Clinically competent nurses
Participants stated that in order to act in a professional manner, nurses need to have certain competencies, namely social skills, expertise & experience, and priority setting.
Participants stated that social skills are an important competency to create a trustful care relationship. They indicated correct behaviour and attitude, composure, making time for patients, and listening and having empathy as essential nursing competencies. According to participants, these social skills convey a sense of commitment to the patient and play a major role in meeting patient expectations.
Nurses must have the ability to develop and maintain good relationships with patients. For patients, nursing care is about being heard and seen. Knowing that you’re in safe hands. You allay their fear and uncertainty. You give patients confidence and hope in return. You offer them several options from which they can choose. Someone who is dependent, and does not know what will happen, is more suspicious and anxious. (Respondent 21, hospital focus group)
Expertise & experience
Participants mentioned three key aspects related to expertise, namely knowledge, technical skills and communicative capabilities. According to participants, the first key aspect means that nurses must have substantive knowledge related to the nursing profession. They indicated that nurses should maintain and follow both existing developments and new insights. According to participants, nurses must continually invest in nursing knowledge and education. In their view, nurses ought to offer state-of-the-art interventions or activities that are in line with the agreed nursing policy.
As a second key aspect related to expertise, participants indicated that nurses must have technical skills in order to provide effective and safe care.
The third aspect mentioned by participants is that nurses must have communicative capabilities. Participants said that nurses serve as spokespersons for patients who are often in vulnerable positions. They stated that nurses are easily accessible and can act as a link between the patient and other professions. According to participants, nurses can use the right substantive arguments on behalf of a patient’s interests or needs. Participants mentioned that this expertise is important for patients because it is related to the quality of care.
If you can answer a care-related question, it gives the patient a certain peace of mind. It signals: she knows what she's talking about. I notice that patients really appreciate it when I share knowledge and offer them information that at the time they don’t yet have. Only then can patients make decisions about their own care. (Respondent 15, nursing home focus group)
In addition to substantive expertise, participants stated that nursing experience is also of influence. According to them, a junior nurse has too little experience to respond creatively to sometimes complex care situations. However, according to participants, junior and senior nurses can learn from each other: they should work as a team and collectively pursue their common objectives. In their view, experience is gained through practice. According to participants, this can be characterised as 'expertise'.
When you suspect someone is contemplating suicide, you need to know how serious this is. Is it just a cry of “I'm not feeling well” or are these serious thoughts? Has the patient already made plans, does the patient have a death wish, or is it an impulsive thought? In that sense you need to reflect on the signals very carefully. You can only learn this from practice. (Respondent 1, mental health care focus group)
As stated by participants, various activities can occur simultaneously during the daily care of patients. According to them, nurses should assess what care is needed and then flexibly coordinate diverse actions with each other. In the view of participants, prioritisation is about the organisation of nursing care. Patients need nurses who have clinical experience in order to coordinate care. Nurses must decide what choices to make, what is urgent and what is important. Those choices influence patient experiences.
Prioritisation is very important. It means that you have to coordinate the daily care and decide which activities have priority. Patients sometimes have to wait for help. If you’re in a hasty mood, you transmit that feeling to patients. It shows immediately. The restlessness affects the other patients. (Respondent 18, nursing home focus group)
Participants said that patients sometimes have to wait before they are taken care of, or that nurses are not immediately available to answer questions or deal with problems. According to participants, patients do not always obtain the right and needed care, especially when the nurses’ workload is high.
Collaborative working relationships
According to participants, it is important to develop and maintain collaborative working relationships with professionals, including those in their own field. In the view of participants, collaborative working relationships exist when all the involved professionals interact and operate in a complementary manner, and show mutual respect that is based on knowledge and expertise. Participants stated that all professionals need to discuss and influence patient care on the basis of their own expertise. Participants believe that problems will be solved sooner when ideas and thoughts are exchanged. In their view, it is about sharing information and communication. As stated by participants, communication and aligning with each other is needed so that no conflicting information is given and uniformity in care or treatment is provided. This generates, according to the participants, composure and clarity towards patients.
Participants believe that collaboration and communication affect how patients experience the quality and effectiveness of care.
We have a patient who is very compulsive. We made agreements about how to approach and handle this patient. We continually need to communicate with each other, physicians, psychologists, nurses. Clear communication is so important, and I miss that sometimes. When you have good relationships it is easier to review and discuss the treatment administered. It will not only increase your knowledge, but also be helpful in the communication with the patient and his family. It’s easier to explain why the specific treatment is being deployed. (Respondent 5, mental health care focus group)
Autonomous nursing practice
Participants in all four focus groups stated that the scope of practice for which they are accountable influences patient experiences. The scope of practice, according to them, means that nurses can control their own work related to patient care and can make independent decisions about patient outcomes based on clinical judgements. Participants therefore believe it is essential to monitor and measure outcomes, as long as the monitoring is directly related to patient care. However, participants indicated that they did not have insight into care results obtained from assessments.
We participate in an annual national prevalence survey. We have to fill out a lot of forms. It’s an administrative burden and takes a lot of time – time we can’t spend on patient care. We get a pile of papers, screen patients and register them. It doesn’t contribute to the quality of care because we never get any feedback. And what does one measurement tell us? It doesn’t inform us whether we are doing well or not. I do not believe that. (Respondent 12, home care focus group)
According to participants, there is no policy to improve patient experiences on the basis of the information derived from assessments. Participants could not indicate whether the interventions deployed are actually leading to desired nursing care results, including patient experiences. Participants feel they have insufficient autonomy to influence this process.
