e s s e d t h a t s o l i c i t i n g feedback on p a t i e n t s a t i s f a c t i o n s h o u l d be conducted by the c a r e g i v e r s w i t h i n the same s e r v i c e such as n u r s e s f o r n u r s i n g , because people from o t h e r departments may m i s i n t e r p r e t the d a t a . O ' S u l l i v a n (1983) noted t h a t f u r t h e r r e s e a r c h w i t h p a t i e n t s a t i s f a c t i o n s h o u l d i n v o l v e an i n v e s t i g a t i o n of how p a t i e n t s d e f i n e s a t i s f a c t i o n . She s u g g e sted t h a t t h i s r e s e a r c h i n c l u d e p a t i e n t s a t i s f a c t i o n w i t h r e s p e c t t o the t e c h n i c a l a s p e c t s of n u r s i n g c a r e , the communication between h e a l t h c a r e p r o v i d e r and p a t i e n t s , e s p e c i a l l y under s t r e s s , and the way p a t i e n t s respond t o i n f o r m a t i o n t h a t a c h i e v e s maximum u n d e r s t a n d i n g . In the l i t e r a t u r e r e v i e w e d , no p u b l i s h e d r e s e a r c h s t u d i e s were found r e g a r d i n g p a t i e n t s a t i s f a c t i o n w i t h n u r s e s and n u r s i n g c a r e i n an emergency room s e t t i n g . Sheehy and Barber (1985) emphasized t h a t the n u r s i n g c a r e p r o v i d e d i n an emergency room i s o f t e n b r i e f and i n t e n s e . They s t a t e d t h a t a c r i t i c a l a s p e c t of the n u r s i n g c a r e i n the emergency room i s the n u r s e ' s a b i l i t y t o q u i c k l y a s s e s s , t r e a t , and s t a b i l i z e the p a t i e n t ' s c o n d i t i o n . However, more knowledge i s needed t o u n d e r s t a n d how n u r s e s can e v a l u a t e the e f f e c t i v e n e s s of t h e i r n u r s i n g c a r e i n terms of p a t i e n t s ' p e r c e p t i o n s of s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s . T h i s s t u d y has the 9 p o t e n t i a l of p r o v i d i n g d a t a which when d i s s e m i n a t e d t o emergency room nurses may improve the q u a l i t y of t h e i r n u r s i n g c a r e . O r g a n i z a t i o n of the Report T h i s r e s e a r c h r e p o r t i s o r g a n i z e d i n t o f i v e c h a p t e r s . Chapter One has o u t l i n e d the c o n t e x t of the problem and the purpose of the s t u d y . Chapter Two p r e s e n t s the l i t e r a t u r e r e v i e w . Chapter Three d e s c r i b e s the r e s e a r c h methodology, i n c l u d i n g d a t a r e g a r d i n g the sample, d a t a c o l l e c t i o n , and a n a l y s i s . Chapter Four p r e s e n t s the f i n d i n g s and i n t e r p r e t a t i o n of the d a t a . C o n c l u s i o n s a r e p r e s e n t e d i n Chapter F i v e w i t h i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n , p r a c t i c e , and r e s e a r c h . CHAPTER TWO Review of R e l a t e d L i t e r a t u r e I n t r o d u c t i o n P a t i e n t s a t i s f a c t i o n d a t a a r e used as i n d e x e s t o measure the q u a l i t y of h e a l t h c a r e s e r v i c e i n n u r s i n g and o t h e r h e a l t h c a r e f i e l d s ( D o e r i n g , 1983; Eck, Meehan, Zlgmund, & P i e r r o , 1989; Harper P e t e r s e n , 1988; H e f f r i n g , N e i l s e n , S z k l a r z , & Dobson, 1986). P a t l e n t s a t i s f a c t i o n w i t h h e a l t h c a r e s e r v i c e s appears t o i n f l u e n c e whether an i n d i v i d u a l seeks m e d i c a l c a r e , c o m p l i e s w i t h t r e a t m e n t , and m a i n t a i n s a c o n t i n u i n g r e l a t i o n s h i p w i t h h e a l t h c a r e p r o v i d e r s ( M c M i l l a n , 1987). I n t h i s c h a p t e r , the d i s c u s s i o n on p a t i e n t s a t i s f a c t i o n w i l l be o r g a n i z e d i n t o t h r e e main s e c t i o n s . The f i r s t s e c t i o n w i l l p r e s e n t an o v e r v i e w of l i t e r a t u r e and r e s e a r c h on p a t i e n t s a t i s f a c t i o n w i t h i n the h e a l t h c a r e f i e l d . The second s e c t i o n w i l l p r e s e n t c u r r e n t l i t e r a t u r e and r e s e a r c h on p a t i e n t s a t i s f a c t i o n w i t h i n the c o n t e x t of n u r s i n g . L a s t l y , the t h i r d s e c t i o n w i l l d i s c u s s p a t i e n t s a t i s f a c t i o n as i t r e l a t e s t o emergency n u r s i n g c a r e s t a n d a r d s and the d i m e n s i o n s of R i s s e r ' s (1975) c r i t e r i o n . P a t i e n t S a t i s f a c t i o n W i t h i n the H e a l t h Care F i e l d H e a l t h c a r e l i t e r a t u r e s u g g e s t s t h a t p a t i e n t s a t i s f a c t i o n i n d i c a t o r s a r e emerging as dominant and c r i t i c a l outcome measures f o r q u a l i t y of c a r e (Donabedian, 1988; M a x w e l l , 1986; S t r a s e n , 1988; V u o r i , 1987). The 11 Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n r e c o g n i z e s p a t i e n t s a t i s f a c t i o n as one of the key f a c t o r s i n p l a n n i n g h o s p i t a l q u a l i t y a s s u r a n c e programs ( H e f f r i n g , N e i l s e n , S z k l a r z , & Dobson, 1986). While l i m i t a t i o n s have been r e c o g n i z e d w i t h the use of p a t i e n t s a t i s f a c t i o n d a t a i n a s s e s s i n g the q u a l i t y of c a r e (Donbedian, 1988; N e l s o n , Hays, L a r s o n , & B a t a l d e n , 1989), t h e y a r e f r e q u e n t l y used by h e a l t h c a r e f a c i l i t i e s as a q u a l i t y a s s u r a n c e measurement (Pr e h n , Mayo, & Weisman, 1989; Weiss & Ramsey, 1989). O ' B r i e n , Lowe and Rennebohm (1987) c l a i m e d t h a t p a t i e n t s ' d i s s a t i s f a c t i o n w i t h c a r e can o f t e n be p r e v e n t e d by d e c i d i n g and r e c o r d i n g what the p a t i e n t wants and needs. These a u t h o r s emphasized t h a t the c a r e g i v e r must u n d e r s t a n d the p a t i e n t ' s p e r c e p t i o n s of h i s or her needs. The l i t e r a t u r e r e v i e w e d on p a t i e n t s a t i s f a c t i o n r e v e a l e d t h a t v a r i o u s f a c t o r s must be c o n s i d e r e d when u s i n g p a t i e n t s a t i s f a c t i o n d a t a as one of the key outcomes of q u a l i t y of c a r e . For example, V u o r i (1987) p o i n t e d out t h a t h e a l t h c a r e p r o v i d e r s and p a t i e n t s have d i f f e r e n t g o a l s f o r c a r e and as w e l l , p a t i e n t s l a c k the s c i e n t i f i c and t e c h n i c a l knowledge n e c e s s a r y t o a d e q u a t e l y a s s e s s the q u a l i t y of c a r e . He a l s o s t a t e d t h a t the c o n c e p t of q u a l i t y i n r e l a t i o n t o p a t i e n t s a t i s f a c t i o n , depends on many d i f f e r e n t f a c t o r s such as the c h a r a c t e r i s t i c s of age, gender, s e x , e d u c a t i o n , and s o c i o e c o n o m i c s t a t u s . G i v e n t h e s e f a c t o r s , he s t r e s s e d t h a t t h e s e a r e the v a r i a b l e s which " b r i n g the e m p i r i c a l v a l i d i t y of a s s e s s i n g p a t i e n t s a t i s f a c t i o n i n t o q u e s t i o n " (p.106). In a d d i t i o n , b oth C l e a r y , Keroy, Karapanos, and McMullen (1989) and N e l s o n , Hays, L a r s o n , and B a t a l d e n (1989) s t a t e d t h a t d a t a from p a t i e n t s a t i s f a c t i o n s u r v e y s a r e o n l y m e a n i n g f u l f o r i m p r o v i n g p a t i e n t c a r e t o the e x t e n t t h a t p a t i e n t s a t i s f a c t i o n measures a r e m e t h o d o l o g i c a l l y sound. These r e s e a r c h e r s c l a i m e d t h a t p a t i e n t s a t i s f a c t i o n d a t a s h o u l d be i n t e r p r e t e d w i t h i n the parameters of the sample s u r v e y e d , the a p p r o p r i a t e n e s s of the a s p e c t s of c a r e b e i n g e v a l u a t e d , and the r e l i a b i l i t y and v a l i d i t y of the measures used t o c o l l e c t p a t i e n t feedback. Weiss and Ramsey (1989) a l s o s u p p o r t the v i e w t h a t c e r t a i n v a r i a b l e s which i n f l u e n c e p a t i e n t s a t i s f a c t i o n must be c o n s i d e r e d when p a t i e n t s a t i s f a c t i o n i n f o r m a t i o n i s used t o e v a l u a t e the q u a l i t y of c a r e . As w e l l as the s o c i o - d e m o g r a p h l c v a r i a b l e s t h a t V u o r i (1987) i d e n t i f i e d , Weiss and Ramsey a l s o i d e n t i f i e d t h a t the c a r e g i v e r s ' a t t r i b u t e s and the type of h e a l t h c a r e s e t t i n g a r e i m p o r t a n t v a r i a b l e s t h a t i n f l u e n c e p a t i e n t s a t i s f a c t i o n . The c a r e g i v e r s ' a t t r i b u t e s i n c l u d e d t h e i r p e r s o n a l i t y t r a i t s and communication s k i l l s . Another f a c t o r t o be c o n s i d e r e d when u s i n g p a t i e n t s a t i s f a c t i o n d a t a i n c l u d e s the i n t e r p e r s o n a l q u a l i t y of the c a r e g i v e r and t h e i r i n t e r a c t i o n w i t h p a t i e n t s (Donabedian, 1988; Weisman & Nathanson, 1985). S p e c i f i c a l l y , Donabedian (1988) c l a i m e d t h a t h e a l t h c a r e p r a c t i t i o n e r s ' performance i s a s s e s s e d i n r e l a t i o n t o t h e i r t e c h n i c a l performance and i n t e r p e r s o n a l s k i l l s . He p o i n t e d out t h a t the p r a c t i t i o n e r s ' t e c h n i c a l performance, which i s based on t h e i r knowledge and use of c u r r e n t t e c h n o l o g y , i s not as r e a d i l y c r i t i c i z e d as the p r a c t i t i o n e r s ' use of i n t e r p e r s o n a l s k i l l s . The i n t e r p e r s o n a l s k i l l s t h a t p a t i e n t s used t o judge c a r e as s a t i s f a c t o r y or d i s s a t i s f a c t o r y i n c l u d e d such a t t r i b u t e s as empathy, c o n c e r n , and s e n s i t i v i t y . F u r t h e r , Donabedian (1988) r e v e a l e d t h a t the i n t e r p e r s o n a l a s p e c t of p a t i e n t c a r e i s o f t e n i g n o r e d i n a s s e s s i n g the q u a l i t y of c a r e . He gave two r e a s o n s t o argue h i s s t a n c e . The f i r s t r e a s o n was t h a t p a t i e n t s ' m e d i c a l r e c o r d s a r e a poor s o u r c e of s u b j e c t i v e d a t a and t h e r e f o r e , a l a c k of a c c e s s i b i l i t y t o p a t i e n t s a t i s f a c t i o n i n f o r m a t i o n e x i s t s i n the m e d i c a l r e c o r d s . The second r e a s o n was the l a c k of e s t a b l i s h e d c r i t e r i a t o measure the a t t r i b u t e s of p r a c t i t i o n e r s ' i n t e r p e r s o n a l s k i l l . A r e v i e w of r e s e a r c h f i n d i n g s on p a t i e n t s a t i s f a c t i o n i n the h e a l t h c a r e f i e l d o t h e r than n u r s i n g showed t h a t t h e m a j o r i t y of p a t i e n t s a t i s f a c t i o n s t u d i e s have been conducted w i t h i n the American h e a l t h c a r e system. The m a j o r i t y of American h e a l t h c a r e f a c i l i t i e s p e r c e i v e p a t i e n t s a t i s f a c t i o n as e q u a l t o consumer s a t i s f a c t i o n . T h e r e f o r e , the b u s i n e s s management p r o c e s s t h a t i n t e g r a t e s q u a l i t y a s s u r a n c e programs, guest r e l a t i o n s and m a r k e t i n g programs (Melum & S i n i o r i s , 1989) i s the c o n c e r n . P a t i e n t s a r e g e n e r a l l y seen as customers and t h e i r p e r c e p t i o n s about the q u a l i t y of an o r g a n i z a t i o n i n f l u e n c e s t h e i r d e c i s i o n s t o s e l e c t , use, and/or r e t u r n t o an o r g a n i z a t i o n (Louden, 1989). I n c o n t r a s t , the n a t i o n w i d e h e a l t h c a r e p l a n i n Canada ensu r e s t h a t a l l r e s i d e n t s of Canada have a c c e s s , on a p r e p a i d b a s i s , f o r m e d i c a l and h o s p i t a l c a r e ( H a s t i n g s , 1985). A c c o r d i n g t o Coburn, D'Arcy, T o r r a n c e , and New (1987), the Canadian p u b l i c or i n d i v i d u a l p a t i e n t i n v o l v e m e n t i s m i n i m a l i n terms of the d e c i s i o n making w i t h h e a l t h c a r e s e r v i c e s . C o n s e q u e n t l y , i t i s i m p o r t a n t t o note t h a t the r e s u l t s of the f o l l o w i n g s t u d i e s , u n l e s s s p e c i f i e d , r e f l e c t an American h e a l t h c a r e p e r s p e c t i v e . A s t u d y conducted on p a t i e n t s a t i s f a c t i o n by Inguanzo and H a r j u (1985) used f i v e f a c t o r s t o o b t a i n p a t i e n t s a t i s f a c t i o n d a t a . P a t i e n t s i n t h i s m e t r o p o l i t a n h o s p i t a l i n the U n i t e d S t a t e s were g i v e n a s a t i s f a c t i o n q u e s t i o n n a i r e t o complete f o l l o w i n g t h e i r h o s p i t a l s t a y . The f i v e f a c t o r s measured were n u r s i n g c a r e , appearance of t h e room, a t t i t u d e s of the h o s p i t a l s t a f f , q u a l i t y of the f o o d , and b i l l i n g p r o c e d u r e s . The r e s u l t s of t h i s s t u d y i n d i c a t e d t h a t 73.4% of the p a t i e n t s a t t a c h e d s i g n i f i c a n t i mportance t o the n u r s i n g c a r e , 77.7% t o the a t t i t u d e s of h o s p i t a l s t a f f , 73.9% t o the room appearance, 45.6% t o the q u a l i t y of f o o d , and 52.8% t o the b i l l i n g p r o c e d u r e s . P a t i e n t d i s s a t i s f a c t i o n w i t h each of t h e s e f i v e f a c t o r s was 15 a l s o examined. In r e l a t i o n t o the n u r s i n g c a r e a s p e c t of h o s p i t a l c a r e , the f i n d i n g s i n d i c a t e d t h a t p a t i e n t s ' d i s s a t i s f a c t i o n r e l a t e d t o d i s c o u r t e o u s n u r s e s ( 3 5 . 7 % ) , not enough n u r s i n g p e r s o n n e l ( 2 9 . 5 % ) , not r e s p o n d i n g p r o m p t l y ( 2 5 . 6 % ) , and n u r s e s not p r o v i d i n g p e r s o n a l i z e d c a r e ( 9 . 1 % ) . These r e s e a r c h e r s c o n c l u d e d t h a t t h e i r f i n d i n g s i n f l u e n c e d m a r k e t i n g s t r a t e g i e s which i n the end would promote the r e t u r n of p a t i e n t s f o r c a r e i n the f u t u r e . H e f f r i n g , N e i l s e n , S z k l a r z , & Dobson (1986) conducted a s t u d y on p a t i e n t s a t i s f a c t i o n a t a 1100 bed r e f e r r a l and t e a c h i n g h o s p i t a l i n A l b e r t a , Canada. These r e s e a r c h e r s used a r e s e a r c h t e c h n i q u e based on consumer s e r v i c e , p r o d u c t m a r k e t i n g , and American h e a l t h c a r e s t u d i e s . T h e i r s t u d y i n v o l v e d an ongoing t e l e p h o n e s u r v e y conducted by a c o r e group of v o l u n t e e r i n t e r v i e w e r s . Over a one year p e r i o d 1,300 p a t i e n t s p a r t i c i p a t e d i n t h i s s t u d y . The purpose was t o measure e m p i r i c a l l y , the l e v e l of p a t i e n t s a t i s f a c t i o n d u r i n g h o s p i t a l c o n f i n e m e n t . The r e s e a r c h e r s r e p o r t e d t h a t 50% of the r e s p o n d e n t s gave the h o s p i t a l a maximum r a t i n g of t e n f o r t h e f o l l o w i n g d e t e r m i n a n t s : open and a p p r o a c h a b l e d o c t o r , a t t e n t i v e and f r i e n d l y n u r s e , the h i g h q u a l i t y of m e d i c a l c a r e , and r e s p e c t f o r c o n f i d e n t i l i t y . However, the key d e t e r m i n a n t of p a t i e n t s a t i s f a c t i o n was s t a f f communicating i n f o r m a t i o n r e g a r d i n g the p a t i e n t ' s c o n d i t i o n and t r e a t m e n t . I t was p o i n t e d out t h a t ongoing and prompt communciation r e q u i r e d g r e a t e r 16 a t t e n t i o n i n c e r t a i n a r e a s of the h o s p i t a l such as the emergency and, o u t - p a t i e n t s e r v i c e s , p o s t - s u r g e r y and d i a g n o s t i c t e s t i n g . P a t i e n t . S a t i s f a c t i o n W i t h i n the C o n t e x t of N u r s i n g  P a t i e n t S a t i s f a c t i o n R e l a t e d t o N u r s i n g Care As q u a l i t y a s s u r a n c e programs have become mandatory i n e v a l u a t i n g h o s p i t a l c a r e f o r a c c r e d i t a t i o n , more s t u d i e s appear t o be u s i n g e m p i r i c a l d a t a from the consumer's p o i n t of view ( H e f f r i n g , N e i l s e n , S z k l a r z , & Dobson, 1986). S t u d i e s which have been conducted t o d e t e r m i n e p a t i e n t s a t i s f a c t i o n i n r e l a t i o n t o n u r s i n g c a r e b e h a v i o u r s a r e l i m i t e d . However, the few American s t u d i e s which were found c l e a r l y i n d i c a t e d t h a t n urses p l a y e d a p r i m a r y r o l e i n meeting the needs and e x p e c t a t i o n s of p a t i e n t s i n h o s p i t a l s (Hinshaw & Atwood, 1982; V e n t u r a , Fox, C o r l e y , & M e r c u r i o , 1982; O b e r s t , 1984). For example, a s t u d y conducted a t a 900 bed American t e a c h i n g h o s p i t a l by Abramowitz, Cote, and B e r r y (1987) found t h a t p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e was a major d e t e r m i n a n t of p a t i e n t s a t i s f a c t i o n w i t h h o s p i t a l s t a y s . The d a t a c o l l e c t i o n i n t h i s s t u d y i n v o l v e d a t e l e p h o n e s u r v e y t o a sample of 841 p a t i e n t s who were d i s c h a r g e d from the h o s p i t a l d u r i n g a s p e c i f i e d t h r e e month p e r i o d . P a t i e n t s were chosen randomly from the s u r g i c a l , g e n e r a l m e d i c i n e , p e d i a t r i c s , and o b s t e t r i c s / g y n e c o l o g y wards. The response r a t e was 91.3%. One of the s i g n i f i c a n t c o n c l u s i o n s drawn about the n u r s i n g c a r e i n t h i s s t u d y was t h a t the n u r s i n g s t a f f were i d e n t i f i e d as the key t o p a t i e n t s a t i s f a c t i o n . Because n u r s e s a r e most a c c e s s i b l e d u r i n g p a t i e n t s ' h o s p i t a l s t a y s , the r e s e a r c h e r s c l a i m e d t h a t n u r s e s a r e the h o s p i t a l ' s f r o n t l i n e r e p r e s e n t a t i v e s . S p i t z e r (1988) a l s o viewed n u r s e s t o be f r o n t l i n e c a r e g i v e r s i n the h e a l t h c a r e s e t t i n g s . Her r e v i e w of r e c e n t s t u d i e s found t h a t p a t i e n t s ' e x p e c t a t i o n s w i t h t h e i r h o s p i t a l i z a t i o n r e l a t e d m o s t l y t o t h e i r i n t e r a c t i o n s w i t h the n u r s e s . O v e r a l l , the f i n d i n g s from her r e v i e w were t h a t h e a l t h c a r e consumers e x p e c t e d n u r s e s t o demonstrate a c a r i n g a t t i t u d e , a t t e n t i v e n e s s , s e n s i t i v i t y t o p h y s i c a l and e m o t i o n a l needs, a w i l l i n g n e s s t o answer q u e s t i o n s , and t o have p r o c e d u r e s e x p l a i n e d . N u rses' i n v o l v e m e n t w i t h p a t i e n t s a t i s f a c t i o n was demonstrated i n a s t u d y conducted by C l e a r y , K e r o y , Karapanos, and McMullen (1989). The purpose of t h i s s t u d y was t o r e f i n e a method of c o l l e c t i n g p a t i e n t i n f o r m a t i o n i n o r d e r t o a s s e s s the q u a l i t y of c a r e . For a one month p e r i o d , a l l m e d i c a l (n=255), s u r g i c a l (n=347), and o b s t e t r i c a l p a t i e n t s (n=329) were m a i l e d p a t i e n t s a t i s f a