Download Patient-centred care and nurses` health

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JOURNAL OF ADVANCED NURSING
ORIGINAL RESEARCH
Patient-centred care and nurses’ health: the role of nurses’ caring
orientation
Anat Drach-Zahavy
Accepted for publication 27 February 2009
Correspondence to A. Drach-Zahavy:
e-mail: [email protected]
Anat Drach-Zahavy PhD
Senior Lecturer
Department of Nursing, University of Haifa,
Israel
D R A C H - Z A H A V Y A . ( 2 0 0 9 ) Patient-centred care and nurses’ health: the role of
nurses’ caring orientation. Journal of Advanced Nursing 65(7), 1463–1474
doi: 10.1111/j.1365-2648.2009.05016.x
Abstract
Title. Patient-centred care and nurses’ health: the role of nurses’ caring orientation.
Aim. This paper is a report of a study of the moderating effect of caring orientation on the relationship of patient-centred care to nurses’ physical and mental
health.
Background. Providing effective patient-centred care is well-accepted as an
important contributor to a host of patients’ health outcomes. Based on two theoretical perspectives – person–environment fit and emotional labour – I suggest that
providing patient-centred care per se does not potentially harm nurses’ health; the
cause is the fit (or non-fit) of a nurse’s caring orientation and the displayed patientcentred care behaviours.
Method. Data were collected in 2007 with a random sample of 325 registered
nurses working in the Israeli public healthcare sector in in-patient units. Caring
orientation, health and control variables were measured via validated questionnaires. Patient-centred care behaviours were assessed by structured observations.
Results. The mental health of nurses who exhibited high caring orientation
combined with high patient-centred care, or that of nurses who exhibited low
caring orientation combined with low patient-centred care, was statistically
significantly higher in comparison with the mental health of nurses who
exhibited incongruent (low/high or high/low) caring orientation and patientcentred care behaviours. For nurses’ physical health, the findings revealed that
providing patient-centred care was associated with worsened health, and possessing a caring orientation was associated with better health.
Conclusions. The findings support the hypotheses that were derived from person–environment fit and emotional labour only with regard to mental health.
Separate theory needs to be developed on how to maintain nurses’ physical
health.
Keywords: caring orientation, nurses’ health, observations, patient-centred care,
questionnaire, role
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A. Drach-Zahavy
Introduction
PCC Behavior
As providing health care in an increasingly financially
restricted and competitive market becomes an essential
feature of the healthcare system, a focus on the patient
emerges as a major component of organizational strategy
(Newman et al. 2005, Liao 2007). Across the globe,
theoreticians and clinicians have expanded the ‘biomedical
model’ to a broad bio-psychosocial orientation and developed the concept of ‘patient-centred care’ (PCC) (Stewart
2002). For example, in 2001, the US Institute of Medicine
endorsed PCC as a central component of high-quality health
care (The Committee on Quality of Health Care in America
2001). Similar trends have been observed in Canada (Sidani
2008), Europe (Griffin et al. 2004) and other western
countries such as Israel (Stewart 2002).
It is increasingly recognized that to achieve PCC and
improve the quality of care, patients, care processes and
healthcare providers should be addressed simultaneously
(Bower et al. 2003, Epstein et al. 2005); yet theoreticians and
practitioners alike argue that healthcare providers are the
least addressed (Korunka et al. 2003, Epstein et al. 2005). As
a result, the healthcare professions are rapidly becoming
recognized as extremely high-risk occupations (Haynes et al.
1999). The present study is directed towards narrowing this
gap by examining the health outcomes of nurses who give
PCC.
Inspired by these concerns, in the study I sought to explore
whether giving high PCC worsens nurses’ physical and
mental health or in fact improves it. To do so, a model was
developed for predicting nurses’ mental and physical health
(Figure 1). From this point of view, neither general positive
effects nor general negative effects on nurses’ health can
necessarily be expected from merely providing PCC. Instead,
the potential effects of PCC on nurses’ health depend on their
values and orientation to caring. The model suggests that
when PCC is displayed by nurses with a high caring
orientation, improved health might be expected. By contrast,
health impairment will be evident when PCC is given by
nurses holding low carrying orientation.
Background
Nurses’ health
A review of the research on nurses’ health in the United States
of America reveals that about 30% of nurses reported
symptoms of high psychological distress and 21Æ8% reported
a work inhibition syndrome (Préville et al. 1991, Bourbonnais et al. 1999). French researchers have reported that, in a
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Caring
orientation
Physical Health
Mental Health
Health Indicators
Figure 1 Model for predicting nurses’ health indicators from
patient-centred care (PCC) behaviour and caring.