Participants stated that the number of nurses available influences how patients experience the quality of care. Although they could not indicate what number they consider sufficient, they think that a sufficient nurse staffing level is linked to team composition or staff mix. For instance, participants indicated the proportion of registered nurses to student nurses, or the number of different nurse qualification levels in one team. Participants stated that several tasks and assignments have been transferred to nurses with a lower qualification in order to work as efficiently as possible and to achieve higher productivity. As a result, participants believe that nursing care is, in general, increasingly developing in the direction of task-centred care in which different working methods are applied. According to them, this affects patient experiences of the quality and effectiveness of nursing care.
Nurses provide care within certain theoretical frameworks that are designed to increase the self-reliance and self-management of the patient. Nurse assistants have a more practical focus and take over patient care at a point when they should not. These two ways of working are confusing for patients. And we think 'How come the patient is made to feel so nervous?’ and afterwards we notice two contradictory ways of working. (Respondent 3, mental health care focus group)
As stated by participants, a sufficient nurse staffing level determines whether patient wishes and needs are met. According to participants, an insufficient deployment of nursing staff has a direct negative impact on patient experience.
I work alone in a group. For example, when I’m in the bathroom with a patient, the other patients are alone. So I have to keep my eyes and ears open and must respond to what occurs. And that is not always easy. I constantly think: I must check if everything is all right. Because I’m responsible for the other patients. I always leave the bathroom door partly open, so I can see and listen to what is going on in the living room. I provide patient care too hastily. My patients obviously feel that. (Respondent 17, nursing home focus group)
Control over nursing practice
The participants stated that control over nursing practice means that nurses are involved in nursing policy or nursing issues. In their view, nurses are not always in charge and cannot always make their own decisions about nursing issues. Participants feel that this affects the quality of nursing care.
In the past, I always made my own schedule. Now we have planners and they don’t have any experience with care. Efficient planning is more important than patient-centred planning. It doesn’t matter whether it suits the patient. The patient should be scheduled later if it fits better in the planned route. (Respondent 9, home care focus group)
The participants stated that if nurses were more involved in the development of nursing policies, this would have a positive influence on patient care. According to them, they would be able to reflect upon and discuss nursing issues related to the quality of patient care, which would improve the quality of care.
Participants indicated that a manager should pay attention to the team spirit and unity. In their view, a manager must be able to handle conflicts, and also be visible and approachable. Participants said that they believe that a manager should ask the opinion of nurses; therefore, in their opinion, regular contact is important.
A manager, according to the participants, must be able to create the right conditions and have the logistical ability to ensure continuity of care. In their view, this means arranging sufficient personnel, replacement staff and succession planning.
Participants find that managers critically examine the deployment of personnel. According to them, the nursing staff mix has drifted towards a model whereby higher-educated nurses are replaced with lower-educated ones. They noted that management is tied to a system that is dominated by controlling costs. Thus in their view, nurses may want to provide a patient with a specific form of care, while management limits care to a maximum number of minutes based on budgetary considerations. According to participants, nurses regularly experience a tension with management in shaping care that meets patient expectations.
We want to provide certain care, but that’s at the expense of something else. If we do one thing, we can’t do another. For instance, we plan 30 minutes for patient care. When a patient wants to go outside for a walk, this will cost him 10 minutes of this total time. So we really have to negotiate with the patient or his family. This leads, of course, to lots of misunderstandings. I understand that feeling. (Respondent 13, nursing home focus group)
According to participants, the focus of nurses is the provision of patient-centred care. They define this as nursing care that is focussed on patient needs and preferences and is intended to increase patient self-management and encourage improved health and recovery.
As participants stated, nurses are the first points of contact for patients. In the participants’ view, they are often with the patient for 24 hours/7 days a week (except for home care) and gather large amounts of information about them. They think that direct contact with patients is crucial to building and maintaining a relationship of trust. The participants believe that high quality nursing care is achieved when patients feel heard and understood, consider themselves to be in safe hands and know that their care problems have been noticed. This, according to the participants, results in positive patient experiences.
We listen to the patient and talk to him. We immerse ourselves in his background. What is important, how he copes and handles care problems. Based on this knowledge, we present the patient with a number of options so that he can decide upon a solution for his care problems. (Respondent 8, home care focus group)
The participants talked about two inhibiting factors that prevent them from improving patient experiences: cost-effectiveness and transparency & accountability goals.
Participants stated that organisation policy is focused on the efficient and effective deployment of people and resources. They mentioned the transfer of tasks to less well qualified nurses in order to work as efficiently as possible and to achieve higher productivity. In their view, care is more and more standardised. At the same time, they noted that care has become increasingly complex. According to them, patients are generally older and have multiple age-related comorbidities. The participants experience an increasing workload and work-associated pressure.
In recent years, patient turnover has increased. It means that patients are discharged quicker. As soon as they recover, they’re sent home. However, patients sometimes also have chronic disorders. I sometimes think it is irresponsible [to send these patients home so quickly]. Patients get less attention because the work pressure is high. (Respondent 22, hospital focus group)
Transparency & accountability goals
Participants reported an increasing administrative workload to account for the quality and costs of care.
So many forms. Entering the data means a double administrative workload. We use different programs. We first have to register in program X. Then we have to register our measurements and enter all kinds of codes in another program. Log in and log out. The registrations and coding are needed for the government and health insurers. It is not always patient related and does not inform us about the health status of patients. (Respondent 23, hospital focus group)
The administrative workload is, according to participants, out of balance. They said that this means that monitoring and registration is aimed not at improving nursing care, but at serving an external accountability goal to inform health insurers and the government.
The participants stated that they have little autonomy to change this policy. According to them, monitoring care results should help nurses to improve their own practice. For them, it means that nurses can reflect upon and discuss nursing issues related to quality of patient care, including the results of patient experiences.