c t i o n q u e s t i o n n a i r e s , two t o t h r e e weeks a f t e r b e i n g d i s c h a r g e d from the h o s p i t a l . A response r a t e of 56.9% f o r m e d i c a l p a t i e n t s , 68.3% f o r s u r g i c a l p a t i e n t s , and 65.0% f o r o b s t e t r i c a l p a t i e n t s was o b t a i n e d . The f i n d i n g s i n d i c a t e d t h a t p a t i e n t s a t i s f a c t i o n d i f f e r e d among the t h r e e p a t i e n t g roups. S a t i s f a c t i o n w i t h p h y s i c i a n s and 18 n u r s e s was a s t r o n g e r d e t e r m i n a n t of o v e r a l l p a t i e n t s a t i s f a c t i o n w i t h the m e d i c a l p a t i e n t s . The s u r g i c a l p a t i e n t group f o c u s s e d on n u r s e s , h o s p i t a l rooms, and the n u r s e s ' a b i l i t y t o c o n t r o l and m i n i m i z e p o s t - o p e r a t i v e p a i n . S a t i s f a c t i o n w i t h p h y s i c i a n s , n u r s e s , and l e n g t h of h o s p i t a l s t a y were the b e s t p r e d i c t o r s of o v e r a l l p a t i e n t s a t i s f a c t i o n f o r the o b s t e t r i c a l p a t i e n t s . A l t h o u g h based on the f i n d i n g s from t h i s s t u d y , the r e s e a r c h e r s c o n c l u d e d t h a t p a t i e n t s a t i s f a c t i o n s u r v e y s need t o be i n d i v i d u a l i z e d t o ad d r e s s the con c e r n s of each p a t i e n t group, i t was i n t e r e s t i n g t o note t h a t i n each of the gro u p s , p a t i e n t s r e p e a t e d l y e v a l u a t e d the n u r s i n g c a r e . P a t i e n t s as In f o r m a n t s of S a t i s f a c t i o n w i t h Care The v a l u e of p a t i e n t s as i n f o r m a n t s i n measuring the q u a l i t y of n u r s i n g c a r e c o n t i n u e s t o be a d d r e s s e d t o d a y . As e a r l y as 1957, A b d e l l a h and L e v i n e r e c o g n i z e d the need t o measure p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . One a s p e c t of t h e i r r e s e a r c h i n v o l v e d the development of a t o o l t o measure p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . T h i s d a t a c o l l e c t i o n t o o l was used i n a s t u d y conducted on n e a r l y 9,000 p a t i e n t s i n 60 h o s p i t a l s . Of the 9,000 p a t i e n t s , 39% were males and 61% were f e m a l e s . P a t i e n t s were asked t o complete a 50 i t e m c h e c k l i s t q u e s t i o n n a i r e i n t e n d e d t o i d e n t i f y whether nu r s e s were f u l f i l l i n g p a t i e n t s ' needs. F i n d i n g s were c a t e g o r i z e d i n t o a s p e c t s of n u r s i n g c a r e which r e l a t e d t o p h y s i c a l and e m o t i o n a l c o m f o r t measures. N u r s i n g c a r e 19 b e h a v i o u r s c o n s i s t e d of n u r s e s d e m o n s t r a t i n g c o u r t e s y , p r o v i d i n g e x p l a n a t i o n s t o p a t i e n t s , and p r o v i d i n g c a r e t h a t met the p a t i e n t s * needs f o r e l i m i n a t i o n , p e r s o n a l h y g i e n e , and s u p p o r t i v e c a r e . The o v e r a l l f i n d i n g s i n d i c a t e d t h a t more than 70% of p a t i e n t s were s a t i s f i e d w i t h most n u r s i n g c a r e b e h a v i o u r s and t h a t p a t i e n t s tended t o e v a l u a t e o n l y t hose n u r s i n g c a r e b e h a v i o u r s which t h e y f e l t competent and c o m f o r t a b l e t o a p p r a i s e . Harper P e t e r s e n (1989) s t a t e d t h a t p a t i e n t s a r e v a l u a b l e i n f o r m a n t s i n p r o v i d i n g i n f o r m a t i o n about the q u a l i t y of c a r e t h e y r e c e i v e . She p o i n t e d out t h a t a l l i n t e r a c t i o n s between the c a r e g i v e r s and p a t i e n t s c o n t r i b u t e t o the p a t i e n t s ' e v a l u a t i o n of the q u a l i t y of c a r e . Harper P e t e r s e n s u g g ested t h a t c a r e g i v e r s ask p a t i e n t s on a d a i l y b a s i s what t h e y e x p e c t from the c a r e g i v e r and how s a t i s f i e d t h e y a r e w i t h t h e c a r e g i v e n t h a t day. She recommended t h a t c a r e g i v e r s s o l i c i t i n f o r m a t i o n from p a t i e n t s r e g a r d i n g s p e c i f i c b e h a v i o u r s t h a t would improve t h e i r c a r e . She s t r e s s e d t h a t t h i s ongoing p r o c e s s of s o l i c i t i n g feedback i s e s s e n t i a l i n m o n i t o r i n g p a t i e n t s a t i s f a c t i o n w h i l e p a t i e n t s a r e r e c e i v i n g c a r e . T r u s s e l and S t r a n d (1978) conducted a s t u d y which compared the use of r e t r o s p e c t i v e a u d i t s and c o n c u r r e n t a u d i t s on the same p a t i e n t s i n o r d e r t o d e t e r m i n e the d i f f e r e n c e s i n p a t i e n t s a t i s f a c t i o n i n f o r m a t i o n . Based on t h e d a t a from 17 p a t i e n t i n t e r v i e w s and a r e v i e w of t h e s e p a t i e n t s ' m e d i c a l r e c o r d s , f i n d i n g s i n d i c a t e d t h a t c o n c u r r e n t a u d i t s produced more and d i f f e r e n t i n f o r m a t i o n . The c o n c u r r e n t a u d i t s p r o v i d e d b e t t e r p a t i e n t i n f o r m a t i o n t han the r e t r o s p e c t i v e a u d i t s and were c o n s i s t e n t l y r e l e v a n t f o r the purpose of i m p r o v i n g n u r s i n g c a r e . However, the time t a k e n t o c o l l e c t the d a t a and the c o s t of c o n d u c t i n g a c o n c u r r e n t a u d i t were s i g n i f i c a n t l y more t h a n a r e t r o s p e c t i v e a u d i t . These r e s e a r c h e r s c o n c l u d e d t h a t m o n i t o r i n g p a t i e n t s a t i s f a c t i o n or d i s s a t i s f a c t i o n d a t a , d u r i n g p a t i e n t s ' h o s p i t a l s t a y s , i s a v a l u a b l e method t o improve the q u a l i t y of n u r s i n g c a r e . On the o t h e r hand, p a t i e n t s as v a l u a b l e i n f o r m a n t s i n e v a l u a t i n g n u r s i n g c a r e were viewed d i f f e r e n t l y by Leppanen Montgomery (1988). A l t h o u g h Leppanen Montgomery agreed t h a t n u r s e s would l i k e t o keep p a t i e n t s s a t i s f i e d , she e x p r e s s e d her c o n c e r n t h a t the consumer approach t o p a t i e n t c a r e has l i m i t a t i o n s and l i a b i l i t i e s . She p o i n t e d out t h a t p a t i e n t s e x p e c t n u r s e s t o a p p l y t h e i r knowledge and e x p e r i e n c e t o e v a l u a t e t h e i r r e q u e s t s i n terms of t h e i r own b e s t i n t e r e s t s . She emphasized t h a t n u r s e s have a f a r more i m p o r t a n t o b l i g a t i o n t o s e t p r i o r i t i e s i n t h e c a r e of t h e i r p a t i e n t s , which i s based on a s s i s t i n g them t o meet t h e i r needs and not i n s a t i s f y i n g t h e i r demands. P a t i e n t S a t i s f a c t i o n R e l a t e d t o A s p e c t s of N u r s i n g Care P a t i e n t s a t i s f a c t i o n i s a m u l t i d i m e n s i o n a l phenomenon used i n a s s e s s i n g the q u a l i t y of n u r s i n g c a r e . A c c o r d i n g t o O b erst (1984), p a t i e n t s ' s u b j e c t i v e p e r c e p t i o n s of c a r e v a r y a c c o r d i n g t o the d i m e n s i o n of n u r s i n g c a r e t h a t i s b e i n g examined. Oberst c i t e d examples of v a r i o u s n u r s i n g c a r e d i m e n s i o n s which i n c l u d e d the a r t of c a r e , the e f f i c a c y of c a r e , the t e c h n i c a l c a r e , and the p h y s i c a l environment where the c a r e i s d e l i v e r e d . On the o t h e r hand, R i s s e r (1975) c o n c e n t r a t e d on the d i m e n s i o n s of t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r , t r u s t i n g r e l a t i o n s h i p , i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p , and the e d u c a t i o n a l r e l a t i o n s h i p w i t h the c a r e g i v e r , s u g g e s t i n g t h e s e as the a r e a s most r e l e v a n t t o p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . A s t u d y conducted by Rempusheski, C h a m b e r l a i n , P i c a r d , R u z a n s k i , and C o l l i e r (1988) i d e n t i f i e d a l i s t of n i n e c a t e g o r i e s which d e f i n e d the elements of c a r e t h a t p a t i e n t s and t h e i r f a m i l i e s p e r c e i v e d as s a t i s f y i n g . T h i s s t u d y was conducted a t a 460 bed urban t e a c h i n g h o s p i t a l i n the n o r t h e a s t e r n U n i t e d S t a t e s . U s i n g a grounded t h e o r y a p p r o a c h , t h i s r e t r o s p e c t i v e s t u d y examined a t o t a l of 63 l e t t e r s randomly s e l e c t e d over a t h r e e y e a r p e r i o d . The u n i t s , which p a t i e n t s ' l e t t e r s commented about, i n c l u d e d : s u r g e r y ( 3 9 % ) , m e d i c a l ( 2 5 % ) , o b s t e t r i c a l ( 1 2 % ) , o p e r a t i n g room ( 1 1 % ) , r e c o v e r y room ( 6 % ) , emergency ( 3 . 5 % ) , and o t h e r u n i t s ( 3 . 5 % ) . The n i n e elements of c a r e i d e n t i f i e d i n t h i s s t u d y i n c l u d e d : q u a l i t i e s of the n u r s e , p a t i e n t c h a r a c t e r i s t i c s , h o s p i t a l image, p r o f e s s i o n a l image, sense of e a r i n g , c o l l a b o r a t i o n / t e a m w o r k , u n c o n d i t i o n a l a c c e p t a n c e ( a c c e p t i n g p a t i e n t s as i n d i v i d u a l s ) , n u t r i e n t power 22 ( n u r s e ' s a b i l i t y t o i n f l u e n c e change), and s e r v i c e q u a l i t y ( p a t i e n t / f a m i l y as a consumer). From th e s e c a t e g o r i e s , the c o ncept of c r i t i c a l j u n c t u r e was d e v e l o p e d which i n d i c a t e d the h i g h e s t l e v e l of p e r c e p t u a l a b i l i t y r e q u i r e d of p r o f e s s i o n a l n u r s e s towards a c h i e v i n g p a t i e n t s a t i s f a c t i o n . C r i t i c a l j u n c t u r e was d e f i n e d as the " v u l n e r a b l e p e r i o d i n a p a t i e n t ' s h o s p i t a l s t a y , when the o c c u r r e n c e of p a r t i c u l a r e v e n t s c r e a t e s the most l a s t i n g i m p r e s s i o n s of t h e h o s p i t a l e x p e r i e n c e and i n f l u e n c e s the c o u r s e of the n u r s e - p a t i e n t r e l a t i o n s h i p " ( p . 1 7 ) . These a u t h o r s c o n c l u d e d t h a t n u r s e s can i n f l u e n c e p a t i e n t s a t i s f a c t i o n by e n c o u r a g i n g p a t i e n t s t o e x p r e s s t h e i r needs and by a l l o w i n g p a t i e n t s and t h e i r f a m i l i e s t o become a c t i v e l y i n v o l v e d i n p a t i e n t c a r e . The l i t e r a t u r e r e v i e w e d i n d i c a t e d t h a t an i m p o r t a n t i s s u e among h e a l t h c a r e p r o v i d e r s i s the p a t i e n t s a t i s f a c t i o n d a t a used t o d e t e r m i n e the q u a l i t y of n u r s i n g c a r e .(Doe-ring, 1983; Ferguson & F e r g u s o n , 1983; Prehn, Mayo, & Weisman, 1989). P r e h n , Mayo, and: Weisman's (1989) r e v i e w of l i t e r a t u r e and r e s e a r c h s t u d i e s on the v a l i d i t y of p a t i e n t s a t i s f a c t i o n d a t a c o n c l u d e d t h a t p a t i e n t s a t i s f a c t i o n d a t a a r e seldom used t o d e v e l o p h e a l t h c a r e p r o t o c o l s because p a t i e n t s do not have the t e c h n i c a l knowledge t o e v a l u a t e the q u a l i t y o f c a r e t h e y r e c e i v e . However, th e s e a u t h o r s s u g g e s t e d t h a t p a t i e n t s a t i s f a c t i o n d a t a e v a l u a t i n g the a f f e c t i v e c o n t e n t of c a r e r e q u i r e s s u b j e c t i v e a p p r a i s a l and i s t h e r e f o r e u s e f u l t o a s s e s s th e q u a l i t y of c a r e d e l i v e r e d . C o n v e r s e l y , the t e c h n i c a l a s p e c t s of n u r s i n g c a r e were not c o n s i d e r e d v a l i d 23 p a t i e n t s a t i s f a c t i o n d a t a because p a t i e n t s g e n e r a l l y l a c k the c l i n i c a l e x p e r t i s e t o e v a l u a t e t h i s a s p e c t of n u r s i n g c a r e . S i m i l a r l y , S p i t z e r (1988) s t a t e d t h a t p a t i e n t s 1 s a t i s f a c t i o n w i t h n u r s i n g c a r e i s based on t h e i r e x p e r i e n c e w i t h n u r s e s ' p h y s i c a l and p s y c h o l o g i c a l c o m f o r t measures. S p e c i f i c a l l y , Ferguson and Ferguson (1983) s t a t e d t h a t p a t i e n t s were more l i k e l y t o a p p r a i s e the n u r s i n g c a r e b e h a v i o u r s such as n u r s e s ' d e m o n s t r a t i o n of c o u r t e s y and a t t e n t i v e n e s s r a t h e r t h a n t e c h n i c a l a c t i v i t i e s . These views a r e congruent w i t h D o e r i n g ' s (1983) f i n d i n g s i n a s t u d y conducted on p a t i e n t s a t i s f a c t i o n . D o e r i n g ' s s t u d y o c c u r r e d i n a 1,070 bed American t e a c h i n g h o s p i t a l . I n her s t u d y , the 1080 p a t i e n t s who were d i s c h a r g e d from two d i v i s i o n s of the h o s p i t a l w i t h i n a s p e c i f i e d p e r i o d of time were m a i l e d a p a t i e n t s a t i s f a c t i o n q u e s t i o n n a i r e . The response r a t e was 65% and 51% from the two h o s p i t a l d i v i s i o n s . D o e r i n g r e p o r t e d t h a t g r e a t e r t h a n 50% of the p a t i e n t s were s a t i s f i e d w i t h the o v e r a l l c a r e and t h a t n u r s i n g c a r e had a s t r o n g impact on p a t i e n t s a t i s f a c t i o n . The q u e s t i o n n a i r e a l s o c o n t a i n e d open ended q u e s t i o n s used t o e l i c i t i n f o r m a t i o n r e g a r d i n g t h e q u a l i t y of n u r s i n g c a r e . The f i n d i n g s i n d i c a t e d t h a t the i n t e r p e r s o n a l a s p e c t s of c a r e were more i m p o r t a n t t o p a t i e n t s than the t e c h n i c a l a s p e c t s of c a r e which p a t i e n t s d i d not f e e l q u a l i f i e d t o judge. S i m i l a r l y , Morales-Mann (1989) conducted a s t u d y which 24 compared n u r s e s ' and p a t i e n t s ' p e r c e p t i o n s of n u r s i n g c a r e i n a p o s t - p a r t u m u n i t of a l a r g e American h o s p i t a l . A L i k e r t s c a l e q u e s t i o n n a i r e , c o n s i s t i n g of 28 n u r s i n g a c t i v i t i e s , was g i v e n t o 50 p a t i e n t s and 25 n u r s e s . The response r a t e was 80% f o r b oth p a t i e n t s and n u r s e s . The f i n d i n g s demonstrated t h a t p a t i e n t s a t i s f a c t i o n w i t h c a r e i n t h i s p o s t - p a r t u m u n i t c o n s i s t e d of n u r s i n g c a r e a c t i v i t i e s r e l a t e d t o p a t i e n t t e a c h i n g , p h y s i c a l c o m f o r t , and p s y c h o s o c i a l c a r e . For example, 60% of the p a t i e n t s f e l t t h a t t h e y c o u l d have b e n e f i t t e d from t e a c h i n g a c t i v i t i e s . The f i n d i n g s a l s o i n d i c a t e d t h a t a d i s c r e p a n c y e x i s t e d between the n u r s e s ' and the p a t i e n t s ' p e r c e p t i o n s of s a t i s f y i n g and d i s s a t i s f y i n g n u r s i n g c a r e a c t i v i t i e s . The n u r s e s were more concerned about the p r o v i s i o n of p h y s i c a l c a r e and depended on the o t h e r h e a l t h c a r e p r o f e s s i o n a l s t o p r o v i d e the p a t i e n t s w i t h ongoing and d i s c h a r g e t e a c h i n g i n f o r m a t i o n . For example, p a t i e n t s were g i v e n b r e a s t f e e d i n g i n f o r m a t i o n by the n u r s e r y n u r s e s and d i e t i c i a n s , and the p ost-partum e x e r c i s e s were t a u g h t by t h e p h y s i o t h e r a p i s t s . The r e s e a r c h e r c l a i m e d t h a t n urses i n t h i s s t u d y viewed the p s y c h o s o c i a l a s p e c t of n u r s i n g c a r e t o be an i m p o r t a n t a c t i v i t y . However, t h e s e n u r s e s e x p l a i n e d t h a t time c o n s t r a i n t s and the emphasis of t h i s p a r t i c u l a r u n i t on n u r s e s ' performance of p h y s i c a l c a r e a c t i v i t i e s c o n t r i b u t e d t o the l a c k of p s y c h o s o c i a l c a r e . F i n a l l y , i t was i n t e r e s t i n g t o note t h a t Morales-Mann's (1989) s t u d y was s i m i l a r t o the f i n d i n g s of a s m a l l p i l o t s t u d y conducted on a g e r i a t r i c ward by Forgan M o r l e (1984). T h i s B r i t i s h s t u d y i n v o l v e d g a i n i n g e l d e r l y p a t i e n t s ' p e r c e p t i o n s of n u r s i n g c a r e a c t i v i t i e s t o d e t e r m i n e p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . Data c o l l e c t i o n was conducted by the s o c i a l worker who i n t e r v i e w e d p a t i e n t s w i t h i n two weeks of d i s c h a r g e from the h o s p i t a l . The sample comprised twenty-two p a t i e n t s , seven men and f i f t e e n women who were d i s c h a r g e d over a s i x months p e r i o d . The f i n d i n g s i n her s t u d y r e v e a l e d t h a t e l d e r l y p a t i e n t s ' s a t i s f a c t i o n w i t h n u r s i n g c a r e p e r t a i n e d t o how n u r s e s met the p a t i e n t s ' p s y c h o s o c i a l needs. The f i n d i n g s a l s o i n d i c a t e d t h a t n u r s e s ' assessment of p a t i e n t s ' e m o t i o n a l needs were not as w e l l conducted as was the assessment of p a t i e n t s ' p h y s i o l o g i c a l needs. T h i s r e s e a r c h e r c o n c l u d e d t h a t e q u a l importance s h o u l d be a t t a c h e d t o meeting both the e m o t i o n a l and p h y s i c a l needs i n o r d e r t o ensure t h a t a l l p a t i e n t s ' c a r e needs a r e s a t i s f i e d . Emergency N u r s i n g Care St a n d a r d s i n R e l a t i o n t o R i s s e r ' s  C r i t e r i o n t o E v a l u a t e P a t i e n t S a t i s f a c t i o n w i t h N u r s i n g  Care Emergency n u r s i n g i s a s p e c i a l i t y a r e a of n u r s i n g (Sheehy & B a r b e r , 1985). Emergency n u r s i n g p r a c t i c e i s unique i n t h a t i t p r o v i d e s n u r s i n g c a r e t o p a t i e n t s of a l l ages r e q u i r i n g s t a b i l i z a t i o n and/or r e s u s c i t a t i o n f o r a v a r i e t y of i l l n e s s e s and i n j u r i e s ( D a i n s , A l e x a n d e r , J o r d a n , L y l e , S c h o e r g e r , R i c e , & I n g a l l s , 1991). In o r d e r t o m o n i t o r and m a i n t a i n a h i g h q u a l i t y of p r a c t i c e i n t h i s s p e c i a l i t y a r e a , n u r s i n g s t a n d a r d s of c a r e a r e d e v e l o p e d t o e v a l u a t e q u a l i t y of c a r e (Dains e t a l . , 1991). B a s i c a l l y , s t a n d a r d s e s t a b l i s h the scope of c l i n i c a l p r a c t i c e and s e r v e as c r i t e r i a f o r e v a l u a t i n g the q u a l i t y of c a r e ( M c A l l i s t e r , 1990). For example, the Canadian S t a n d a r d s of Emergency N u r s i n g P r a c t i c e d e v e l o p e d by the N a t i o n a l Emergency Nu r s e s ' A f f i l i a t i o n (NENA) i n 1986 i s comprised of f o u r s t a n d a r d s t o measure emergency n u r s i n g p r a c t i c e . S t a n d a r d I o u t l i n e s emergency n u r s i n g p r a c t i c e u s i n g a c o n c e p t u a l model, S t a n d a r d I I d e s c r i b e s n u r s i n g c a r e a c t i v i t i e s u s i n g the n u r s i n g p r o c e s s , S t a n d a r d I I I f o c u s s e s on n u r s e - p a t i e n t i n t e r a c t i o n , and S t a n d a r d IV r e l a t e s t o the p r o f e s s i o n a l b e h a v i o u r s . o f emergency n u r s e s . A r e v i e w of n u r s i n g c a r e s t a n d a r d s i n r e l a t i o n t o emergency n u r s i n g (Dains e t a l . , 1991; NENA, 1986; R e g i s t e r e d Nurses' A s s o c i a t i o n of O n t a r i o , 1981) r e v e a l e d t h a t the Canadian St a n d a r d s of Emergency N u r s i n g P r a c t i c e (NENA, 1986) c o r r e s p o n d e d most c l o s e l y t o R i s s e r ' s (1975) f o u r d i m e n s i o n s t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . T a b l e s One t o Four (pp. 27-30), i l l u s t r a t e t h e congruency between the f o u r d i m e n s i o n s of R i s s e r ' s (1975) e v a l u a t i v e c r i t e r i o n and t h e Canadian Standards of Emergency N u r s i n g P r a c t i c e (NENA, 1986). An example of a performance s t a n d a r d i s a l s o p r e s e n t e d f o r f u r t h e r c l a r i f i c a t i o n . T a b le 1 Congruency Between t h e T e c h n i c a l - p r o f e s s i o n a l B e h a v i o u r  Dimension ( R i s s e r , 1975) and S t a n d a r d of Emergency  N u r s i n g P r a c t i c e I (NENA. 1986) Dimension: T e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r d i m e n s i o n i n c l u d e s the t e c h n i c a l a c t i v i t i e s and knowledge base r e q u i r e d by nurses t o c o m p e t e n t l y p e r f o r m n u r s i n g t a s k s . S t a n d a r d I : Emergency n u r s i n g p r a c t i c e uses the n u r s i n g p r o c e s s method f o r c a r r y i n g out the independent, i n t e r d e p e n d e n t , and dependent f u n c t i o n s of emergency n u r s i n g p r a c t i c e . Performance Standard The nurse implements c a r e based on n e c e s s a r y knowledge, a t t i t u d e s , and s k i l l s r e q u i r e d f o r n u r s i n g a c t i o n . 