80
Low PCC behavior
High PCC behavior
75
70
65
60
55
50
Low caring values
High caring values
Figure 2 Mental Health by patient-centred care (PCC) behaviour
and caring values.
study of female hospital workers (43% nurses), 26% had a
high score on the General Health Questionnaire (Goldberg
1986), indicating an elevated risk for minor psychiatric
morbidity. Moreover, 32% reported fatigue, 31% sleep
impairment, 28% medication use (antidepressants, sedatives,
or sleeping pills) and 21% had a psychiatric diagnosis on
routine medical check (mostly depressive state or irritability
(Estryn-Behar et al. 1990). In Canada, nurses were found to
have higher than expected rates of suicide and alcohol and
drug abuse, higher rates of hospital admission for mental
disorders and elevated admission rates to mental health
centres (Sauter et al. 1990). Such cross-national evidence led
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Haynes et al. (1999) to conclude that nursing is rapidly
becoming recognized as an extremely high-risk occupation.
Patient-centred care and health
Patient-centred care calls for self-awareness, reflective listening, use of empathy and development of excellent communication skills by clinicians (Mead & Bower 2000, Epstein
et al. 2005). It includes enacting such behaviours as exploring
the social and psychological (as well as biomedical) aspects of
the patient’s health status; understanding the personal
meaning of the illness for the patient by eliciting their
concerns, ideas, expectations, needs, feelings and functioning;
promoting the understanding of the patient within their
unique psychosocial context; sharing power and responsibility, and developing common therapeutic goals that are
concordant with the patient’s values.
Engaging in PCC should potentially enhance nurses’ sense
of empowerment, responsibility and job significance, and
hence result in an improvement in health (Gessner 1998).
This argument might especially hold because nurses frequently apply for such jobs precisely because of their social
motives and values (Ravlin & Meglino 1987, Judge & Bretz
1992). Recent studies have shown that nurses and physicians
derive satisfaction mainly from encounters with patients
(Robertson et al. 1994, Dingman et al. 1999). For example,
Dingman et al. showed that PCC is fundamental to nurses’
work. Through PCC, including informing, treating with
respect and showing concern for personal stress, nurses
maintain their sense of self-worth. Hence, their opportunities
for giving PCC might fulfil their basic motivation to engage in
their jobs in the first place, thereby contributing to their
health.
On the other hand, engaging in PCC could potentially
constitute an extra demand, which might actually intensify
the already-existing high levels of stress and workload, with
impaired health status as a resulting effect (McArdle et al.
1995). In this vein, recent studies have shown that healthcare
providers perceive intensive encounters with patients and
their families as fundamental sources of stress (Rose et al.
2007). Although not focusing directly on PCC, the study by
Schaufeli et al. (1996) showed that high demands by patients
led to a perceived lack of patient-related reciprocity (e.g.,
little appreciation for the effort and time invested), which was
related to burnout. Lim and Yuen (1998) noted that much of
nurses’ dissatisfaction arose from unreasonable demands by
patients and their relatives. Nurses reported that they were
not treated with respect, and that patients urged nurses to
comply with their wishes without taking work-related constraints into account. These encounter-specific stressors were
Patient-centred care and nurses’ health
positively associated with job-induced tension (r = 0Æ31). The
effects emerging in these studies were often smaller than those
caused by other stressors, such as time pressure (Schaufeli &
Enzmann 1998). In the light of this conflicting evidence,
Schaufeli and Enzmann concluded that health impairment is
not particularly related to stressful social interactions at
work.
In summary, the literature reveals that there is no definite
answer to the quandary of how giving PCC affects nurses’
health. These contradictory findings highlight the need to
examine the role of moderator variables that determine the
direction of the relationship between PCC and nurses’ health.
Authors in the domains of both PCC behaviour and caring
point to the blurring of the two concepts, and argue that
researchers have too often failed to distinguish what healthcare providers think from what they actually do (Watson
2002, Epstein et al. 2005). I differentiate between caring,
which describes a moral philosophy guiding nurses’ behaviour in encounters with patients, and PCC, which we define
as actions in service of caring (Epstein et al. 2005). The
following discussion provides theoretical arguments as well
as empirical support for the contention that nurses’ mental
and physical health is determined by the joint effects of PCC
behaviours and caring orientation.
Impact of caring orientation and PCC behaviour on
nurses’ health
Morse et al. (1991) are often quoted for their identification of
the (at least) five notions of caring the literature as a human
trait, a moral imperative, affect towards one’s patient, an
interpersonal interaction and a therapeutic intervention. In
this paper, caring is treated as a moral philosophy, with three
core values: the importance of considering patients’ needs,
wants, perspectives and individual experiences; the importance of offering patients opportunities to provide input into,
and participate in, their care; and the value of enhancing
partnership and understanding in the patient. Theorists of
caring have tried to capture the essence and values of the
nursing process in the caring process. For example, in the
theory of human caring, Watson (1988) attempted to bring
meaning to the nursing discipline as a distinct profession with
its own unique values, knowledge, ethics and mission, which
consequently influence practices. In essence, the caring
process is the formation of a humanistic–altruistic system of
values, with the development of a helping–trusting human
caring relationship and a protective and corrective mental,
physical, societal and spiritual environment for patients.