28 T a b l e 2 Congruency Between the T r u s t i n g R e l a t i o n s h i p Dimension ( R i s s e r . 1975) and S t a n d a r d of Emergency N u r s i n g P r a c t i c e I I I (NENA. 1986) Dimension; T r u s t i n g r e l a t i o n s h i p d i m e n s i o n r e l a t e s t o how n u r s e s f o s t e r c o n s t r u c t i v e and c o m f o r t a b l e n u r s e - p a t i e n t i n t e r a c t i o n and communication. S t a n d a r d I I I : Performance Standard 1.1: Emergency n u r s i n g p r a c t i c e The nurse w i l l p r o v i d e a r e q u i r e s t h a t the n a t u r e of a c l i m a t e and the n u r s e - p a t i e n t i n t e r a c t i o n environment which w i l l be a f a c i l i t a t i v e r e l a t i o n s h i p . reduce the i n i t i a l a n x i e t y and d e v e l o p the b e g i n n i n g of mutual t r u s t . 29 Ta b l e 3 Congruency Between t h e I n t e r - i n t r a p e r s o n a l R e l a t i o n s h i p  Dimension ( R i s s e r , 1975) and S t a n d a r d of Emergency  N u r s i n g P r a c t i c e I I I (NENA. 1986) Dimension; I n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p d i m e n s i o n i s t h e e x p r e s s i v e f u n c t i o n of the n u r s e , both v e r b a l and n o n v e r b a l b e h a v i o u r s . S t a n d a r d I I I : Performance S t a n d a r d 1^2.: Emergency n u r s i n g p r a c t i c e Nurses make v e r b a l r e q u i r e s t h a t the n a t u r e of and n o n v e r b a l the n u r s e - p a t i e n t i n t e r a c t i o n communication be a f a c i l i t a t i v e r e l a t i o n s h i p . p u r p o s e f u l , t i m e l y , and a p p r o p r i a t e t o the p a t i e n t ' s c o n d i t i o n and s i t u a t i o n . 30 T a b l e 4 Congruency Between the E d u c a t i o n a l R e l a t i o n s h i p Dimension  ( R i s s e r , 1975) and S t a n d a r d of Emergency N u r s i n g  P r a c t i c e I I (NENA. 1986) Dimension: E d u c a t i o n a l r e l a t i o n s h i p d i m e n s i o n i s the i n f o r m a t i o n exchange between the nurse and p a t i e n t . Standard XI: performance standard 4.6: Emergency n u r s i n g p r a c t i c e Nurses a s s i s t the uses the n u r s i n g p r o c e s s as p a t i e n t and r e l e v a n t t h e method f o r c a r r y i n g out o t h e r s t o a c q u i r e the independent, i n t e r d e p e n d e n t knowledge about and dependent f u n c t i o n s of i l l n e s s , p r e v e n t i o n of emergency p r a c t i c e . i n j u r y , and t r e a t m e n t . Summary A r e v i e w of l i t e r a t u r e and r e s e a r c h on p a t i e n t s a t i s f a c t i o n w i t h i n the h e a l t h c a r e f i e l d and w i t h i n the c o n t e x t of n u r s i n g has been p r e s e n t e d . As w e l l , the emergency n u r s i n g c a r e s t a n d a r d s i n r e l a t i o n t o R i s s e r ' s (1975) c r i t e r i o n t o e v a l u a t e p a t i e n t s a t i s f a c t i o n have been d i s c u s s e d . The approach t o p a t i e n t s a t i s f a c t i o n w i t h i n the American h e a l t h c a r e system i s p r i m a r i l y f o c u s s e d on o b t a i n i n g i n f o r m a t i o n f o r the purpose of e n h a n c i n g m a r k e t i n g s t r a t e g i e s and m a i n t a i n i n g q u a l i t y a s s u r a n c e programs. However, w i t h i n the n u r s i n g f i e l d of b oth Canada and the U n i t e d S t a t e s , d e t e r m i n a n t s of p a t i e n t s a t i s f a c t i o n a r e concerned w i t h the n u r s i n g c a r e a c t i v i t i e s t h a t meet p a t i e n t s ' p h y s i c a l and p s y c h o s o c i a l needs. Based on the l i t e r a t u r e r e v i e w e d , i t i s e v i d e n t t h a t p a t i e n t s a t i s f a c t i o n as an i n d e x t o measure the q u a l i t y of c a r e i s a v a l u a b l e e v a l u a t i v e t o o l . 32 CHAPTER THREE Methodology I n t r o d u c t i o n T h i s c h a p t e r d e s c r i b e s the r e s e a r c h d e s i g n , sample s e l e c t i o n , r e s e a r c h s e t t i n g , d a t a c o l l e c t i o n p r o c e d u r e , d a t a c o l l e c t i o n i n s t r u m e n t , and e t h i c a l c o n s i d e r a t i o n s of t h e s t u d y . A d e s c r i p t i o n of the p i l o t t e s t and d a t a a n a l y s i s p r o c e d u r e i s a l s o i n c l u d e d . Research Design T h i s s t u d y used an e x p l o r a t o r y d e s c r i p t i v e d e s i g n t o d e t e r m i n e s u b j e c t s ' p e r c e p t i o n s of s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s , d u r i n g t h e i r emergency room e x p e r i e n c e . Data were c o l l e c t e d u s i n g a d a t a c o l l e c t i o n i n s t r u m e n t d e v e l o p e d by the r e s e a r c h e r . A p i l o t t e s t c o n s i s t i n g of two i n t e r v i e w s , was conducted i n i t i a l l y t o t e s t the d a t a c o l l e c t i o n i n s t r u m e n t . A t o t a l of 10 i n t e r v i e w s were conducted f o r the a c t u a l s t u d y . R e s e a r c h S e t t i n g T h i s s t u d y was conducted i n a l a r g e m e t r o p o l i t a n h o s p i t a l i n the Vancouver a r e a . The number of p a t i e n t v i s i t s t o the emergency room i n t h i s h o s p i t a l average 48,000 t o 50,000 per y e a r . T h i s emergency room p r o v i d e s emergency c a r e on 24 hour b a s i s . Emergency c a r e i s g i v e n f o r a wide v a r i e t y of i n j u r y / i l l n e s s c o n d i t i o n s , i n c l u d i n g p a t i e n t s p r e s e n t i n g w i t h m u s c u l o s k e l e t a l 33 i n j u r i e s / i l l n e s s e s . Sample S e l e c t i o n S u b j e c t s i n t h i s s t u d y were r e q u i r e d t o meet the f o l l o w i n g c r i t e r i a : 1. s t a y e d i n the emergency room f o r a time p e r i o d of a t l e a s t one hour p r i o r t o t h e i r i n - p a t i e n t h o s p i t a l i z a t i o n . 2. r e c e i v e d n u r s i n g c a r e i n the emergency, room. 3. a d m i t t e d t o the h o s p i t a l f o r a p e r i o d of two t o f i v e d a ys. 4. e x p e r i e n c e d an o r t h o p e d i c i n j u r y or i l l n e s s . 5. r e q u i r e d t o read and w r i t e E n g l i s h . 6. r e q u i r e d t o be over 21 y e a r s of age. 7. o r i e n t a t e d t o p e r s o n , p l a c e , and t i m e . S e l e c t i o n P r o c e d u r e I n i t i a l l y , the r e s e a r c h e r s u b m i t t e d a l e t t e r t o the N u r s i n g R e s e a r c h Committee of the h o s p i t a l r e q u e s t i n g p e r m i s s i o n t o conduct the s t u d y (Appendix A ) . Once a p p r o v a l was r e c e i v e d , the r e s e a r c h e r met w i t h each head nurse from the f o u r o r t h o p e d i c wards t o d i s c u s s the s t u d y . The r e s e a r c h e r asked each head nurse t o d i s t r i b u t e the i n f o r m a t i o n l e t t e r s (Appendix B) t o p r o s p e c t i v e s u b j e c t s . The l e t t e r e x p l a i n e d the purpose of the s t u d y and what would be r e q u i r e d of the s u b j e c t s . Each head nurse agreed t o c o n t a c t the r e s e a r c h e r by t e l e p h o n e t o i n f o r m her of i n t e r e s t e d s u b j e c t s . The head n u r s e s a l s o informed the s t a f f of the s t u d y . The a c t u a l sample f o r the s t u d y was o b t a i n e d from two of the f o u r o r t h o p e d i c wards. A f t e r each of the p r o s p e c t i v e s u b j e c t s r e a d t h e i n f o r m a t i o n l e t t e r , t h e y were asked t o i n f o r m the head nurse i f t h e y were i n t e r e s t e d i n p a r t i c i p a t i n g . The r e s e a r c h e r t h e n v i s i t e d t h e s u b j e c t on the ward t o i n t r o d u c e h e r s e l f , and t o c o n f i r m t h a t the s u b j e c t met the s e l e c t i o n c r i t e r i a . U s i n g the i n f o r m a t i o n l e t t e r as a g u i d e , s u b j e c t s ' q u e s t i o n s were c l a r i f i e d . I f t h e s u b j e c t agreed t o p a r t i c i p a t e i n t h e s t u d y , the r e s e a r c h e r proceeded t o have the s u b j e c t r e a d and s i g n the c onsent form (Appendix C ) . E i g h t s u b j e c t s agreed t o an i n t e r v i e w the same day and two s u b j e c t s r e q u e s t e d t h a t the r e s e a r c h e r i n t e r v i e w them the f o l l o w i n g day. Data C o l l e c t i o n The d a t a r e g a r d i n g s u b j e c t s ' emergency room e x p e r i e n c e were c o l l e c t e d u s i n g s e m i - s t r u c t u r e d i n t e r v i e w s . The s t u d y d e s i g n a l l o w e d the r e s e a r c h e r the o p t i o n of a second i n t e r v i e w f o r c l a r i f i c a t i o n of s u b j e c t s ' p e r c e p t i o n s of s a t i s f y i n g or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s . Second i n t e r v i e w s were not r e q u i r e d . The r e f i n e m e n t of the d a t a c o l l e c t i o n i n s t r u m e n t may have i n f l u e n c e d t h e need f o r c l a r i f i c a t i o n of the d a t a . Each i n t e r v i e w l a s t e d a p p r o x i m a t e l y 45 m i n u t e s . At the b e g i n n i n g of each i n t e r v i e w , the r e s e a r c h e r completed P a r t A (Appendix D) of the d a t a c o l l e c t i o n i n s t r u m e n t . P a r t A of t h e d a t a c o l l e c t i o n i n s t r u m e n t i n v o l v e d c o l l e c t i n g demographic d a t a and o t h e r d a t a r e l e v a n t t o the s t u d y , i n c l u d i n g s u b j e c t s ' p r e v i o u s emergency room a d m i s s i o n s , c o n c u r r e n t m e d i c a l c o n d i t i o n s , and presence of s u p p o r t p e o p l e . The r e s e r c h e r completed t h i s segment of the i n t e r v i e w i n w r i t i n g . A f t e r the c o m p l e t i o n of P a r t A, the r e s e a r c h e r completed P a r t B (Appendix D) of the d a t a c o l l e c t i o n i n s t r u m e n t . P a r t B, the i n t e r v i e w guide c o n s i s t e d of i n t e r v i e w q u e s t i o n s which a s s i s t e d the r e s e a r c h e r t o e l i c i t s u b j e c t s ' p e r c e p t i o n s of s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s , d u r i n g t h e i r emergency room e x p e r i e n c e . T h i s p a r t of t h e i n t e r v i e w was a u d i o t a p e d . U n l e s s s u b j e c t s were c o n f i n e d t o bed, t h e y were g i v e n the c h o i c e of where the i n t e r v i e w took p l a c e . Data C o l l e c t i o n I n s t r u m e n t The d a t a c o l l e c t o n i n s t r u m e n t was d e v e l o p e d by the r e s e a r c h e r and c o n s i s t e d of two p a r t s , A and B. P a r t A i n c l u d e d a p r e p a r e d s e t of q u e s t i o n s t o c o l l e c t demographic d a t a and s p e c i f i c d a t a r e l e v a n t t o the s t u d y i n c l u d i n g the s u b j e c t s ' p r e v i o u s emergency room e x p e r i e n c e , c o n c u r r e n t m e d i c a l c o n d i t i o n s , and presence of s u p p o r t p e o p l e . T h i s p a r t was completed i n w r i t i n g by the r e s e a r c h e r . P a r t B, the second s e c t i o n of the d a t a c o l l e c t i o n i n s t r u m e n t , c o n s i s t e d of the s e m i - s t r u c t u r e d i n t e r v i e w 36 g u i d e . The i n t e r v i e w guide was comprised of open and c l o s e d q u e s t i o n s . T h i s s e c t i o n of d a t a c o l l e c t i o n i n s t r u m e n t was a u d i o t a p e d . The r e s e a r c h e r u t i l i z e d t h r e e s o u r c e s t o f o r m u l a t e q u e s t i o n s f o r the i n t e r v i e w g u i d e . The f i r s t s o u r c e was t h e f o u r d i m e n s i o n s of R i s s e r ' s e v a l u a t i v e c r i t e r i o n ( R i s s e r , 1975), which i n c l u d e d the t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r r e l a t i o n s h i p , the t r u s t i n g r e l a t i o n s h i p , t h e i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p , and e d u c a t i o n a l r e l a t i o n s h i p . The d e f i n i t i o n s of t h e s e d i m e n s i o n s p r i m a r i l y formed the b a s i s of the i n t e r v i e w guide q u e s t i o n s . For example, the t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r r e l a t i o n s h i p was d e f i n e d as the t e c h n i c a l a c t i v i t i e s and knowledge base r e q u i r e d by n u r s e s t o c o m p e t e n t l y p e r f o r m n u r s i n g c a r e t a s k s . The i n t e r v i e w q u e s t i o n s i n t h i s d i m e n s i o n p e r t a i n e d t o how n u r s e s demonstrated t h e i r a b i l i t y t o p r l o r i z e , a s s e s s , and p e r f o r m n u r s i n g s k i l l s w i t h r e s p e c t t o s u b j e c t s ' i n j u r y / i l l n e s s . The t r u s t i n g r e l a t i o n s h i p was d e f i n e d as n u r s e s f o s t e r i n g c o n s t r u c t i v e and c o m f o r t a b l e n u r s e - p a t i e n t i n t e r a c t i o n and communication. I n t e r v i e w q u e s t i o n s i n t h i s d i m e n s i o n c o n s i s t e d of how n u r s e s demonstrated, i n t e r e s t i n p a t i e n t s , s e n s i t i v i t y t o p a t i e n t s and t h e i r f e e l i n g s , and l i s t e n i n g t o p a t i e n t s ' problems. The i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p d i m e n s i o n was d e f i n e d as the v e r b a l and n o n v e r b a l e x p r e s s i v e f u n c t i o n s of the n u r s e . Thus, i n t e r v i e w q u e s t i o n s i n t h i s d i m e n s i o n r e l a t e d t o how nurses communicated both v e r b a l l y and n o n v e r b a l l y w i t h p a t i e n t s . V e r b a l communication q u e s t i o n s p e r t a i n e d t o how n u r s e s i n i t i a t e d , m a i n t a i n e d , and d i r e c t e d s o c i a l i n t e r a c t i o n s . N o n v e r b a l communication q u e s t i o n s p e r t a i n e d t o how nurses p r e s e n t e d t hemselves i n r e l a t i o n t o appearance and body language. The d e f i n i t i o n of the e d u c a t i o n a l r e l a t i o n s h i p was d e f i n e d as the i n f o r m a t i o n exchange between n u r s e s and p a t i e n t s . The i n t e r v i e w q u e s t i o n s i n t h i s d i m e n s i o n i n v o l v e d a s k i n g s u b j e c t s t o r e c a l l i f n u r s e s asked a p p r o p r i a t e q u e s t i o n s , answered q u e s t i o n s , and e x p l a i n e d p r o c e d u r e s . The r e s e a r c h e r ' s n u r s i n g knowledge a n d 1 0 y e a r s of n u r s i n g e x p e r i e n c e i n emergency n u r s i n g was the second s o u r c e used t o f o r m u l a t e t h e i n t e r v i e w guide q u e s t i o n s . The r e s e a r c h e r ' s f a m i l i a r i t y w i t h the r o u t i n e c a r e f o r p a t i e n t s r e c e i v i n g n u r s i n g c a r e i n an emergency room p r o v i d e d the knowledge t o o r g a n i z e the q u e s t i o n s i n the i n t e r v i e w g u i d e . For example, the f i r s t group of i n t e r v i e w q u e s t i o n s p e r t a i n e d t o the i n i t i a l assessment by the nurse on a d m i s s i o n . The r e s e a r c h e r ' s r e v i e w of a wide v a r i e t y of l i t e r a t u r e r e l a t e d t o the o r t h o p e d i c emergency n u r s i n g c a r e was the t h i r d s o u r c e used t o f o r m u l a t e the i n t e r v i e w q u e s t i o n s . The r e s e a r c h e r s t r u c t u r e d the i n t e r v i e w q u e s t i o n s around t h e n u r s i n g c a r e b e h a v i o u r s t h a t would be demonstrated i n n u r s i n g p a t i e n t s w i t h an o r t h o p e d i c i n j u r y / i l l n e s s . For 38 example, the q u e s t i o n s d e v e l o p e d i n r e l a t i o n t o an o r t h o p e d i c i n j u r y / i l l n e s s i n c l u d e d p o s i t i o n i n g , s p l i n t i n g , and p a i n management. P i l o t T e s t A p i l o t t e s t was conducted f o r the purpose of r e f i n i n g t h e d a t a c o l l e c t i o n i n s t r u m e n t . Two s u b j e c t s p a r t i c i p a t e d i n the p i l o t t e s t . In r e v i e w i n g the p i l o t t e s t d a t a , the r e s e a r c h e r found t h a t two changes t o the d a t a c o l l e c t i o n i n s t r u m e n t were n e c e s s a r y . The f i r s t change i n v o l v e d c l a r i f i c a t i o n of s u b j e c t s ' p e r c e p t i o n s of n u r s i n g c a r e b e h a v i o u r s . The n u r s i n g c a r e b e h a v i o u r s which were e l i c i t e d i n . t h e i n t e r v i e w d i d not c o n s i s t e n t l y c l a r i f y whether s u b j e c t s p e r c e i v e d the n u r s i n g c a r e b e h a v i o u r s t o be s a t i s f y i n g or d i s s a t i s f y i n g . T h e r e f o r e , the a d d i t i o n of a summary st a t e m e n t a t the end of each s e t of i n t e r v i e w q u e s t i o n s a l l o w e d the r e s e a r c h e r t o v a l i d a t e whether s u b j e c t s p e r c e i v e d the n u r s i n g c a r e b e h a v i o u r s t o be s a t i s f y i n g or d i s s a t i s f y i n g . The second change i n the d a t a c o l l e c t i o n i n s t r u m e n t i n v o l v e d the r e v i s i o n of t h e i n t e r v i e w q u e s t i o n s r e l a t e d t o the i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p d i m e n s i o n . Q u e s t i o n s r e l a t e d t o the i n t e r p e r s o n a l component i n t h i s d i m e n s i o n were not e l i c i t i n g n u r s i n g c a r e b e h a v i o u r s t h a t demonstrated an i n t e r p e r s o n a l r e l a t i o n s h i p . One example of a r e v i s i o n was the a d d i t i o n of a q u e s t i o n t h a t asked s u b j e c t s whether n u r s e s were c o u r t e o u s or p o l i t e i n t h e i r 39 v e r b a l i n t e r a c t i o n w i t h the s u b j e c t s . By i n t e g r a t i n g examples of i n t e r p e r s o n a l n u r s i n g c a r e b e h a v i o u r s i n t o the i n t e r v i e w q u e s t i o n s , the r e s e a r c h e r was a b l e t o d i r e c t the s u b j e c t s t o e l i c i t s a t i s f y i n g or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s i n t h i s p a r t of the d i m e n s i o n . Data A n a l y s i s P r o c e d u r e The a u d i o t a p e d i n t e r v i e w s were t r a n s c r i b e d by the r e s e a r c h e r . Data d e s c r i b i n g the n u r s i n g c a r e b e h a v i o u r s were i d e n t i f i e d and l i s t e d under one of the f o u r d i m e n s i o n s of R i s s e r ' s e v a l u a t i v e c r i t i e r i o n ( R i s s e r , 1975). I f a n u r s i n g c a r e b e h a v i o u r r e l a t e d t o more t h a n one d i m e n s i o n , t h e r e s e a r c h e r a s s i g n e d t h e n u r s i n g c a r e b e h a v i o u r t o one of the d i m e n s i o n s . The t h r e e s o u r c e s from which the i n t e r v i e w q u e s t i o n s were de v e l o p e d g u i d e d t h i s d e c i s i o n . These were R i s s e r ' s c r i t e r i o n f o r e v a l u a t i n g p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e , the r e s e a r c h e r ' s emergency n u r s i n g knowledge and e x p e r i e n c e , and the r e s e a r c h e r ' s r e v i e w of l i t e r a t u r e on o r t h o p e d i c emergency n u r s i n g , i n c l u d i n g the Canadian St a n d a r d s f o r Emergency N u r s i n g P r a c t i c e (NENA, 1986). W i t h i n each of the f o u r d i m e n s i o n s , s i m i l a r n u r s i n g c a r e b e h a v i o u r s were s o r t e d and grouped under broad h e a d i n g s . For example, i n t h e t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r d i m e n s i o n , the n u r s i n g c a r e b e h a v i o u r s of a n a l g e s i c a d m i n i s t r a t i o n and i n t r a v e n o u s i n s e r t i o n s were grouped as t e c h n i c a l a c t i v i t i e s . C o n c u r r e n t l y , the n u r s i n g 40 c a r e b e h a v i o u r s i n each d i m e n s i o n were c a t e g o r i z e d as s a t i s f y i n g or d i s s a t i s f y i n g . E t h i c a l C o n s i d e r a t i o n s P r i o r t o commencement of the s t u d y , the r e s e a r c h e r r e c e i v e d a p p r o v a l from the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee For R e s e a r c h and Other S t u d i e s I n v o l v i n g Human S u b j e c t s . D u r i n g the c o u r s e of t h i s s t u d y , the r e s e a r c h e r was employed i n t h e emergency room of a Vancouver h o s p i t a l . T h e r e f o r e , the r e s e a r c h e r p u r p o s e l y chose a n o t h e r emergency room as the r e s e a r c h s e t t i n g . Each s u b j e c t was g i v e n an i n f o r m a t i o n l e t t e r by the head n u r s e . The conse n t forms were e x p l a i n e d by the r e s e a r c h e r and s u b s e q u e n t l y s i g n e d i n the presence of the r e s e a r c h e r . A copy of the s i g n e d c o n s e n t form was g i v e n t o each s u b j e c t . S u b j e c t s were a l s o informed of t h e r i g h t t o . withdraw a t any time d u r i n g the c o u r s e of the s t u d y w i t h o u t j e o p a r d i z i n g t h e i r h e a l t h c a r e . C o n f i d e n t i a l i t y was m a i n t a i n e d t h r o u g h c o d i n g of the d a t a . The s u b j e c t s ' names were known o n l y t o t h e r e s e a r c h e r . The t r a n s c r i b e d d a t a were coded by the r e s e a r c h e r and r e v i e w e d by the r e s e a r c h e r and her t h e s i s committee members. The a u d i o t a p e s and t r a n s c r i b e d d a t a were d e s t r o y e d a f t e r c o m p l e t i o n of the s t u d y . 41 Summary T h i s c h a p t e r d e s c r i b e d the methodology used i n t h i s s t u d y . The r e s e a r c h d e s i g n , s e t t i n g , sample, d a t a c o l l e c t i o n , and d a t a a n a l y s i s were d i s c u s s e d . The p i l o t t e s t was d e s c r i b e d and the e t h i c a l c o n s i d e r a t i o n s were o u t l i n e d . CHAPTER FOUR P r e s e n t a t i o n of F i n d i n g s and D i s c u s s i o n I n t r o d u c t i o n T h i s c h a p t e r i s o r g a n i z e d i n t o t h r e e s e c t i o n s . The f i r s t s e c t i o n d e s c r i b e s the c h a r a c t e r i s t i c s of the s u b j e c t s , the second p r e s e n t s the f i n d i n g s , and the t h i r d d i s c u s s e s the r e s u l t s of the s t u d y . C h a r a c t e r i s t i c s of the S u b j e c t s P a r t A of the d a t a c o l l e c t i o n i n s t r u m e n t g a t h e r e d d a t a r e g a r d i n g t h e c h a r a c t e r i s t i c s of t h e s u b j e c t s . The s u b j e c t s i n t h i s s t u d y c o n s i s t e d of seven men and t h r e e women. T h e i r ages ranged from 23 t o 81 y e a r s . A l l the s u b j e c t s were h i g h s c h o o l g r a d u a t e s . Two s u b j e c t s had a u n i v e r s i t y e d u c a t i o n . Seven s u b j e c t s were c u r r e n t l y employed i n a t r a d e or p r o f e s s i o n a l work. Three s u b j e c t s were r e t i r e d . Nine s u b j e c t s e x p e r i e n c e d an o r t h o p e d i c i n j u r y as a r e s u l t of an a c c i d e n t a t t h e i r home or w o r k p l a c e . A l t h o u g h each s u b j e c t s u s t a i n e d an o r t h o p e d i c i n j u r y , t he type and s e v e r i t y of each i n j u r y v a r i e d . One s u b j e c t ' s a d m i s s i o n t o the emergency room was r e l a t e d t o a p o s t - o p e r a t i v e c o m p l i c a t i o n of an o r t h o p e d i c i n j u r y . A l l the s u b j e c t s were i n t e r v i e w e d two t o f i v e days p o s t - o p e r a t i v e l y . Nine s u b j e c t s had e x p e r i e n c e d p a s t m e d i c a l t r e a t m e n t i n an emergency room. Four of th e s e s u b j e c t s s t a t e d t h a t t h e y had r e q u i r e d h o s p i t a l i z a t i o n f o l l o w i n g p r e v i o u s emergency 43 room t r e a t m e n t . A l l the s u b j e c t s s t a t e d t h a t t h e y had e x p e r i e n c e i n accompanying someone e l s e t o an emergency room. ; The s u b j e c t s ' l e n g t h of s t a y i n the emergency room v a r i e d . The s h o r t e s t s t a y was one and a h a l f hours w h i l e the l o n g e s t s t a y was o v e r n i g h t . E i g h t s u b j e c t s had a s u p p o r t person w a i t w i t h them d u r i n g t h e i r s t a y i n the emergency room. P r e s e n t a t i o n of the F i n d i n g s The f i n d i n g s p r e s e n t s u b j e c t s ' p e r c e p t i o n s of n u r s i n g c a r e b e h a v i o u r s i n the emergency room. The i d e n t i f i e d n u r s i n g c a r e b e h a v i o u r s were c a t e g o r i z e d a c c o r d i n g t o the f o u r d i m e n s i o n s of R i s s e r ' s (1975) c r i t e r i o n t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . T e c h n i c a l - p r o f e s s i o n a l B e h a v i o u r Dimension The t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r d i m e n s i o n was d e f i n e d as the n u r s i n g c a r e b e h a v i o u r s t h a t i n c l u d e the knowledge and t e c h n i c a l a c t i v i t i e s r e q u i r e d by n u r s e s t o c o m p e t e n t l y p e r f o r m n u r s i n g c a r e t a s k s ( R i s s e r , 1975). The f i n d i n g s i n t h i s s t u d y i n d i c a t e d t h a t s u b j e c t s (n=10) i d e n t i f i e d f o u r n u r s i n g c a r e b e h a v i o u r s which were p e r c e i v e d as s a t i s f y i n g or d i s s a t i s f y i n g i n r e l a t i o n t o the t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r d i m e n s i o n . These were nur s e s d e m o n s t r a t i n g knowledge i n the assessment of the i n j u r y / i l l n e s s , p r i o r i t i z i n g placement, p e r f o r m i n g t e c h n i c a l a c t i v i t i e s s k i l l f u l l y , and p r o v i d i n g p h y s i c a l c o m f o r t . See Table 5, page 44. Table 5 T e c h n i c a l - p r o f e s s i o n a l B e h a v i o u r Dimension; S u b j e c t s '  P e r c e p t i o n s of N u r s i n g Care B e h a v i o u r s N u r s i n g c a r e b e h a v i o u r s S u b j e c t s ' p e r c e p t i o n s n = 10 S a t i s f y i n g D i s s a t i s f y i n g No response 1. D e m o n s t r a t i n g knowledge 7 3 0 i n t h e assessment of i n j u r y / i l l n e s s . 2. P r i o r i t i z i n g placement 9 1 0 3. P e r f o r m i n g t e c h n i c a l 7 3 0 a c t i v i t i e s s k i l l f u l l y . 4. P r o v i d i n g p h y s i c a l 8 2 0 co m f o r t Nine of the t e n s u b j e c t s s t a t e d t h a t t h e y were s a t i s f i e d w i t h how the n u r s e s were a b l e t o make a q u i c k and a c c u r a t e assessment on a d m i s s i o n . Seven of the t e n s u b j e c t s were s a t i s f i e d w i t h the n u r s e s ' assessments of t h e i r i n j u r y / i l l n e s s t h r o u g h o u t t h e i r emergency room s t a y . These s u b j e c t s (n=7) s t a t e d t h a t the n u r s e s appeared knowledgeable and e x p e r i e n c e d . However, t h r e e of the t e n s u b j e c t s s t a t e d t h a t t h e n u r s e s had i n a p p r o p r i a t e l y a s s e s s e d t h e i r i n j u r y / i l l n e s s a f t e r t h e i r i n i t i a l assessment by the t r i a g e n u r s e , which l e d t o t h e i r d i s s a t i s f a c t i o n . D i s s a t i s f i e d n u r s i n g c a r e b e h a v i o u r s p r i m a r i l y r e l a t e d t o n u r s e s ' assessment of s u b j e c t s ' d i s c o m f o r t . Nine of the t e n s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' p r i o r i t i z a t i o n s of t h e i r i n j u r y / i l l n e s s i n terms of a p p r o p r i a t e placement i n a t r e a t m e n t a r e a . Four of the s e s u b j e c t s r e c e i v e d immediate t r e a t m e n t and commented t h a t t h e y were s a t i s f i e d w i t h the n u r s e ' s prompt a t t e n t i o n and a c t i o n i n p r i o r i t i z i n g the s e v e r i t y of t h e i r i n j u r y . Another s u b j e c t , who was a l s o t a k e n i m m e d i a t e l y i n t o the t r e a t m e n t a r e a , commented t h a t the nurse had r e c o g n i z e d h i s d i s c o m f o r t and h i s need t o l a y down even though h i s case was not u r g e n t . F i v e of the t e n s u b j e c t s s t a t e d t h a t t h e y were i n i t i a l l y i n s t r u c t e d t o w a i t i n the w a i t i n g a r e a . Four of t h e s e s u b j e c t s were s a t i s f i e d w i t h the nur s e ' s i n s t r u c t i o n and p e r c e i v e d t h a t the nurse had a p p r o p r i a t e l y a s s e s s e d and p r i o r i t i z e d t h e i r i n j u r y / i l l n e s s . One s u b j e c t who was d i s s a t i s f i e d w i t h the w a i t i n the w a i t i n g room p e r c e i v e d t h a t h i s i n j u r y / i l l n e s s r e q u i r e d immediate a t t e n t i o n . Seven of the t e n s u b j e c t s were s a t i s f i e d w i t h the n u r s e s ' performance of t e c h n i c a l a c t i v i t i e s . F i v e of the s e s u b j e c t s s t a t e d t h a t t h e y had an i n t r a v e n o u s i n f u s i o n s t a r t e d . However, o n l y t h r e e c o u l d r e c a l l the nurse a c t u a l l y p e r f o r m i n g t h i s t e c h n i c a l s k i l l . For example, one s u b j e c t who had a m e d i c a l background, s t a t e d t h a t the nurse demonstrated e x p e r i e n c e and s k i l l f u l l y performed the i n t r a v e n o u s i n s e r t i o n . Another s u b j e c t who had p r e v i o u s l y e x p e r i e n c e d s e v e r a l i n t r a v e n o u s i n s e r t i o n s , s t a t e d t h a t the nurse was p r o f i c i e n t a t t h i s s k i l l . As w e l l , f o u r of the seven s u b j e c t s were s a t i s f i e d w i t h n u r s e s m o n i t o r i n g t h e i r v i t a l s i g n s and a s s e s s i n g t h e i r n e u r o v a s c u l a r s t a t u s . These s u b j e c t s commented t h a t t h e y were s a t i s f i e d w i t h how t h e n u r s e s performed t h e i r assessments w i t h d e x t e r i t y and examined t h e i r c o n d i t i o n s k i l l f u l l y f o r o t h e r i n j u r i e s t h a t c o u l d have r e s u l t e d from t h e i r p r i m a r y i n j u r y . The t h r e e d i s s a t i s f i e d s u b j e c t s p e r c e i v e d t h a t the n u r s e s d i s p l a y e d n o n v e r b a l u n c a r i n g b e h a v i o u r s w h i l e p e r f o r m i n g the t e c h n i c a l t a s k s . However, th e s e s u b j e c t s c o u l d not r e c a l l any f a u l t w i t h t h e s e n u r s e s ' t e c h n i c a l s k i l l s . E i g h t of the t e n s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' p r o v i s i o n of p h y s i c a l c o m f o r t measures. They i d e n t i f i e d t h a t t h e n u r s e s s k i l l f u l l y p r o v i d e d p h y s i c a l c o m f o r t t h r o u g h e f f e c t i v e p o s i t i o n i n g , s p l i n t i n g , and a d m i n i s t e r i n g p a i n m e d i c a t i o n . Two of the t e n s u b j e c t s s t a t e d t h a t t h e y were d i s s a t i s f i e d w i t h how t h e i r nurse p r o v i d e d p h y s i c a l c o m f o r t . One s t a t e d t h a t she asked the nurse f o r a p i l l o w and i c e t o p o s i t i o n and c o m f o r t her p a i n f u l and s w o l l e n arm. As a r e s u l t , t h i s s u b j e c t p e r c e i v e d t h a t she had t o ask the nurse t o p r o v i d e p h y s i c a l c o m f o r t . The second s u b j e c t s t a t e d t h a t the nurse was r e l u c t a n t t o a d m i n i s t e r the p a i n m e d i c a t i o n t h a t he had 47 e x p e c t e d t o r e c e i v e . T h i s s u b j e c t a l s o p e r c e i v e d t h a t the nurse was u n c a r i n g about h i s d i s c o m f o r t . T r u s t i n g R e l a t i o n s h i p Dimension The d i m e n s i o n of a t r u s t i n g r e l a t i o n s h i p was d e f i n e d as the n u r s i n g c a r e b e h a v i o u r s which r e l a t e d t o how nurses f o s t e r c o n s t r u c t i v e and c o m f o r t a b l e n u r s e - p a t i e n t i n t e r a c t i o n s ( R i s s e r , 1975). The f i n d i n g s i n d i c a t e d t h a t t h e s u b j e c t s (n=10) i d e n t i f i e d t h r e e n u r s i n g c a r e b e h a v i o u r s which were p e r c e i v e d as s a t i s f y i n g or d i s s a t i s f y i n g i n r e l a t i o n t o the t r u s t i n g r e l a t i o n s h i p d i m e n s i o n . These i n c l u d e d n u r s e s a t t e n d i n g t o s u b j e c t s p r o m p t l y on a d m i s s i o n , u s i n g a t t e n d i n g and l i s t e n i n g s k i l l s , and p r o v i d i n g r e a s s u r a n c e t o s u b j e c t s and t h e i r s u p p o r t p e r s o n s . See T a b l e 6, page 48. 48 Table 6 T r u s t i n g R e l a t i o n s h i p Dimension; S u b j e c t s ' P e r c e p t i o n s o£ N u r s i n g Care B e h a v i o u r s N u r s i n g c a r e b e h a v i o u r s S u b j e c t s ' p e r c e p t i o n s n=10 S a t i s f y i n g D i s s a t i s f y i n g No response 1. A t t e n d i n g t o p r o m p t l y 10 0 0 on a d m i s s i o n 2. U s i n g a t t e n d i n g and 7 3 0 l i s t e n i n g s k i l l s 3. P r o v i d i n g r e a s s u r a n c e 7 0 3 The f i n d i n g s i n d i c a t e d t h a t a l l the s u b j e c t s (n=10), whether or not t h e y were u r g e n t c a s e s , were s a t i s f i e d w i t h b e i n g met p r o m p t l y on a d m i s s i o n . Four of the t e n s u b j e c t s s t a t e d t h a t t h e y had v e r y l i t t l e i n t e r a c t i o n w i t h the nurse who i m m e d i a t e l y d i r e c t e d them on a r r i v a l i n t o t h e t r e a t m e n t a r e a . The s i x o t h e r s u b j e c t s s t a t e d t h a t t h e y were met p r o m p t l y by a nurse who asked them q u e s t i o n s p e r t a i n i n g t o t h e i r i n j u r y / i l l n e s s . Seven of the t e n s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' a t t e n d i n g and l i s t e n i n g s k i l l s . These s u b j e c t s remarked on how the n u r s e s checked on t h e i r c o n d i t i o n r e g u l a r l y . Two of the seven s u b j e c t s s t a t e d t h a t the n u r s e s were g e n u i n e l y c oncerned about them. F i v e of the seven s u b j e c t s s t a t e d t h a t t h e y f e l t s a t i s f i e d w i t h how the n u r s e s l i s t e n e d t o 49 both t h e i r p h y s i c a l c o m p l a i n t s and e m o t i o n a l c o n c e r n s . Three of the t e n s u b j e c t s were d i s s a t i s f i e d w i t h some of the n u r s e s ' a t t e n d i n g and l i s t e n i n g s k i l l s . One of t h e s e s u b j e c t s was d i s s a t i s f i e d because the nurse had not performed the c a t h e t e r i z a t i o n t h a t she had s a i d would be done. C o n s e q u e n t l y , t h i s s u b j e c t was f e e l i n g u n c o m f o r t a b l e and p e r c e i v e d t h a t she was e i t h e r f o r g o t t e n about or unheard. Another s u b j e c t was d i s s a t i s f i e d because one of the n u r s e s who performed a t e c h n i c a l t a s k l a c k e d eye c o n t a c t , and gave no v e r b a l r e s p o n s e . As a r e s u l t , t h i s p a r t i c u l a r s u b j e c t p e r c e i v e d t h i s n u r s e ' s b e h a v i o u r as u n c a r i n g and m e c h a n i c a l . Data a l s o i n d i c a t e d t h a t t h r e e of t h e t e n s u b j e c t s s t a t e d t h a t t h e y became d i s s a t i s f i e d l a t e r due t o t h e unexpected w a i t i n g time between the n u r s e ' s i n i t i a l assessment and the e x a m i n a t i o n by the p h y s i c i a n . Seven of the t e n s u b j e c t s had s u p p o r t p e r s o n s who were p r e s e n t d u r i n g t h e i r e n t i r e emergency room s t a y . They were s a t i s f i e d w i t h how n u r s e s p r o v i d e d r e a s s u r a n c e t o the s u p p o r t p e r s o n s . Four of the seven s u b j e c t s a l s o commented t h a t the n u r s e s ' v e r b a l encouragement p r o v i d e d e m o t i o n a l c o m f o r t and h e l p e d t o a l l e v i a t e t h e i r a n x i e t i e s and f e a r s . Seven of the t e n s u b j e c t s were s a t i s f i e d and g r a t e f u l t h a t the n u r s e s a l l o w e d the s u b j e c t s and t h e i r s u p p o r t persons t o w a i t t o g e t h e r . Three of the t e n s u b j e c t s who d i d not have s u p p o r t persons p r e s e n t d i d not respond t o t h i s q u e s t i o n . However, t h e y f e l t s a t i s f i e d because the nurses 50 i n q u i r e d i f the s u b j e c t s ' s u p p o r t persons had been n o t i f i e d . Four of the seven s u b j e c t s who had s u p p o r t persons p r e s e n t p e r c e i v e d t h a t the v i s i b i l i t y of the nurses p r o v i d e d r e a s s u r a n c e . They s t a t e d t h a t the v i s i b i l i t y of the n u r s e s p r o v i d e d them w i t h the r e a s s u r a n c e t h a t t h e y c o u l d depend on the nu r s e s when h e l p was needed. These s u b j e c t s a l s o commented t h a t s e e i n g the n u r s e s nearby h e l p e d them t o f e e l l e s s a l o n e . The o t h e r t h r e e s u b j e c t s who had s u p p o r t persons p r e s e n t s t a t e d t h a t o b s e r v i n g the a c t i o n i n the emergency room p r e v e n t e d them from a s k i n g f o r h e l p because t h e y assumed the nu r s e s were t o o busy. I n t e r - i n t r a p e r s o n a l R e l a t i o n s h i p Dimension The i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p d i m e n s i o n was d e f i n e d as the e x p r e s s i v e f u n c t i o n s of the n u r s e . These b e h a v i o u r s i n c l u d e d both v e r b a l and n o n v e r b a l n u r s i n g c a r e b e h a v i o u r s ( R i s s e r , 1975). The f i n d i n g s i n t h i s s t u d y i n d i c a t e d t h a t the s u b j e c t s (n=10) i d e n t i f i e d both v e r b a l an n o n v e r b a l n u r s i n g c a r e b e h a v i o u r s i n the i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p d i m e n s i o n . These i n c l u d e d n u r s e s d e m o n s t r a t i n g a c a r i n g / h e l p i n g a t t i t u d e , i n t r o d u c i n g t h e m s e l v e s by name and t i t l e , i d e n t i f y i n g t hemselves t h r o u g h u n i f o r m a t t i r e , and communciation u s i n g body language, s p e c i f i c a l l y , t hose of eye c o n t a c t , f a c i a l e x p r e s s i o n s , g e s t u r e s , and tone of v o i c e . A c a r i n g / h e l p i n g a t t i t u d e w i t h i n the c o n t e x t of t h i s s t u d y was d e f i n e d as the words and mannerisms t h a t c r e a t e i n a n o t h e r an i m p r e s s i o n of mutual t r u s t ( B l a t t t n e r , 1981; Wiendenbach & F a l l s , 1978). See Ta b l e 7, page 51. Table 7 I n t e r - i n t r a p e r s o n a l R e l a t i o n s h i p Dimension: S u b j e c t s '  P e r c e p t i o n s of N u r s i n g Care B e h a v i o u r s N u r s i n g c a r e b e h a v i o u r s S u b j e c t s ' p e r c e p t i o n s n=10 S a t i s f y i n g D i s s a t i s f y i n g No response 1. D e m o n s t r a t i n g a c a r i n g / 9 h e l p i n g a t t i t u d e 2. I n t r o d u c i n g s e l f 4 by name and t i t l e 3. I d e n t i f y i n g t h r o u g h 6 u n i f o r m a t t i r e 4. Communicating u s i n g 7 body language Nine of the t e n s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' c a r i n g / h e l p i n g a t t i t u d e s t h r o u g h both v e r b a l and n o n v e r b a l b e h a v i o u r s . D e s c r i p t i v e words such as c o n c e r n e d , c o u r t e o u s , f r i e n d l y , k i n d , n i c e , and/or open were used t o d e s c r i b e the n u r s e s ' b e h a v i o u r s . Two of the n i n e s u b j e c t s s t a t e d t h a t the n u r s e s ' p o l i t e r e sponses made them f e e l r e s p e c t e d . I n a d d i t i o n , a n o t h e r s u b j e c t commented t h a t the nu r s e s were c o u r t e o u s towards each o t h e r when communicating 52 i n s t r u c t i o n s . Only one s u b j e c t was d i s s a t i s f i e d w i t h the n u r s e s ' v e r b a l and n o n v e r b a l b e h a v i o u r s . T h i s s u b j e c t s t a t e d t h a t h i s i n t e r a c t i o n s w i t h some of the nurses were v e r y p r o f e s s i o n a l and b u s i n e s s l i k e , which he p e r c e i v e d as u n c a r i n g and u n f r i e n d l y . The s u b j e c t s (n=9) who p e r c e i v e d the n u r s e s t o be f r i e n d l y commented t h a t the m a j o r i t y of n u r s e s were open and easy t o approach. One s u b j e c t s t a t e d t h a t he a p p r e c i a t e d the n u r s e s ' sense of humor which h e l p e d him l e s s e n h i s a n x i e t y . Of the t e n s u b j e c t s i n t h i s s t u d y , f o u r were s a t i s f i e d w i t h the n u r s e s ' i n t r o d u c t i o n s of the m s e l v e s and one was d i s s a t i s f i e d because the n u r s e s had not i n t r o d u c e d t h e m s e l v e s . A l t h o u g h the f i v e r e m a i n i n g s u b j e c t s c o u l d not r e c a l l n u r s e s ' i n t r o d u c t i o n s , t h e y a l l agreed t h a t t h i s would have been a n i c e g e s t u r e . Three of t h e s u b j e c t s who were s a t i s f i e d p e r c e i v e d the n u r s e s t o have acknowledged them as persons r a t h e r than i n j u r y / i l l n e s s c a s e s . S i m i l a r i l y , a n o t h e r s u b j e c t commented t h a t n u r s e s were on f i r s t name b a s i s which he p e r c e i v e d as p e r s o n a b l e . However, the s u b j e c t who was d i s s a t i s f i e d because she d i d not r e c e i v e an i n t r o d u c t i o n commented t h a t t h i s l e d t o her c o n f u s i o n w i t h some i n f o r m a t i o n about her c a r e . S i x of the t e n s u b j e c t s were s a t i s f i e d w i t h i d e n t i f y i n g the n u r s e s by t h e i r u n i f o r m a t t i r e . However, t h i s p e r c e p t i o n was c o n f i r m e d by o b s e r v i n g o t h e r c h a r a c t e r i s t i c s of the n u r s e s such as the c o n v e r s a t i o n s and the r o l e s t h a t were b e i n g performed. F i v e of the s i x s u b j e c t s s t a t e d t h a t t h e y c o u l d e a s i l y i d e n t i f y t he nurses by t h e i r w h i t e or p a s t e l c o l o r e d u n i f o r m s . Four of the t e n s u b j e c t s were d i s s a t i s f i e d as t h e y were unable t o i d e n t i f y t h e nu r s e s a c c o r d i n g t o t h e i r u n i f o r m a t t i r e . These f o u r s u b j e c t s commented t h a t t h e y observed some of the s t a f f w e a r i n g the c o n v e n t i o n a l o p e r a t i n g room u n i f o r m s , which added t o t h e i r c o n f u s i o n of n u r s e s ' i d e n t i t i e s . One of t h e s e s u b j e c t s assumed t h a t the women were l i k e l y the n u r s e s . U n t i l i t was c l a r i f i e d , a n o t her s u b j e c t assumed t h a t the male nurse d r e s s e d i n the o p e r a t i n g room u n i f o r m was an a n e s t h e t i s t . Three of the t e n s u b j e c t s a l s o remarked t h a t n u r s e s s h o u l d wear some i d e n t i f i c a t i o n which i n d i c a t e d t h e i r name and t i t l e . Seven of the t e n s u b j e c t s were s a t i s f i e d w i t h t h e i r o b s e r v a t i o n of n u r s e s ' body language. F i v e of the s e seven s u b j e c t s p e r c e i v e d the nur s e s t o demonstrate a c a r i n g / h e l p i n g a t t i t u d e t h r o u g h t h e i r body language. One of t h e s e s u b j e c t s s t a t e d t h a t the nurses had an openess about t h e i r approach t o p a t i e n t s . Three of the t e n s u b j e c t s were d i s s a t i s f i e d w i t h n u r s e s ' n o n v e r b a l b e h a v i o u r s . D i s s a t i s f a c t i o n w i t h t h e s e b e h a v i o u r s p r i m a r i l y r e l a t e d t o the h u r r i e d mannerisms and b u s i n e s s l i k e a t t i t u d e s of the n u r s e s . One of the s e s u b j e c t s s t a t e d t h a t the n u r s e s ' h u r r i e d b e h a v i o u r s c r e a t e d a sense of "busyness" which r e s u l t e d i n her h e s i t a n c y t o c a l l f o r h e l p . A second s u b j e c t remarked t h a t a few of the n u r s e s ' tone of v o i c e sounded p r o f e s s i o n a l and b u s i n e s s l i k e which was p e r c e i v e d as u n c a r i n g . E d u c a t i o n a l R e l a t i o n s h i p Dimension The d i m e n s i o n of an e d u c a t i o n a l r e l a t i o n s h i p was d e f i n e d as the i n f o r m a t i o n exchange between the nurse and p a t i e n t ( R i s s e r , 1975). The f i n d i n g s i n t h i s s t u d y i n d i c a t e d t h a t s u b j e c t s (n=10) i d e n t i f i e d f o u r n u r s i n g c a r e b e h a v i o u r s i n the e d u c a t i o n a l r e l a t i o n s h i p d i m e n s i o n . These b e h a v i o u r s i n c l u d e d nurses a s k i n g s u b j e c t s a p p r o p r i a t e q u e s t i o n s , u p d a t i n g or k e e p i n g s u b j e c t s i n f o r m e d , e x p l a i n i n g p r o c e d u r e s , and i n s t r u c t i n g how t o c a l l f o r h e l p . See Table 8, page 54. T a b l e 8 E d u c a t i o n a l R e l a t i o n s h i p Dimension: S u b j e c t s '  P e r c e p t i o n s of N u r s i n g Care B e h a v i o u r s N u r s i n g c a r e b e h a v i o u r s S u b j e c t s ' p e r c e p t i o n s n=10 S a t i s f y i n g D i s s a t i s f y i n g No response 1. A s k i n g a p p r o p r i a t e q u e s t i o n s 2. U p d a t i n g i n f o r m a t i o n 3. E x p l a i n i n g p r o c e d u r e s 4. I n s t r u c t i n g how t o c a l l f o r h e l p 8 2 0 8 2 0 7 3 0 6 2 1 E i g h t of the t e n s u b j e c t s were s a t i s f i e d t h a t nurses had asked a p p r o p r i a t e q u e s t i o n s . F i v e of the e i g h t s u b j e c t s commented t h a t the t y p e s of q u e s t i o n s t h a t nurses asked r e l a t e d t o t h e i r i n j u r y / i l l n e s s and t h e i r need f o r e m o t i o n a l s u p p o r t . Four of t h e s e f i v e s u b j e c t s s t a t e d t h a t t h e s e n u r s e s appeared knowledgeable and e x p e r i e n c e d . Two of the t e n s u b j e c t s were d i s s a t i s f i e d w i t h n u r s e s * q u e s t i o n s . One s u b j e c t s t a t e d t h a t she had e x p e c t e d the n u r s e s t o q u e s t i o n her about her c h r o n i c i l l n e s s . As t h i s q u e s t i o n i n g d i d not o c c u r and because t h i s s u b j e c t f e l t t h a t her c h r o n i c i l l n e s s r e l a t e d t o her emergency a d m i s s i o n she p e r c e i v e d t h a t the n u r s e s l a c k e d a p p r o p r i a t e knowledge. The o t h e r s u b j e c t who was d i s s a t i s f i e d commented on a few of the n u r s e s ' a b r u p t n e s s w i t h t h e i r q u e s t i o n s which he p e r c e i v e d as u n c a r i n g . E i g h t of the t e n s u b j e c t s were s a t i s f i e d t h a t the n u r s e s kept them informed or updated of t h e i r p r o g r e s s t h r o u g h o u t t h e i r emergency room s t a y . These s u b j e c t s s t a t e d t h a t t h e y were p a r t i c u l a r l y i n t e r e s t e d t o have i n f o r m a t i o n about t h e i r i n j u r y / i l l n e s s , d i a g n o s t i c t e s t s , and the r e a s o n s f o r the d e l a y s which o c c u r r e d w i t h t e s t s , o p e r a t i o n t i m e , and s e e i n g t h e i r p h y s i c i a n . For example, one s u b j e c t was s a t i s f i e d t h a t the nurse informed him about h i s d e l a y f o r s u r g e r y . As a r e s u l t , he was a b l e t o i n f o r m h i s f a m i l y and keep them updated. Two of the t e n s u b j e c t s were d i s s a t i s f i e d t h a t the n u r s e s had not p r o v i d e d ongoing i n f o r m a t i o n . These two s u b j e c t s s t a t e d t h a t the nurses 56 d i d not keep them informed r e g a r d i n g t h e i r l o n g w a i t t o see the p h y s i c i a n . Seven of the t e n s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' e x p l a n a t i o n s of n u r s i n g p r o c e d u r e s performed i n the emergency room. A l t h o u g h t h r e e of the t e n s u b j e c t s commented on the n u r s e s ' t e c h n i c a l s k i l l s a t s t a r t i n g i n t r a v e n o u s i n f u s i o n s , o n l y two of them s t a t e d t h a t the nurse e x p l a i n e d t h i s p rocedure w e l l . The o t h e r s u b j e c t who r e c e i v e d no e x p l a n a t i o n was a m e d i c a l d o c t o r . T h i s s u b j e c t s t a t e d t h a t she was not d i s s a t i s f i e d and t h a t an e x p l a n a t i o n was u n n e c e s s a r y i n her c a s e . Seven of the t e n s u b j e c t s who were s e n t t o the o p e r a t i n g room d u r i n g t h e i r emergency room s t a y were s a t i s f i e d w i t h n u r s e s ' e x p l a n a t i o n s of the p r e - o p e r a t i v e p r e p a r a t i o n . As w e l l , a l l t h e s e s u b j e c t s (n=7) were s a t i s f i e d w i t h n u r s e s ' c l a r i f i c a t i o n of p h y s i c i a n s ' I n f o r m a t i o n r e g a r d i n g t h e i r o p e r a t i o n and c o n d i t i o n . Three of the t e n s u b j e c t s were d i s s a t i s f i e d w i t h n u r s e s l a c k of e x p l a n a t i o n . One of the s e t h r e e s u b j e c t s commented t h a t the nurse d i d not e x p l a i n the r e a s o n f o r r e l o c a t i n g her t o a n o t h e r a r e a which concerned her s i g n i f i c a n t o t h e r when he r e t u r n e d and c o u l d not f i n d h e r . Nine of the t e n s u b j e c t s responded t o the q u e s t i o n c o n c e r n i n g n u r s e s i n s t r u c t i n g p a t i e n t s t o c a l l f o r h e l p . A l l t hese s u b j e c t s (n=9) r e c a l l e d h a v i n g no i n s t r u c t i o n s t o c a l l f o r h e l p . However, seven of the s e n i n e s u b j e c t s were s a t i s f i e d w i t h the v i s i b i l i t y of the n u r s e s ' presence which 57 t h e y p e r c e i v e d as a method t o c a l l f o r h e l p . Two of the n i n e s u b j e c t s were d i s s a t i s f i e d w i t h n u r s e s ' l a c k of i n s t r u c t i o n s t o c a l l f o r h e l p . As th e s e two s u b j e c t s were l o c a t e d i n p r i v a t e rooms the nurses were not as v i s i b l e t o them. They both s t a t e d t h a t i t was d i s s a t i s f y i n g t o " c a l l o u t " f o r a nurse from t h e i r room. D i s c u s s i o n In f o l l o w i n g s e c t i o n the d i s c u s s i o n of the f i n d i n g s i s p r e s e n t e d . The f i n d i n g s a r e d i s c u s s e d i n r e l a t i o n t o the f o u r d i m e n s i o n s of R i s s e r ' s (1975) c r i t e r i o n t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . T e c h n i c a l - p r o f e s s i o n a l B e h a v i o u r Dimension On a d m i s s i o n , n i n e of the t e n s u b j e c t s were s a t i s f i e d t h a t the n u r s e s q u i c k l y a s s e s s e d and p r i o r i t i z e d t h e i r i n j u r y / i l l n e s s . These s u b j e c t s were a l s o s a t i s f i e d t h a t t h e y were a s s i g n e d t o an a p p r o p r i a t e a r e a t o a w a i t t r e a t m e n t . Only one s u b j e c t was d i s s a t i s f i e d because he p e r c e i v e d t h a t the nurse had i n a p p r o p r i a t e l y a s s e s s e d the s e v e r i t y of h i s i n j u r y . These f i n d i n g s i n d i c a t e d t h a t the m a j o r i t y of s u b j e c t s (n=9) were s a t i s f i e d w i t h the performance of the t r i a g e n u r s e . They p e r c e i v e d t h a t the nurses had the t r a i n i n g , s k i l l , and e x p e r i e n c e n e c e s s a r y t o q u i c k l y and a c c u r a t e l y a s s e s s the c h i e f c o m p l a i n t and a s s i g n the p a t i e n t t o the a p p r o p r i a t e emergency room a r e a t o a w a i t t r e a t m e n t ( K i t t & K a i s e r , 1990). The Canadian St a n d a r d s of Emergency N u r s i n g P r a c t i c e (NENA, 1986), s t a t e d t h a t the nurse c o n t i n u e s the p r o c e s s 58 of c l i n i c a l d e c i s i o n - m a k i n g u n t i l the n u r s e - p a t i e n t r e l a t i o n s h i p i s t e r m i n a t e d . A l l the s u b j e c t s (n=10) were aware of the ongoing m o n i t o r i n g by the n u r s e s . I t was e v i d e n t from the f i n d i n g s t h a t n u r s e s ' assessments of s u b j e c t s ' l e v e l of d i s c o m f o r t were p e r c e i v e d as s a t i s f y i n g or d i s s a t i s f y i n g . S u b j e c t s ' (n=10) comments r e l a t i n g t o n u r s e s ' assessment s k i l l s were made i n terms of how nur s e s a c c u r a t e l y or i n a c c u r a t e l y a s s e s s e d t h e i r p a i n and p r o v i d e d or had not p r o v i d e d p h y s i c a l c o m f o r t . O r t h o p e d i c i n j u r y / i l l n e s s p a i n i s s e v e r e and p a t i e n t s r e q u i r e reassessment of t h e i r p a i n f r e q u e n t l y , e s p e c i a l l y a f t e r m a n i p u l a t i o n or t r e a t m e n t ( Herron & Nance 1990). F u r t h e r m o r e , p a t i e n t s ' r e a c t i o n s t o p a i n a r e p r i m a r i l y a p h y s i c a l problem and o f t e n r e s u l t i n a n x i e t y i f not a s s e s s e d and t r e a t e d a p p r o p r i a t e l y ( M c C a f f e r y & Beebe, 1989). I t i s i n t e r e s t i n g t o note t h a t the n u r s e ' s assessment of p a i n i n t h i s s t u d y was seen by the s u b j e c t s as an i m p o r t a n t n u r s i n g c a r e b e h a v i o u r . A l s o noted i s t h a t , a l l the s u b j e c t s had e x p e r i e n c e d an o t h r o p e d i c i n j u r y / i l l n e s s and t h i s may e x p l a i n why thes e s u b j e c t s a s s o c i a t e d n u r s e s ' assessment s k i l l w i t h p a i n and p h y s i c a l c o m f o r t . For example, one s u b j e c t who had h i s l e g m a n i p u l a t e d was g i v e n a p a i n m e d i c a t i o n w i t h o u t h a v i n g t o ask. As a r e s u l t , he was c o m f o r t a b l e and s a t i s f i e d t h a t t h e nurse had made an a p p r o p r i a t e assessment. On the o t h e r hand, another s u b j e c t who d i d not r e c e i v e a p a i n m e d i c a t i o n upon h i s 59 r e q u e s t , c l a i m e d d i s s a t i s f a c t i o n w i t h h i s n u r s e s ' s assessment of h i s p a i n . He p e r c e i v e d t h a t t h e nurse had i n a p p r o p r i a t e l y a s s e s s e d h i s p a i n which s u b s e q u e n t l y i n c r e a s e d h i s l e v e l of a n x i e t y and d i s c o m f o r t . The f i n d i n g s a l s o i n d i c a t e d t h a t i n t h i s d i m e n s i o n , the p h y s i c a l c o m f o r t measures and s p e c i f i c t e c h n i c a l a c t i v i t i e s which the s u b j e c t s (n=10) i d e n t i f i e d as s a t i s f y i n g , were few i n number and s i m i l a r i n terms of the k i n d s of a c t i v i t i e s . These n u r s i n g c a r e b e h a v i o u r s were i d e n t i f i e d by K e r r (1980), Sheehy and Barber (1985), S i d e s (1986), and Rodts (1986) as i m p o r t a n t n u r s i n g i n t e r v e n t i o n s when c a r i n g f o r p a t i e n t s w i t h o r t h o p e d i c c o n d i t i o n s i n an emergency room s e t t i n g . G i v e n t h a t a l l the s u b j e c t s i n t h i s s t u d y had e x p e r i e n c e d an o r t h o p e d i c i n j u r y / i l l n e s s , t h i s may have accounted f o r the narrow range of n u r s i n g c a r e b e h a v i o u r s which were commonly i d e n t i f i e d by the s u b j e c t s . The f i n d i n g s i n t h i s s t u d y demonstrated t h a t the a c t u a l t e c h n i q u e s used by the n u r s e s t o p e r f o r m v a r i o u s n u r s i n g a c t i v i t i e s were not always p e r c e i v e d i n terms of a s a t i s f a c t o r y or u n s a t i s f a c t o r y performance. For example o n l y t h r e e of the f i v e s u b j e c t s , who had an i n t r a v e n o u s i n f u s i o n s t a r t e d , commented on the n u r s e s ' s k i l l a t i n s e r t i n g the i n t r a v e n o u s n e e d l e . These t h r e e s u b j e c t s had p r e v i o u s knowledge and/or e x p e r i e n c e w i t h t h i s t e c h n i c a l p r o c e d u r e . O v e r a l l , t h i s s t u d y found t h a t s u b j e c t s (n=10) c o u l d not s p e c i f i c a l l y r e c a l l and/or c r i t i q u e n u r s e s ' performance of p r o c e d u r e s r e q u i r i n g s p e c i a l i z e d t e c h n i c a l 60 s k i l l s . These f i n d i n g s were c o n s i s t e n t w i t h the a u t h o r s who s t a t e d t h a t the average p a t i e n t d i d not have the e x p e r t i s e t o e v a l u a t e the t e c h n i c a l component of n u r s i n g i n t e r v e n t i o n s i n the h o s p i t a l s e t t i n g ( D o e r i n g , 1983; Ferguson & Ferguson, 1983; S p i t z e r , 1988). One of the f i v e s u b j e c t s who had an i n t r a v e n o u s i n f u s i o n s t a r t e d remarked t h a t she c o u l d o n l y r e c a l l the e x p e r i e n c e of the nurse h a v i n g t o h e l p her i n t o a gown a f t e r the procedure was completed which she thought was i n a p p r o p r i a t e . S i m i l a r l y , t h r e e of the t e n s u b j e c t s s t a t e d t h a t t h e y were s a t i s f i e d w i t h the n u r s e s ' e f f i c i e n c y i n m o n i t o r i n g t h e i r v i t a l s i g n s but commented on t h e i r d i s s a t i s f a c t i o n w i t h the u n c a r i n g b e h a v i o u r d i s p l a y e d by the n u r s e s d u r i n g the p r o c e d u r e . For example, one s u b j e c t p e r c e i v e d t h a t the nurse was v e r y d e x t e r o u s a t t a k i n g her v i t a l s i g n s but gave no eye c o n t a c t t h r o u g h o u t t h i s p r o c e d u r e . T h e r e f o r e , the s u b j e c t p e r c e i v e d , the performance of t h i s t e c h n i c a l s k i l l as a d i s s a t i s f y i n g e x p e r i e n c e . A c c o r d i n g t o D a v i s (1984), n o n v e r b a l messages have a s t r o n g e r and more immediate impact. S i m i l a r i l y , D o e r i n g (1983) found t h a t p a t i e n t s i n her s t u d y e v a l u a t e d the i n t e r p e r s o n a l a s p e c t s of c a r e r a t h e r t h a n t h e t e c h n i c a l a s p e c t s . These f i n d i n g s emphasized the f a c t t h a t p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e i n v o l v e s p a t i e n t s ' e x p e r i e n c e s w i t h the p h y s i c a l and p s y c h o l o g i c a l comfort nurses p r o v i d e . These f i n d i n g s a l s o p o i n t e d out t h a t p a t i e n t s tended t o e v a l u a t e o n l y those n u r s i n g c a r e 61 b e h a v i o u r s which t h e y f e l t competent and c o n f i d e n t t o a p p r a i s e ( A b d e l l a h & L e v i n e , 1957). T r u s t i n g R e l a t i o n s h i p Dimension B r a d l e y and E d i n b e r g (1986) and Hein (1980) s t r e s s e d t h a t i n a n u r s e - c l i e n t r e l a t i o n s h i p , a p o s i t i v e f i r s t e n c o u n t e r w i t h the c l i e n t i s c r i t i c a l as t h i s p r o v i d e s the c l i e n t w i t h the b e l i e f t h a t the nurse i s a r e l i a b l e and dependable p e r s o n . I n t h i s s t u d y , a l l the s u b j e c t s (n=10) e x p r e s s e d t h e i r s a t i s f a c t i o n w i t h the nurse meeting them p r o m p t l y on a d m i s s i o n . A f a c t o r t h a t may have i n f l u e n c e d p a t i e n t s a t i s f a c t i o n i n t h i s s i t u a t i o n was the r o l e of the t r i a g e n u r s e . In t h i s s t u d y , the t r i a g e nurse who was s t a t i o n e d i n the l o b b y of the emergency room s o r t e d and a l l o c a t e d a l l a r r i v i n g p a t i e n t s t o s p e c i f i c a r e a s of the emergency room. T h e r e f o r e , i t i s p o s s i b l e t h a t t h i s r o u t i n e n u r s i n g c a r e p r o c e d u r e i n f l u e n c e d p a t i e n t s t o g a i n t r u s t and f e e l s a t i s f i e d w i t h n u r s e s * i n t e r a c t i o n i m m e d i a t e l y on a d m i s s i o n . A c c o r d i n g t o K i t t and K a i s e r (1990), a nurse s t a t i o n e d i n the l o b b y of the emergency room p r o v i d e d the p a t i e n t s w i t h immediate c o n t a c t w i t h a p r o f e s s i o n a l p e r s o n . The f i n d i n g s i n t h i s s t u d y i n d i c a t e d t h a t t h e n u r s e s ' a t t e n d i n g and l i s t e n i n g s k i l l s were e f f e c t i v e n u r s i n g c a r e b e h a v i o u r s which f o s t e r e d a t r u s t i n g r e l a t i o n s h i p . The a t t e n d i n g and l i s t e n i n g s k i l l s used by some of the n urses were d e s c r i b e d by f o u r of the seven s u b j e c t s as b e i n g g e n u i n e l y concerned about the p a t i e n t s . T h i s a b i l i t y t o communicate a genuine c o n c e r n f o r p a t i e n t s i s what Lewis (1973) d e f i n e d as the communication of t r u s t . D i s p l a y i n g g e s t u r e s t h a t the s u b j e c t s (n=7) p e r c e i v e d as k i n d n e s s was a n o t h e r n u r s i n g c a r e b e h a v i o u r t h a t s a t i s f i e d them. Wiendenbach and F a l l s (1978) s t a t e d t h a t any g e s t u r e which i n d i c a t e s r e c o g n i t i o n and a c c e p t a n c e of the o t h e r may l a y the groundwork t o d e v e l o p i n g a t r u s t i n g r e l a t i o n s h i p . On the o t h e r hand, t h r e e of the t e n s u b j e c t s who were d i s s a t i s f i e d about s p e c i f i c i n c i d e n t s which o c c u r r e d d u r i n g t h e i r emergency room s t a y r e l a t e d the s i t u a t i o n t o n u r s e s ' l a c k of a t t e n d i n g and l i s t e n i n g s k i l l s . One s u b j e c t who e x p e c t e d t o be c a t h e t e r i z e d p e r c e i v e d t h a t she was f o r g o t t e n or unheard. T h i s s i t u a t i o n may have promoted m i s t r u s t as b u i l d i n g a t r u s t i n g r e l a t i o n s h i p r e q u i r e s d e p e n d a b i l i t y , c o n s i s t e n c y ( N o r t o n & M i l l e r , 1986) and c r e d i b i l i t y (Egan, 1986). Another s u b j e c t p e r c e i v e d a nurse t o be u n c a r i n g and m e c h a n i c a l w h i l e p e r f o r m i n g a p r o c e d u r e . As w e l l , t h i s s u b j e c t ' s response t o the p e r c e i v e d u n c a r i n g and m e c h a n i c a l b e h a v i o u r s may have c o n t r i b u t e d t o m i s t r u s t as b u i l d i n g t r u s t i n v o l v e s t h e r a p e u t i c communication ( D a v i s , 1984). A c c o r d i n g t o B r a d l e y and E d i n b e r g (1986), t h e r a p e u t i c communication f o s t e r s an atmosphere of t r u s t and i n v o l v e s a t t e n d i n g and a c t i v e l i s t e n i n g s k i l l s which a r e v i s u a l , a u d i t o r y , and k i n e s t h e t i c i n n a t u r e . A c c o r d i n g t o Hein (1980), time t a k e s on more meaning i n the h o s p i t a l . She p o i n t e d out t h a t w a i t i n g not o n l y d e c r e a s e s an i n d i v i d u a l ' s s e l f - e s t e e m and evokes d e f e n s i v e n e s s , but i t a l s o l e n d s t o d e s t r o y i n g the t r u s t and r a p p o r t of the r e l a t i o n s h i p . The f i n d i n g s i n t h i s s t u d y i n d i c a t e d t h a t t h r e e of the t e n s u b j e c t s who were s a t i s f i e d w i t h the n u r s e s ' prompt a t t e n t i o n on a d m i s s i o n became d i s s a t i s f i e d over the unexpected w a i t i n g time t o see the p h y s i c i a n . C o n s e q u e n t l y , t h e s e s u b j e c t s ' t r u s t w i t h the n u r s e s d e c r e a s e d as the w a i t i n g time i n c r e a s e d . They remarked t h a t the n u r s e s were i n s e n s i t i v e t o t h e l e n g t h of t h e i r s t a y i n the w a i t i n g room. G i v e n t h a t the n u r s i n g c a r e b e h a v i o u r s of a t t e n d i n g , l i s t e n i n g , and s e n s i t i v i t y h e l p t o b u i l d a t r u s t i n g r e l a t i o n s h i p ( N o r t o n & M i l l e r , 1986; Wiendenbach & F a l l s , 1978), i t i s p o s s i b l e t h a t t h e s e s u b j e c t s p e r c e i v e d a l a c k of t r u s t w i t h the n u r s e s . A l l t he s u b j e c t s (n=10) a r r i v e d f o r emergency c a r e on an unplanned and urg e n t b a s i s . T h e r e f o r e , b u i l d i n g a t r u s t i n g r e l a t i o n s h i p w i t h t h e s e s u b j e c t s was an i n t e g r a l component of n u r s i n g c a r e , n e c e s s a r y t o f a c i l i t a t e emergency t r e a t m e n t ( M i l l e r , 1983; Sheehy & B a r b e r , 1985). The f i n d i n g s i n d i c a t e d t h a t n u r s e s p r o v i d i n g r e a s s u r a n c e enhanced a t r u s t i n g r e l a t i o n s h i p . Seven of the t e n s u b j e c t s s t a t e d t h a t t h e y were s a t i s f i e d w i t h how the nurses r e a s s u r e d them. For example, one s u b j e c t s t a t e d t h a t he a p p r e c i a t e d the nurse who hel p e d the p h y s i c i a n t o a p p l y the t r a c t i o n because she had r e a s s u r e d him t h r o u g h o u t the p r o c e d u r e . T h i s e x p e r i e n c e was s i m i l a r f o r t h r e e o t h e r 64 s u b j e c t s who a l s o had some type of m a n i p u l a t i o n p r o c e d u r e . The i m p l e m e n t a t i o n of t h e s e p r o c e d u r e s r e q u i r e d s u b j e c t s ' c o - o p e r a t i o n and t r u s t i n the n u r s e s ( D a v i t z & D a v i t z , 1981; D u l d t , G r i f f i n , & P a t t o n , 1984; K e r r , 1980; Sheehy & B a r b e r , 1985). C o n s i d e r i n g t h a t a l l the s u b j e c t s (n=10) i n t h i s s t u d y had undergone emergency t r e a t m e n t which i n v o l v e d s p l i n t i n g , t r a c t i o n and/or m a n i p u l a t i o n of t h e i r i n j u r y , the f i n d i n g s u n d e r s c o r e the importance of n u r s e s r e a s s u r i n g p a t i e n t s d u r i n g any t r e a t m e n t or p r o c e d u r e . In an emergency room s e t t i n g where the environment i s c h a r a c t e r i z e d by the b r e v i t y of p a t i e n t i n t e r a c t i o n and where the s t r e s s f u l c l i m a t e i s c r e a t e d by l a c k of c o n t r o l over the numbers of i n d i v i d u a l s s e e k i n g c a r e (American Nurses' A s s o c i a t i o n , 1975), the emergency nurse i s r e q u i r e d t o p r o v i d e an environment and c l i m a t e which w i l l reduce the i n i t i a l a n x i e t y and d e v e l o p the b e g i n n i n g of mutual t r u s t (NENA, 1986). In t h i s s t u d y seven of the t e n s u b j e c t s were s a t i s f i e d w i t h the r e a s s u r a n c e t h a t n u r s e s p r o v i d e d them. These s u b j e c t s (n=7) s t a t e d t h a t the v i s i b i l i t y of the n u r s e s p r o v i d e d them w i t h a sense of r e a s s u r a n c e and t h u s , a f e e l i n g of b e i n g l e s s a l o n e . T h i s c o n c u r s w i t h French's (1983) view t h a t even i f a nurse i s a s t r a n g e r and does not communicate v e r b a l l y , the mere p h y s i c a l presence of a nurse p r o v i d e s c o n s i d e r a b l e r e a s s u r a n c e and a l l e v i a t e s a n x i e t y and l o n e l i n e s s f o r p a t i e n t s . The openness of the p h y s i c a l l a y o u t i n t h i s emergency room may have f a c i l i t a t e d the v i s i b i l i t y of the n u r s e s , thus s e r e n d i p i t o u s l y c o n t r i b u t i n g 65 t o p a t i e n t s a t i s f a c t i o n or these s u b j e c t s ' p e r c e p t i o n s of r e a s s u r a n c e . F u r t h e r , the d a t a i n t h i s s t u d y i n d i c a t e d t h a t n urses p r o v i d e d r e a s s u r a n c e by e n c o u r a g i n g the presence of a s i g n i f i c a n t o t h e r . Seven of the t e n s u b j e c t s who were accompanied by t h e i r s u p p o r t persons were s a t i s f i e d when nur s e s a l l o w e d them t o w a i t a t the b e d s i d e . A c c o r d i n g t o the S t a n d a r d s of Emergency N u r s i n g P r a c t i c e (NENA, 1986), n u r s e s s h o u l d f a c i l i t a t e p a t i e n t s ' s i g n i f i c a n t o t h e r s t o p a r t i c i p a t e i n p a t i e n t c a r e . As w e l l , g i v e n t h a t p a t i e n t s o f t e n w a i t f o r a l o n g p e r i o d of time t o see a p h y s i c i a n or r e c e i v e t r e a t m e n t i n the emergency room, i t i s p o s s i b l e t h a t when p a t i e n t s share the w a i t w i t h t h e i r s u p p o r t p e r s o n s , t h i s h e l p s t o a l l e v i a t e the s t r e s s f u l e x p e r i e n c e ( H e i n , 1980). I n t e r - i n t r a p e r s o n a l R e l a t i o n s h i p Dimension In the n u r s i n g l i t e r a t u r e r e v i e w e d by the w r i t e r , i n t e r - i n t r a p e r s o n a l communication was a s a l i e n t f e a t u r e i n promoting a t h e r a p e u t i c n u r s e - p a t i e n t r e l a t i o n s h i p ( B l a t t n e r , 1981; B r a d l e y & E d i n b e r g , 1986; C l a r k , 1984; L e w i s , 1973; Sundeen, S t u a r t , R a n k i n , & Cohen, 1989). A c c o r d i n g t o the Stan d a r d s f o r Emergency N u r s i n g P r a c t i c e (NENA, 1986), the emergency nurse s e l e c t s n u r s i n g a c t i o n s based on the h i g h e s t p r o b a b i l i t y of e f f e c t i v e n e s s and a c c e p t a b i l i t y by the p a t i e n t . The e f f e c t i v e n e s s and a c c e p t a b i l i t y of n u r s e s ' v e r b a l and n o n v e r b a l b e h a v i o u r s 66 were c l e a r l y i d e n t i f i e d by seven of the t e n s u b j e c t s i n t h i s s t u d y . For example, t h e s e s u b j e c t s used words such as con c e r n e d , c o u r t e o u s , f r i e n d l y , k i n d , n i c e and/or open t o d e s c r i b e n u r s e s ' c a r i n g / h e l p i n g a t t i t u d e s . G i v e n t h a t n u r s e s ' a t t i t u d e s a f f e c t the degree of t r u s t (Wiendenbach & F a l l s , 1978), i t was i n t e r e s t i n g t o d i s c o v e r t h a t t h e s e f i n d i n g s were a l s o c o n s i s t e n t w i t h b e h a v i o u r s i n the t r u s t i n g r e l a t i o n s h i p d i m e n s i o n . One of the seven s u b j e c t s remarked on n u r s e s ' sense of humor. He found t h a t the n u r s e s ' humor h e l p e d d e c r e a s e h i s a n x i e t y d u r i n g h i s emergency room s t a y . S i m i l a r i l y , R o binson (1978) p o i n t e d out t h a t one of the uses of humor i n n u r s i n g s i t u a t i o n s s e r v e s t o r e l i e v e a n x i e t y , s t r e s s , and t e n s i o n . F u r t h e r , she s t a t e d t h a t a n x i e t y i s one of the most common s o u r c e s of d i s c o m f o r t which prompts the use of humor. However, H e r t h (1984) emphasized t h a t humor cannot be e f f e c t i v e u n l e s s i t i s t i m e l y . Four of the f i v e s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' i n t r o d u c t i o n s of t h e m s e l v e s . One s u b j e c t s u g g e s t e d t h a t ' a l l n u r s e s s h o u l d wear an i d e n t i f i c a t i o n t a g which s t a t e s t h e i r name and t i t l e . These f i n d i n g s were c o n s i s t e n t w i t h t h e Standards f o r Emergency N u r s i n g P r a c t i c e (NENA, 1986) which s t a t e s t h a t a l l emergency nurses i d e n t i f y themselves by name and r o l e . F u r t h e r , f o u r of t h e f i v e s u b j e c t s p e r c e i v e d t h a t an i n t r o d u c t i o n by the nurse was a p e r s o n a b l e g e s t u r e . A c c o r d i n g t o Sundeen, S t u a r t , R a n k i n , and Cohen (1989), an i n t r o d u c t i o n i n any i n t e r p e r s o n a l r e l a t i o n s h i p s e t s the tone f o r the r e s t of the r e l a t i o n s h i p . As w e l l , t h e s e a u t h o r s s t r e s s e d t h a t an i n t r o d u c t i o n i s a r e c i p r o c a l o f f e r i n g and f r i e n d l y g e s t u r e which i n d i c a t e s an openess t o r e l a t e t o each o t h e r and sh a r e f u r t h e r . Wiendenbach and F a l l s (1978) a l s o agreed t h a t a v e r b a l i n t r o d u c t i o n can be a method of g i v i n g a broad opening t o i n i t i a t e i n t e r a c t i o n . I n a d d i t i o n , she s t a t e d t h a t t h i s w i l l a l s o e n a b l e the c l i e n t s t o f o c u s t h e i r t h o u g h t s more r e a d i l y on the I n f o r m a t i o n and t h u s , a d j u s t t h e i r minds t o the nurs e ' s presence and i n t e n t . C o n s i d e r i n g t h i s f a c t , i t p r o v i d e d some b a s i s f o r the f i n d i n g t h a t one of the f i v e s u b j e c t s was d i s s a t i s f i e d because she d i d not r e c e i v e an i n t r o d u c t i o n from the n u r s e . Because the nurse d i d not i n t r o d u c e h i m s e l f i n t h i s s i t u a t i o n , the i n f o r m a t i o n g i v e n by him about t h i s s u b j e c t ' s c a r e was c o n f u s i n g as she thought she was s p e a k i n g t o an a n e s t h e t i s t and not a n u r s e . T h i s s t u d y found t h a t n u r s e s ' a t t i r e h e l p e d the s u b j e c t s t o i d e n t i f y the nu r s e s i n the emergency room. S i x of the t e n s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' u n i f o r m as a means t o i d e n t i f y the n u r s e s . For example, f i v e of the s i x s u b j e c t s s t a t e d t h a t t h e y c o u l d e a s i l y i d e n t i f y the nurses by t h e i r w h i t e or p a s t e l c o l o r e d u n i f o r m s . However, i t was i n t e r e s t i n g t o f i n d t h a t two of the f o u r s u b j e c t s who were d i s s a t i s f i e d w i t h n u r s e s ' u n i f o r m s appeared t o s t e r e o t y p e the nu r s e s when t h e y c o u l d not i d e n t i f y the s t a f f w e a r i n g the c o n v e n t i o n a l o p e r a t i n g room u n i f o r m . 68 These f i n d i n g s c o n c u r r e d w i t h B r a d l e y and E d i n b e r g ' s (1986) view t h a t n u r s e s i n u n i f o r m s p r o v i d e d p a t i e n t s w i t h a means of i d e n t i f y i n g n u r s e s and a sense of s e c u r i t y . F u r t h e r , a r e v i e w of r e s e a r c h conducted by D u l d t , G r i f f i n and P a t t o n (1984), c o n c l u d e d t h a t n u r s e s a l s o r e l y on u n i f o r m s and g e n e r a l appearance t o i n d i c a t e s i g n s of s t a t u s , a u t h o r i t y , knowledge, and d e s i r e d p a t t e r n s of response b e h a v i o u r s . The f i n d i n g s i n d i c a t e d t h a t a v a r i e t y of n o n v e r b a l b e h a v i o u r s were communicated t o a l l s u b j e c t s (n=10) i n t h i s s t u d y . Seven of the t e n s u b j e c t s were s a t i s f i e d and t h r e e of the t e n s u b j e c t s were d i s s a t i s f i e d w i t h n u r s e s ' n o n v e r b a l b e h a v i o u r s . S i n c e 55% t o 65% of conveyed messages a r e r e c e i v e d t h r o u g h n o n v e r b a l cues ( D a v i s , 1984) i t i s p o s s i b l e t h a t many of the s u b j e c t s ' (n=10) p e r c e p t i o n s of t h e i r s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h n o n v e r b a l b e h a v i o u r s may not have been communicated t o the r e s e a r c h e r . However, the s u b j e c t s (n=7) were s a t i s f i e d w i t h n u r s e s ' use of body language s p e c i f i c a l l y r e l a t e d t o eye c o n t a c t , f a c i a l e x p r e s s i o n s , g e s t u r e s , and tone of v o i c e . The f i n d i n g s i n t h i s s t u d y i n d i c a t e d t h a t t h e n o n v e r b a l b e h a v i o u r s d i d not occur a l o n e . Seven of the t e n s u b j e c t s who were s a t i s f i e d w i t h n u r s e s ' n o n v e r b a l b e h a v i o u r s used more than one g e s t u r e t o d e s c r i b e t h e i r r e s p o n s e s . For example, seven of the t e n s u b j e c t s s t a t e d t h a t t h e n u r s e s ' tone of v o i c e , s m i l e s , and open manners conveyed c o u r t e o u s , f r i e n d l y , and k i n d r e s p o n s e s . I n c o n t r a s t , the t h r e e s u b j e c t s who were d i s s a t i s f i e d w i t h the n u r s e s 1 n o n v e r b a l b e h a v i o u r s s t a t e d t h a t some of the n urses conveyed a b u s i n e s s l i k e tone of v o i c e , l a c k e d eye c o n t a c t , and moved about u s i n g h u r r i e d mannerisms which i n f l u e n c e d t h e s e s u b j e c t s t o sense the busyness of the emergency room. S i m i l a r i l y , D u l d t , G r i f f i n , and P a t t o n (1984) p o i n t e d out t h a t n o n v e r b a l communications seldom occur a l o n e , t h e r e f o r e , t h e s e a u t h o r s s u ggested t h a t p e r c e i v e d n o n v e r b a l b e h a v i o u r s s h o u l d be judged w i t h i n the c o n t e x t of more than one b e h a v i o u r and the s i t u a t i o n . E d u c a t i o n a l R e l a t i o n s h i p Dimension As a performance s t a n d a r d w i t h i n the S t a n d a r d s f o r Emergency N u r s i n g P r a c t i c e (NENA, 1986), the emergency nurse c o l l e c t s d a t a r e l a t i n g t o the n a t u r e of t h e d i f f i c u l t y , the s e v e r i t y of the h e a l t h problem, and the urgency needed f o r i n t e r v e n t i o n . The urgency of d e c i s i o n making i n emergency n u r s i n g i n v o l v e s g a t h e r i n g p e r t i n e n t i n f o r m a t i o n q u i c k l y and a c c u r a t e l y ( S i d e s , 1986). The f i n d i n g s i n t h i s s t u d y i n d i c a t e d t h a t e i g h t of the t e n s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' q u e s t i o n s . A c c o r d i n g t o Hein (1980) the purpose of nurses a s k i n g q u e s t i o n s was t o " i n v i t e , d i r e c t , and e x p l o r e the v e r b a l and n o n v e r b a l c o n t e n t o f f e r e d by the p a t i e n t " ( p . 4 2 ) . I t i s p o s s i b l e t h a t t h e s e s u b j e c t s (n=8) had a s a t i s f y i n g e x p e r i e n c e w i t h n u r s e s ' q u e s t i o n s . The e i g h t s u b j e c t s s t a t e d t h e y p e r c e i v e d the n urses t o be knowledgeable and e x p e r i e n c e d 70 r e g a r d i n g t h e i r need t o be asked q u e s t i o n s c o n c e r n i n g t h e i r i n j u r y / i l l n e s s and t h e i r need f o r e m o t i o n a l s u p p o r t . However, two of the t e n s u b j e c t s were d i s s a t i s f i e d w i t h n u r s e s ' q u e s t i o n s . One s u b j e c t p e r c e i v e d t h a t n u r s e s s h o u l d have asked more q u e s t i o n s about her c h r o n i c i l l n e s s c o n d i t i o n as she f e l t t h i s p e r t a i n e d t o her p r e s e n t i n g c o m p l a i n t . T h i s s u b j e c t p e r c e i v e d t h a t t h i s a d d i t i o n a l i n f o r m a t i o n would have made nur s e s more aware of her i n d i v i d u a l needs. The o t h e r s u b j e c t was d i s s a t i s f i e d t h a t the nurse had not asked the a p p r o p r i a t e q u e s t i o n s t o d e t e r m i n e the s e v e r i t y of h i s p a i n . As a r e s u l t , he p e r c e i v e d t h i s nurse t o be l a c k i n g i n knowledge and i n s i s t e d on s p e a k i n g w i t h h i s p h y s i c i a n . T h i s s u b j e c t a l s o remarked about the n u r s e ' s a b r u p t manner w i t h her q u e s t i o n s which he a g a i n , p e r c e i v e d as u n c a r i n g . These f i n d i n g s appeared t o r e f l e c t F r i t z , R u s s e l l , W i l c o x , and S h i r k ' s (1984) view t h a t s e e k i n g i n f o r m a t i o n i s d i r e c t l y r e l a t e d t o t h e p a t i e n t ' s a b i l i t y t o u n d e r s t a n d the r e a s o n i n g f o r the q u e s t i o n s which can i n f l u e n c e t h e i r c o m p l i a n c e or noncompliance w i t h t r e a t m e n t and c a r e . The f i n d i n g s i n d i c a t e d t h a t e i g h t of the t e n s u b j e c t s were s a t i s f i e d t h a t n u r s e s kept them i n f o r m e d . These s u b j e c t s (n=8) i d e n t i f e d t h a t nurses p r o v i d e d i n f o r m a t i o n c o n c e r n i n g t h e i r c o n d i t i o n , d i a g n o s t i c t e s t s , o p e r a t i o n t i m e , and the reasons f o r d e l a y s such as w a i t i n g t o see the p h y s i c i a n . The f i n d i n g s a l s o i n d i c a t e d t h a t of the n i n e s u b j e c t s who responded t o the q u e s t i o n about i n s t r u c t i o n s t o c a l l f o r h e l p , t h e r e were o n l y two s u b j e c t s who were d i s s a t i s f i e d t h a t n u r s e s l e f t them w i t h no i n f o r m a t i o n or i n s t r u c t i o n s . Due t o the open a r e a s of the emergency room, t h i s may have i n f l u e n c e d s u b j e c t s ' s a t i s f a c t i o n i n t h i s a r e a or r e l a t e d t o t h i s a s p e c t of c a r e . T h i s s i t u a t i o n was s i m i l a r t o the f i n d i n g s i n the t r u s t i n g r e l a t i o n s h i p d i m e n s i o n where s u b j e c t s a l s o p e r c e i v e d r e a s s u r a n c e and t h u s , s a t i s f a c t i o n w i t h n u r s e s ' v i s i b i l i t y i n t h e emergency room. Nurses p r o v i d i n g i n f o r m a t i o n was a l s o c o n s i d e r e d an i m p o r t a n t f i n d i n g i n Dennis' (1990) s t u d y which r e v e a l e d t h a t n u r s e s p l a y e d a c e n t r a l r o l e i n f o s t e r i n g the f l o w of i n f o r m a t i o n t o p a t i e n t s . Her f i n d i n g s i n d i c a t e d t h a t n u r s e s a c t e d as p a t i e n t a d v o c a t e s and c o - o r d i n a t o r s of p a t i e n t c a r e . In her d i s c u s s i o n , Dennis s t r e s s e d t h a t n urses can communicate and r e i n f o r c e the importance t h a t p a t i e n t s a t t a c h t o h a v i n g i n f o r m a t i o n about t h e i r i l l n e s s , c a r e , and t r e a t m e n t . F a u l k n e r (1984) a l s o s u g g e s t e d t h a t n urses were i n t h e b e s t p o s i t i o n t o communicate p a t i e n t i n f o r m a t i o n because of t h e i r c l o s e n e s s and c o n t i n u o u s c o n t a c t w i t h p a t i e n t s . As w e l l , A r n o l d and Boggs (1989) s t a t e d t h a t p a t i e n t s ' l e v e l of e d u c a t i o n a f f e c t s how t h e y r e a c t t o p a t i e n t i n f o r m a t i o n . These a u t h o r s a l s o l i s t e d o t h e r f a c t o r s which need t o be c o n s i d e r e d b e f o r e i n f o r m a t i o n i s g i v e n t o p a t i e n t s . These f a c t o r s i n c l u d e d t h e p a t i e n t ' s l e v e l of a n x i e t y , the meaning of t h e problem 72 t o the p a t i e n t , and the p a t i e n t ' s p r e v i o u s l i f e e x p e r i e n c e s . A c c o r d i n g t o F r e n c h (1983), p r o v i d i n g e x p l a n a t i o n s i s a s k i l l . K e r r (1980) s t r e s s e d the n u r s e s ' e x p l a n a t i o n s t o emergency p a t i e n t s a r e an i m p o r t a n t s o u r c e of r e a s s u r a n c e . The s t u d y found t h a t seven of the t e n s u b j e c t s were s a t i s f i e d t h a t n u r s e s p r o v i d e d e x p l a n a t i o n s f o r p r o c e d u r e s . I t was i n t e r e s t i n g t o note t h a t n u r s e s gave e x p l a n a t i o n s f o r s i m i l a r n u r s i n g s i t u a t i o n s t h a t F r e n c h (1983) had c l a i m e d as b e i n g a p p r o p r i a t e . He s t a t e d t h a t e x p l a n a t i o n s s h o u l d be g i v e n i n response t o p a t i e n t s ' q u e s t i o n s i n o r d e r t o p r o v i d e c l a r i f i c a t i o n , a l l e v i a t e a n x i e t y , and/or g a i n t h e i r c o - o p e r a t i o n . In t h i s s t u d y , seven of the t e n s u b j e c t s were s a t i s f i e d w i t h n u r s e s ' p r e - o p e r a t i v e e x p l a n a t i o n s which a l l e v i a t e d t h e i r a n x i e t y . These s u b j e c t s were a l s o s a t i s f i e d t h a t n u r s e s c l a r i f i e d i n f o r m a t i o n r e g a r d i n g t h e i r c o n d i t i o n . As w e l l , two s u b j e c t s s t a t e d t h e y were s a t i s f i e d w i t h n u r s e s ' e x p l a n a t i o n of the i n t r a v e n o u s i n f u s i o n which gained, t h e i r c o - o p e r a t i o n . Summary The f i n d i n g s and d i s c u s s i o n were p r e s e n t e d a c c o r d i n g t o the f o u r d i m e n s i o n s of R i s s e r ' s (1975) c r i t e r i o n t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . The d i s c u s s i o n was s u p p o r t e d by n u r s i n g l i t e r a t u r e and w i t h the few n u r s i n g r e s e a r c h s t u d i e s t h a t c o u l d be found by 73 the w r i t e r . The f i n d i n g s i n d i c a t e d o v e r a l l s a t i s f a c t i o n w i t h the n u r s i n g c a r e b e h a v i o u r s i n the f o u r e v a l u a t i v e d i m e n s i o n s . The f i n d i n g s r e v e a l e d t h a t s u b j e c t s were a b l e t o r e c a l l and i d e n t i f y s a t i s f y i n g or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s . The n u r s i n g c a r e b e h a v i o u r s i d e n t i f i e d r e l a t e d t o the p h y s i c a l and p s y c h o s o c i a l c o m f o r t and s a f e t y needs which s u b j e c t s f e l t competent and c o n f i d e n t t o a p p r a i s e . The n u r s i n g c a r e b e h a v i o u r s i n the t r u s t i n g r e l a t i o n s h i p d i m e n s i o n formed the f o u n d a t i o n f o r p a t i e n t s a t i s f a c t i o n w i t h i n the o t h e r t h r e e d i m e n s i o n s of R i s s e r ' s e v a l u a t i v e c r i t e r i o n . 74 CHAPTER FIVE Summary, C o n c l u s i o n s , and I m p l i c a t i o n s f o r N u r s i n g Summary The purpose of t h i s e x p l o r a t o r y d e s c r i p t i v e s t u d y was to d e t e r m i n e o r t h o p e d i c p a t i e n t s ' p e r c e p t i o n s of s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s d u r i n g t h e i r emergency room e x p e r i e n c e . Nurses i n the emergency room, work i n a c l i n i c a l l y s p e c i a l i z e d a r e a and a r e i n v o l v e d i n the management of p a t i e n t s , of a l l ages, r e q u i r i n g s t a b i l i z a t i o n and/or r e s u s c i t a t i o n f o r a v a r i e t y of i l l n e s s e s and/or i n j u r i e s . Emergency n u r s i n g d i f f e r s from o t h e r t y p e s of n u r s i n g c a r e d e l i v e r y i n t h a t n u r s e - p a t i e n t i n t e r a c t i o n s a r e u s u a l l y of s h o r t d u r a t i o n and occur i n a s t r e s s f u l m i l i e u . As w e l l , p a t i e n t s e x p e c t immediate a t t e n t i o n (Sheehy & B a r b e r , 1985). These f a c t o r s may i n f l u e n c e how p a t i e n t s p e r c e i v e s a t i s f a c t i o n w i t h the n u r s i n g c a r e t h e y r e c e i v e i n the emergency room. In t h e h e a l t h c a r e l i t e r a t u r e r e v i e w e d , p a t i e n t s a t i s f a c t i o n d a t a a r e I d e n t i f i e d as a key d e t e r m i n a n t , and a v a l u a b l e e v a l u a t i v e t o o l , i n the measurement of the q u a l i t y of c a r e . Knowledge of p a t i e n t s a t i s f a c t i o n w i t h c a r e w i l l f a c i l i t a t e t he d e l i v e r y of q u a l i t y n u r s i n g c a r e w i t h i n the s t r e s s f u l c l i m a t e of an emergency room. T h e r e f o r e , i t i s i m p o r t a n t f o r emergency room n u r s e s t o be c o g n i z a n t of p a t i e n t s ' p e r c e p t i o n s of s a t i s f y i n g and/or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s . No p u b l i s h e d n u r s i n g r e s e a r c h r e l a t e d t o p a t i e n t s a t i s f a c t i o n w i t h emergency n u r s i n g c a r e c o u l d be found by the r e s e a r c h e r . The c o n c e p t u a l framework which guided t h i s s t u d y was based on R i s s e r ' s (1975) e v a l u a t i v e c r i t e r i o n which i s a measure of p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . R i s s e r ' s e v a l u a t i v e c r i t e r i o n c o n s i s t s of f o u r d i m e n s i o n s : t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r , t r u s t i n g r e l a t i o n s h i p , i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p , and e d u c a t i o n a l r e l a t i o n s h i p . The s t u d y p o p u l a t i o n c o n s i s t e d of t e n s u b j e c t s who were a d m i t t e d t o the emergency room of a l a r g e m e t r o p o l i t a n h o s p i t a l i n the Vancouver a r e a . A l l s u b j e c t s were a d m i t t e d f o r t r e a t m e n t of an o r t h o p e d i c i n j u r y / i l l n e s s . A s e m i - s t r u c t u r e d i n t e r v i e w g u i d e , d e v e l o p e d by t h e r e s e a r c h e r , was used t o ask s u b j e c t s t o r e c a l l t h e i r emergency room e x p e r i e n c e . The i n t e r v i e w q u e s t i o n s were based on t h r e e s o u r c e s . These i n c l u d e d R i s s e r ' s e v a l u a t i v e c r i t e r i o n , the r e s e a c h e r ' s emergency room knowledge and e x p e r i e n c e , and knowledge g a i n e d from a l i t e r a t u r e r e v i e w of o r t h o p e d i c emergency n u r s i n g , i n c l u d i n g S t a n d a r d s of Care f o r Emergency N u r s i n g P r a c t i c e . A l l t h e i n t e r v i e w s were a u d i o t a p e d and t r a n s c r i b e d by the r e s e a r c h e r . Data d e s c r i b i n g the n u r s i n g c a r e b e h a v i o u r s were i d e n t i f i e d and c a t e g o r i z e d a c c o r d i n g t o the f o u r d i m e n s i o n s of R i s s e r ' s (1975) e v a l u a t i v e c r i t e r i o n . The f i n d i n g s f o r each d i m e n s i o n i n d i c a t e d t h a t s u b j e c t s were a b l e t o r e c a l l many o£ t h e i r I n t e r a c t i o n s w i t h the n u r s e s In the emergency room. I n the d i m e n s i o n of t e c h n i c a l - p r o f e s s i o n a l b e h a v i o u r , s u b j e c t s i n d i c a t e d s a t i s f a c t i o n w i t h n u r s e s d e m o n s t r a t i n g knowledge i n the assessment of t h e i r i n j u r y / i l l n e s s , p r i o r i t i z i n g placement on a d m i s s i o n , p e r f o r m i n g t e c h n i c a l a c t i v i t i e s s k i l l f u l l y , and p r o v i d i n g p h y s i c a l c o m f o r t . In the d i m e n s i o n of t r u s t i n g r e l a t i o n s h i p , s u b j e c t s i n d i c a t e d s a t i s f a c t i o n w i t h n urses a t t e n d i n g t o s u b j e c t s p r o m p t l y on a d m i s s i o n , u s i n g a t t e n d i n g and l i s t e n i n g s k i l l s e f f e c t i v e l y , and p r o v i d i n g r e a s s u r a n c e . In the d i m e n s i o n of i n t e r - i n t r a p e r s o n a l r e l a t i o n s h i p , s u b j e c t s i n d i c a t e d s a t i s f a c t i o n w i t h nurses d e m o n s t r a t i n g a c a r i n g / h e l p i n g a t t i t u d e , i n t r o d u c i n g t h e m s e l v e s by name and t i t l e , i d e n t i f y i n g t h e m s e l v e s t h r o u g h a t t i r e , and u s i n g e f f e c t i v e v e r b a l and n o n v e r b a l communication. I n the e d u c a t i o n a l r e l a t i o n s h i p d i m e n s i o n , s u b j e c t s i n d i c a t e d s a t i s f a c t i o n w i t h n u r s e s a s k i n g a p p r o p r i a t e q u e s t i o n s , u p d a t i n g i n f o r m a t i o n , e x p l a i n i n g p r o c e d u r e s , and i n s t r u c t i n g s u b j e c t s how t o c a l l f o r h e l p . S u b j e c t s e x p r e s s e d d i s s a t i s f a c t i o n when nu r s e s l a c k e d t h e s e n u r s i n g c a r e b e h a v i o u r s . The s t u d y f i n d i n g s i n d i c a t e d o v e r a l l s a t i s f a c t i o n w i t h the n u r s i n g c a r e b e h a v i o u r s i n each of the f o u r e v a l u a t i v e d i m e n s i o n s . S u b j e c t s a p p r a i s e d and/or commented on those n u r s i n g c a r e b e h a v i o u r s which t h e y f e l t competent and c o n f i d e n t t o e v a l u a t e . These n u r s i n g c a r e b e h a v i o u r s r e l a t e d t o b a s i c p h y s i c a l and p s y c h o s o c i a l needs. The s t u d y f i n d i n g s i n d i c a t e d t h a t the b e h a v i o u r s r e l a t e d t o the t r u s t i n g r e l a t i o n s h i p d i m e n s i o n formed the f o u n d a t i o n f o r p a t i e n t s a t i s f a c t i o n w i t h i n the o t h e r t h r e e d i m e n s i o n s . I t was I n t e r e s t i n g t o note from the f i n d i n g s t h a t t h r e e s u b j e c t s * comments r e l a t e d a s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r t o a " c a r i n g b e h a v i o u r " and a d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r t o an " u n c a r i n g b e h a v i o u r " . T h i s may i n d i c a t e a p o s s i b l e r e l a t i o n s h i p between s a t i s f y i n g and c a r i n g n u r s i n g c a r e b e h a v i o u r s and as w e l l , d i s s a t i s f y i n g and u n c a r i n g n u r s i n g c a r e b e h a v i o u r s . C o n c l u s i o n s The s m a l l sample s i z e and the f o c u s on o r t h o p e d i c p a t i e n t s a f f e c t s the g e n e r a l i z a b i l i t y of the s t u d y . However, the f i n d i n g s of the s t u d y suggest the f o l l o w i n g : 1. S u b j e c t s were a b l e t o r e c a l l and i d e n t i f y v a r i o u s s a t i s f y i n g or d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s . S u b j e c t s f e l t competent and c o n f i d e n t t o a p p r a i s e the n u r s i n g c a r e b e h a v i o u r s r e l a t e d t o t h e i r b a s i c p h y s i c a l and p s y c h o s o c i a l needs. T h e r e f o r e , i t i s i m p o r t a n t f o r n u r s e s t o communicate w i t h p a t i e n t s , i n o r d e r t o a s c e r t a i n t h e i r p e r c e p t i o n s of t h e i r p h y s i c a l and p s y c h o s o c i a l needs. T h i s i n f o r m a t i o n can then be used t o i n d i v i d u a l i z e n u r s i n g c a r e f o r p a t i e n t s . T h i s w i l l f a c i l i t a t e n u rses p r o v i d i n g s a t i s f y i n g n u r s i n g c a r e 78 t o p a t i e n t s . 2. S u b j e c t s ' p e r c e p t i o n s of s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s i n a l l of the d i m e n s i o n s demonstrated t h e importance of the t r i a g e n u r s e ' s r o l e . I n t h i s emergency room, the l o c a t i o n and r o l e of the t r i a g e n urse was s i g n i f i c a n t t o p a t i e n t s a t i s f a c t i o n . S u b j e c t s ' p o s i t i v e response t o the t r i a g e nurse demonstrates the importance of t h i s r o l e i n an emergency room s e t t i n g . 3. The t r u s t i n g r e l a t i o n s h i p d i m e n s i o n s i g n i f i c a n t l y i n f l u e n c e d s u b j e c t s ' sense of s a t i s f a c t i o n w i t h i n the o t h e r d i m e n s i o n s . T h i s u n d e r s c o r e s t h e importance and the need f o r n u r s e s t o d e v e l o p a t r u s t i n g r e l a t i o n s h i p w i t h p a t i e n t s . I m p l i c a t i o n s f o r N u r s i n g  I m p l i c a t i o n s f o r N u r s i n g E d u c a t i o n T h i s s t u d y has s e v e r a l i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n . The f i n d i n g s r e i n f o r c e the importance of t e a c h i n g s t u d e n t s e f f e c t i v e communication t e c h n i q u e s and t h e r a p e u t i c r e l a t i o n s h i p s k i l l s . Because most b a s i c n u r s i n g e d u c a t i o n programs do not p r o v i d e s t u d e n t s w i t h c l i n i c a l e x p e r i e n c e s i n s e t t i n g s such as the emergency room, i t i s i m p o r t a n t t h a t a l t e r n a t i v e l e a r n i n g e x p e r i e n c e s be p r o v i d e d t o enable s t u d e n t s t o communicate e f f e c t i v e l y i n t h e s e s e t t i n g s . The urg e n t n a t u r e of the emergency room and the b r e v i t y of n u r s e - p a t i e n t i n t e r a c t i o n s i n an emergency room s e t t i n g , o f t e n r e q u i r e emergency room nu r s e s t o u t i l i z e communication t e c h n i q u e s which a s s i s t p a t i e n t s t o cope w i t h the s t r e s s or c r i s e s r e l a t e d t o t h e i r h e a l t h problem. Nurse e d u c a t o r s i n the c l a s s r o o m s e t t i n g can impart t o n u r s i n g s t u d e n t s an u n d e r s t a n d i n g of the v a r i o u s communication t e c h n i q u e s used i n an emergency room s e t t i n g . As an a l t e r n a t i v e l e a r n i n g e x p e r i e n c e , f o r example, the n u r s i n g c a r e b e h a v i o u r s t h a t p a t i e n t s p e r c e i v e d as s a t i s f y i n g i n t h i s s t u d y , can be demonstrated t h r o u g h t e a c h i n g a c t i v i t i e s such as r o l e p l a y i n g s i m u l a t e d c r i s e s t e c h n i q u e s . Nurse e d u c a t o r s can a l s o e x t e n d t h i s t e a c h i n g t o the c l i n i c a l s e t t i n g by r o l e m o d e l l i n g communication t e c h n i q u e s t h a t a r e r e q u i r e d when c r i s e s s i t u a t i o n s o c c u r . A n x i e t y i s o f t e n e x h i b i t e d by emergency room p a t i e n t s . The f i n d i n g s i n t h i s s t u d y i n d i c a t e t h a t p a t i e n t s a r e l e s s a n x i o u s , and more s a t i s f i e d w i t h the c a r e when nur s e s p r o v i d e them w i t h i n f o r m a t i o n c o n c e r n i n g t h e i r c o n d i t i o n . T h e r e f o r e , i t i s i m p o r t a n t f o r emergency room n u r s e s t o l e a r n a r e p e r t o i r e of communication t e c h n i q u e s i n o r d e r t o a s s e s s p a t i e n t s ' a n x i e t y and implement a p p r o p r i a t e n u r s i n g i n t e r v e n t i o n s t o a l l e v i a t e i t . Nurse e d u c a t o r s i n n u r s i n g s t a f f development can p r o v i d e l e a r n i n g e x p e r i e n c e s f o r emergency room nurses i n c r i s i s i n t e r v e n t i o n , s t r e s s r e d u c t i o n , and p a t i e n t t e a c h i n g . The f i n d i n g s i n the t e c h n i c a l - p r o f e s s i o n a l d i m e n s i o n , 80 demonstrated t h a t p a t i e n t s e x p e c t the nurse t o have t e c h n i c a l competence, a r e s u p p o r t e d by the l i t e r a t u r e . These f i n d i n g s emphasize the need f o r nurse e d u c a t o r s t o p r e p a r e graduate nurses t o a l e v e l of p r o f i c i e n c y t h a t promotes p a t i e n t s ' c o n f i d e n c e and s a t i s f a c t i o n w i t h t e c h n i c a l n u r s i n g c a r e . I n a d d i t i o n , i t i s i m p o r t a n t f o r nurse e d u c a t o r s t o p l a y an a c t i v e r o l e In d e s i g n i n g and c o o r d i n a t i n g p o s t - g r a d u a t e emergency n u r s i n g s p e c i a l t y programs. In a h i g h l y t e c h n i c a l environment such as an emergency room, not o n l y do p a t i e n t s e xpect t e c h n i c a l competence from n u r s e s , but a l s o v a l u e n u r s i n g c a r e b e h a v i o u r s which promote t r u s t such as compassion, warmth, s u p p o r t , and c o n c e r n . G i v e n t h a t t h i s s t u d y demonstrated the importance of b u i l d i n g a t r u s t i n g r e l a t i o n s h i p w i t h p a t i e n t s , i t i s i m p o r t a n t f o r emergency room nu r s e s t o d i s p l a y n u r s i n g c a r e b e h a v i o u r s t h a t e s t a b l i s h and m a i n t a i n t r u s t . Nurse e d u c a t o r s have a r o l e i n t e a c h i n g and e n c o u r a g i n g emergency room nurses t o u t i l i z e s e l e c t e d n u r s i n g c a r e b e h a v i o u r s which a r e f o c u s s e d on e s t a b l i s h i n g a n u r s e - p a t i e n t t r u s t i n g r e l a t i o n s h i p . S u b j e c t s i n t h i s s t u d y d e s c r i b e d v a r i o u s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s as c a r i n g and d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s as u n c a r i n g . Thus, t h i s f i n d i n g i n d i c a t e d a p o s s i b l e r e l a t i o n s h i p between s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s and c a r i n g . I f n u r s e s a r e concerned about p a t i e n t s ' p e r c e p t i o n s of the n u r s i n g c a r e t h e y p r o v i d e 81 and g i v e n t h i s p o s s i b l e r e l a t i o n s h i p between s a t i s f y i n g and c a r i n g n u r s i n g c a r e b e h a v i o u r s , i t i s i m p o r t a n t f o r nurse e d u c a t o r s t o i n t e g r a t e the concept of c a r i n g i n both b a s i c and p o s t - b a s i c n u r s i n g e d u c a t i o n . Nurse e d u c a t o r s can t e a c h the concept of c a r i n g t h r o u g h o u t the c u r r i c u l u m i n both c l a s s r o o m t h e o r y and i n the c l i n i c a l s e t t i n g . I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e Nurses i n v o l v e d i n the c a r e of emergency room p a t i e n t s can i n f l u e n c e and/or promote p a t i e n t s a t i s f a c t i o n i n r e l a t i o n t o v a r i o u s a s p e c t s of n u r s i n g p r a c t i c e . The t r i a g e n u r s e ' s r o l e i n t h i s s t u d y was s i g n i f i c a n t i n i n f l u e n c i n g s u b j e c t s ' p e r c e p t i o n s of s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h n u r s i n g c a r e . I t i s i m p o r t a n t t o c o n s i d e r the impact of t h e t r i a g e n u r s e ' s r o l e , i n terms of p r omoting p a t i e n t s a t i s f a c t i o n , when p l a n n i n g p a t i e n t c a r e a s s i g n m e n t s . G i v e n t h a t s u b j e c t s r e c a l l e d and i d e n t i f i e d n u r s i n g c a r e b e h a v i o u r s t h a t t h e y p e r c e i v e d as s a t i s f y i n g or d i s s a t i s f y i n g , n u r s e s must be c o g n i z a n t of p a t i e n t s as v a l u a b l e i n f o r m a n t s . I n f o r m a t i o n c o u l d be c o l l e c t e d from p a t i e n t s f o l l o w i n g d i s c h a r g e from the emergency room v i a a s u r v e y . T h i s would p r o v i d e n u r s i n g s t a f f w i t h v a l u a b l e i n f o r m a t i o n r e g a r d i n g p a t i e n t s ' p e r c e p t i o n s of n u r s i n g c a r e b e h a v i o u r s . S u b j e c t s ' p e r c e p t i o n s of s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h n u r s i n g c a r e were based on the 82 f o r m a t i o n of a t r u s t i n g r e l a t i o n s h i p . The importance of n u r s e s b u i l d i n g a t r u s t i n g r e l a t i o n s h i p w i t h p a t i e n t s i s a l s o c o n s i s t e n t l y documented i n n u r s i n g l i t e r a t u r e . G i v e n t h a t t h e n u r s e - p a t i e n t i n t e r a c t i o n s i n the emergency room a r e o f t e n b r i e f i n t i m e , u t i l i z i n g the n u r s i n g c a r e b e h a v i o u r s of a t t e n d i n g t o p a t i e n t s p r o m p t l y on a d m i s s i o n , u s i n g a t t e n d i n g and l i s t e n i n g s k i l l s , and p r o v i d i n g r e a s s u r a n c e which were i d e n t i f i e d i n t h i s s t u d y may a s s i s t n u r s e s t o e f f e c t i v e l y respond t o p a t i e n t s ' p h y s i c a l and p s y c h o s o c i a l needs. These n u r s i n g c a r e b e h a v i o u r s may a l s o a p p l y t o o t h e r n u r s i n g a r e a s where n u r s e - p a t i e n t i n t e r a c t i o n s a r e b r i e f , such as an a m b u l a t o r y c a r e or s u r g i c a l day c a r e s e t t i n g . I m p l i c a t i o n s f o r N u r s i n g R esearch The f i n d i n g s of t h i s s t u d y demonstrate the importance of p a t i e n t s as v a l u a b l e i n f o r m a n t s i n i d e n t i f y i n g s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h the n u r s i n g c a r e b e h a v i o u r s . F u r t h e r r e s e a r c h u s i n g a l a r g e r sample and random s a m p l i n g c o u l d s u p p o r t the f i n d i n g s and/or y i e l d more i n f o r m a t i o n . R e p l i c a t i o n of t h i s s t u d y u s i n g p a t i e n t s w i t h o t h e r i n j u r y / i l l n e s s c o n d i t i o n s i n an emergency room s e t t i n g would c o n t r i b u t e t o the u n d e r s t a n d i n g of n u r s i n g c a r e b e h a v i o u r s t h a t p a t i e n t s view as s a t i s f y i n g and/or d i s s a t i s f y i n g . T h i s s t u d y was conducted i n an emergency room s e t t i n g , 83 where nu r s e s d e l i v e r h i g h l y t e c h n i c a l and i n t e n s i v e n u r s i n g c a r e . F u r t h e r r e s e a r c h would i n d i c a t e whether th e n u r s i n g c a r e b e h a v i o u r s which p a t i e n t s i d e n t i f i e d as s a t i s f y i n g or d i s s a t i s f y i n g i n t h i s s t u d y a r e s i m i l a r when o t h e r n u r s i n g s e t t i n g s a r e used, such as the i n t e n s i v e c a r e u n i t . 84 R e f e r e n c e s A b d e l l a h , F.G. 6c L e v l n e , E. (1957). 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P a t i e n t s a t i s f a c t i o n : An a t t r i b u t e or i n d i c a t o r of the q u a l i t y of c a r e ? Q u a l i t y Review  B u l l e t i n . 13, 106-108. 89 Weisman, C. & Nathanson, C.A. (1985). P r o f e s s i o n a l and c l i e n t outcomes. M e d i c a l C a r e r 23 f 1179-1192. Weiss, G.L. & Ramsey, C.A. (1989). R e g u l a r s o u r c e of p r i m a r y m e d i c a l c a r e and p a t i e n t s a t i s f a c t i o n . Q u a l i t y  Review B u l l e t i n . 15. 180-184. Wiendenbach, E. & F a l l s , C. (1978). Communication: Key t o  e f f e c t i v e n u r s i n g . New York: T i r e s i a s . Appendix A 90 An e x p l o r a t o r y d e s c r i p t i v e s t u d y : O r t h o p e d i c  p a t i e n t s ' p e r c e p t i o n s of s a t i s f a c t i o n w i t h  n u r s i n g c a r e i n the emergency room Date Addressed t o H o s p i t a l I am a R e g i s t e r e d Nurse i n the Masters of N u r s i n g program a t the U n i v e r s i t y of B r i t i s h C o lumbia. I would l i k e your c o - o p e r a t i o n i n a s t u d y which I am c o n d u c t i n g f o r my master's t h e s i s . My s t u d y concerns p a t i e n t s who had been i n the emergency department p r i o r t o h o s p i t a l i z a t i o n f o r an o r t h o p e d i c i n j u r y . The purpose of my s t u d y i s t o determine t h r o u g h an e x p l o r a t o r y d e s c r i p t i v e s t u d y what p a t i e n t s i d e n t i f y as s a t i s f y i n g and / o r d i s s a t i s f y i n g n u r s i n g c a r e b e h a v i o u r s a f t e r t h e i r emergency room e x p e r i e n c e I would l i k e p e r m i s s i o n t o a c c e s s p r o s p e c t i v e p a r t i c i p a n t s from the h o s p i t a l f o r t h i s s t u d y . The c r i t e r i a f o r the s t u d y sample i n c l u d e s : 1) h o s p i t a l i z e d p a t i e n t s who had more than one hour of n u r s i n g c a r e i n the emergency department, 2) a r e over 21 y e a r s of age, 3) have been 2 t o 5 days i n t o h o s p i t a l i z a t i o n , and 4) have e x p e r i e n c e d an o r t h o p e d i c i n j u r y . The p a r t i c i p a n t s w i l l be asked t o p a r t i c i p a t e i n one t o two i n - d e p t h i n t e r v i e w s l a s t i n g a p p r o x i m a t e l y 20 t o 30 minutes each. E t h i c a l c o n s i d e r a t i o n s such as c o n f i d e n t i a l i t y , and i n f o r m e d consent w i l l be adhered t o . The r e s u l t s of t h i s s t u d y w i l l be r e p o r t e d i n a t h e s i s . I f t h i s r e q u e s t i s g r a n t e d , p l e a s e c o n t a c t me a t . T h i s s t u d y w i l l be approved by the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee f o r Research and Other S t u d i e s I n v o l v i n g Human S u b j e c t s . Thank-you f o r your c o - o p e r a t i o n . S i n c e r e l y , I r e n e R o h r e r , RN, BSN. U n i v e r s i t y of B r i t i s h Columbia S c h o o l of N u r s i n g Appendix D An e x p l o r a t o r y d e s c r i p t i v e s t u d y ; O r t h o p e d i c  p a t i e n t s ' p e r c e p t i o n s of s a t i s f a c t i o n w i t h  n u r s i n g c a r e i n the emergency room No. Date I n t e r v i e w Guide: P a r t A The i n t e r v i e w guide c o n s i s t s of the demographic q u e s t i o n s and q u e s t i o n s r e l a t i n g t o n u r s i n g c a r e b e h a v i o u r s . The i n t e r v i e w w i l l b e g i n w i t h t h e c o l l e c t i o n of demographic d a t a . Demographic Data: Age E d u c a t i o n l e v e l O c c u p a t i o n Nature of i n j u r y Cause of i n j u r y . P r e v i o u s a d m i s s i o n s t o emergency room Yes No Reason f o r a d m i s s i o n C o n c u r r e n t m e d i c a l c o n d i t i o n s Yes No I f y e s , p l e a s e s t a t e Support pe r s o n p r e s e n t i n the emergency room Yes No I f y e s , p l e a s e s t a t e r e l a t i o n s h i p 94 I n t e r v i e w Guide: P a r t B Q u e s t i o n s t o I d e n t i f y N u r s i n g Care B e h a v i o u r s The q u e s t i o n s i n t h i s i n t e r v i e w g u i d e r e l a t e t o R i s s e r ' s (1975) d i m e n s i o n s t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h n u r s i n g c a r e . T h i s g u i d e w i l l d i r e c t t h e c o n v e r s a t i o n i n e x p l o r i n g p a t i e n t s ' p e r c e p t i o n s of n u r s i n g c a r e b e h a v i o u r s . Based on p a r t i c i p a n t s ' r e s p o n s e s c l a r i f i c a t i o n q u e s t i o n s w i l l be a s k e d . I'd l i k e us t o t a l k about the c a r e you r e c e i v e d from t h e n u r s e s d u r i n g the time you were i n the emergency room. Most o f t e n , p a t i e n t s coming i n t o the emergency room expect t o be c a r e d f o r as soon as p o s s i b l e . . How l o n g was i t b e f o r e you were seen by a nurse? . Did you f e e l t h a t t h i s was soon enough f o r you? - I f no, what were your r e a s o n s f o r n e e d i n g t o see the nurse sooner? Summarize s u b j e c t ' s response t o v a l i d a t e s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h the n u r s i n g c a r e b e h a v i o u r s . Most o f t e n p a t i e n t s who have had a bone or muscle i n j u r y s u f f e r from p a i n . I t i s u n d e r s t a n d a b l e t h a t p a t i e n t s who a r e u n c o m f o r t a b l e want immediate r e l i e f of t h e i r p a i n . . D i d you have p a i n from your i n j u r y ? - I f y e s , would you d e s c r i b e the p a i n ? . Were you a b l e t o t e l l the nurse t h a t you wanted h e l p t o r e l i e v e your p a i n ? - I f y e s , d i d she appear t o u n d e r s t a n d your c o n c e r n . . I f your p a i n was not r e l i e v e d , what do you t h i n k t h a t the nurse c o u l d have done f o r you? - I f s u g g e s t i o n s g i v e n , d i d you mention t h e s e s u g g e s t i o n s t o the nurse? . What ways d i d the nurse make you f e e l c o m f o r t a b l e ? (prompts i f n e c e s s a r y : e.g. i n f o r m the D o c t o r , g i v e m e d i c a t i o n , s u p p o r t i n g the i n j u r y w i t h p i l l o w s , and/or r e a s s u r i n g by s t a y i n g w i t h them) . A f t e r the nurse took c a r e of your p a i n , d i d s/he check w i t h you r e g u l a r l y t o make s u r e t h a t you were c o m f o r t a b l e ? Summarize s u b j e c t ' s response t o v a l i d a t e s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h n u r s i n g c a r e b e h a v i o u r s . Many d i f f e r e n t h e a l t h c a r e workers a r e p r e s e n t i n the emergency room a t any g i v e n t i m e , such as d o c t o r s , n u r s e s , c l e r k s and housekeeping s t a f f . . Were you a b l e t o e a s i l y i d e n t i f y who the nurses were i n the emergency room? - I f y e s , how were you a b l e t o r e c o g n i z e the 95 n u r s e s ? - i f no, what was c o n f u s i n g t o you? . Was i t c l e a r t o you which nurse i n the emergency room was g o i n g t o c a r e f o r you? . Did you know the nurse by h i s or her name? - I f no, was t h i s i m p o r t a n t t o you?. D i d your nurse g i v e you any i n s t r u c t i o n s on how you c o u l d c a l l f o r h e l p ? - I f y e s , what i n s t r u c t i o n s d i d s/he g i v e t o you? . I f you d i d c a l l f o r a s s i s t a n c e , d i d someone come pr o m p t l y ? . How would you d e s c r i b e t h e n u r s e s i n t h e i r i n t e r a c t i o n w i t h you? (prompts: were t h e y c o u r t e o u s , p o l i t e , p l e a s a n t , easy t o t a l k t o ? ) Summarize s u b j e c t ' s response t o v a l i d a t e s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h t h e n u r s i n g c a r e b e h a v i o u r s . Many ti m e s p a t i e n t s have no p r e v i o u s warning of t h e i r a d m i s s i o n t o the emergency room. T h i s d i s r u p t i o n u s u a l l y a f f e c t s d a i l y r o u t i n e and p l a n s . T h e r e f o r e , i t i s u n d e r s t a n d a b l e t h a t p a t i e n t s f e e l a f r a i d and a n x i o u s i n t h e emergency room. . How d i d your i n j u r y a f f e c t you e m o t i o n a l l y when you were i n the emergency room? . D i d you f e e l t h a t the nurse understood how you f e l t ? - I f y e s , how d i d the nurse make you f e e l l e s s a n x i o u s and a f r a i d ? ( e . g . v e r b a l and n o n v e r b a l communication s k i l l s ) . How d i d the nurse keep you informed of your c o n d i t i o n ? . I f a s u p p o r t p e r s o n was p r e s e n t , were you a b l e t o have them w a i t w i t h you i n the emergency room? - I f no, d i d t h e nurse e x p l a i n t o you why s/he d i d not a l l o w v i s i t o r s ? Summarize s u b j e c t ' s response t o v a l i d a t e s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h n u r s i n g c a r e b e h a v i o u r s . G i v e n t h a t people have e x p e c t a t i o n s of most s i t u a t i o n s i t i s u n d e r s t a n d a b l e t h a t p a t i e n t s have o p i n i o n s about the c a r e t h e y e x p e c t and the r e a l c a r e t h a t t h e y r e c e i v e d u r i n g h o s p i t a l i z a t i o n . . What do you t h i n k about t h e c a r e you r e c e i v e d from the n u r s e s i n the emergency room? . Do you f e e l t h a t the nurse knew how t o t a k e c a r e of your i n j u r y ? - I f y e s , would you g i v e me some examples of how the nurse showed h i s or her knowledge and a b i l i t y t o c a r e f o r you? - I f no, what concerned you about the n u r s e ' s a b i l i t y ? 96 . Do you f e e l t h a t the nurse gave c l e a r e x p l a n a t i o n s and i n s t r u c t i o n s when c a r i n g f o r you? - I f no, what d i d you not underst a n d ? - How c o u l d the nurse have made h i s or her e x p l a n a t i o n c l e a r e r f o r you? . What d i d you l i k e about the n u r s i n g c a r e you r e c e i v e d i n the emergency room? - Probe f o r examples. . Was t h e r e a n y t h i n g t h a t you d i s l i k e d about the c a r e you r e c e i v e d from n u r s e s i n t h e emergency room? - Probe f o r examples. . Ask f o r o v e r a l l s a t i s f a c t i o n w i t h c a r e r e c e i v e d d u r i n g emergency room s t a y . Summarize s u b j e c t ' s r e s p o n s e s t o v a l i d a t e s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h n u r s i n g c a r e b e h a v i o u r s . 

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