According to the Advocate Health Care Model (Schaffner
et al. 1999), five values, alongside professional codes for
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A. Drach-Zahavy
actions, underlie the nursing caring process and nurses’
commitment to caring. These are compassion, equality,
excellence, partnership and stewardship. Hence, caring can
be seen as a moral philosophy that guides nurses’ behaviour
in encounters with patients.
How does caring orientation moderate the relationship
between providing PCC and nurses’ health? Two theoretical
perspectives frame the following discussion: person–environment fit (Mitchell et al. 2001) and emotional labour
(Hochschild 1983, Brotheridge & Grandey 2001). Both
perspectives suggest that delivering PCC per se does not
potentially cause strain and harm nurses’ health; rather, the
cause is the congruence (or incongruence) of a nurse’s
personal orientation and the behaviours displayed. Nevertheless, each perspective implies slightly different mechanisms
as driving the relationship.
The emotional labour perspective
Arguments based on the emotional labour literature (e.g.,
Hochschild 1983) point to the health hazards bound up with
occupational roles. In particular, those in the helping professions, such as nursing, require ‘efforts, planning and control in order to express organizationally desired emotions
during interpersonal transactions’ (Morris & Feldman 1996,
p. 987). Studies in the emotional labour domain have shown
that the frequency of emotional labour occurrences (Hochschild 1983), attentiveness needed as compared with more
routine ‘scripted’ responses (Sutton & Rafaeli 1988), length
of interactions with clients (Cordes & Dougherty 1993), and
variety of emotions required to be expressed (Morris &
Feldman 1996) overtax employees and lead to health
impairment. However, recent research has identified several
factors that better explain why some aspects of PCC harm
health, whereas others improve it. The main factor identified
by emotional labour researchers is emotional dissonance,
which occurs when an employee is required to express emotions that are not genuinely felt in a particular situation (Zapf
2002). In this vein, incongruent conditions of PCC and caring
might potentially create emotional dissonance. An example is
a young idealistic nurse with a caring orientation who works
in an emergency unit where she is obliged to focus on costeffectiveness considerations and ‘getting the job done’. She
may well encounter emotional dissonance when she adheres
to the expressed rules in the unit, which circumscribe her
PCC behaviours. A similar example is that of a nurse in a
neonatal intensive care unit who is expected to show
friendliness, keen interest and empathy towards worried
young parents, but her instrumental rather than caring orientation dictates to her to focus more on physical aspects of
care such as respiratory care and infection control. This nurse
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may encounter situations where she involuntarily feels distracted by or even anger towards families that prevent her
from complying with expectations of providing PCC.
Empirical findings have showed negative health effects of
emotional dissonance. For example, Zapf (2002) found positive correlations between irritation and emotional dissonance and psychosomatic complaints.
In contrast, when PCC behaviour is congruent with one’s
caring orientation, namely low PCC shown by a nurse
possessing a low caring orientation, or high PCC by a nurse
possessing a high caring orientation, it is less likely to induce
emotional dissonance. Consequently, decline in health is less
expected. In summary, research in the area of emotional
labour evinces support for our model.
Person–environment fit perspective
Arguments based on person–environment theories also
emphasize that the maladjustment/misfit, rather than just the
demand to give PCC, inhibits employees’ health. Accordingly, the person (nurse) carries a set of attributes to their:
professional identity (Hogan & Roberts 2000), skills and
physiological and cognitive abilities to conduct their tasks
(Kielhofner 1995, Dawis 2000), personal/professional goals
(Little 2000), and professional orientations and values
(Dawis 2000). The environment is also seen as having a set of
characteristics, corresponding to those of the person: job
content and demands for expected behaviours in a particular
role (Dawis 2000). The person–environment relationship
occurs when the person (nurse) interacts with the environment through their work, and both the person and environment measure their needs against each other’s abilities to
reinforce them (Walsh & Holland 1992). In the context of
the present study, high PCC behaviour by a nurse with a
caring orientation, or low PCC behaviour by a nurse with a
low caring orientation, can be regarded as situations where
both the person’s and the environment’s needs are met.
Consequently, the nurses’ health will be improved. However,
if maladjustment is experienced by the person (or the environment), an impairment on nurses’ health is expected
(Takase et al. 2005).
Hypotheses
To sum up, borrowing on the emotional labour, and person–
organization fit theories, I propose that the relationship
between PCC and physical and mental health is moderated by
the nurse’s caring orientation such that:
• When high PCC behaviour is exhibited in a high caringoriented nurse, physical and mental health will be
enhanced.
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When high PCC behaviour is exhibited in a low caringoriented nurse, physical and/or mental health will be impaired.
• When low PCC behaviour is exhibited in a high caringoriented nurse, physical and/or mental health will be impaired.
• When low PCC behaviour is exhibited in a low caringoriented nurse, physical and/or mental health will be enhanced.
We further propose that these relationships will occur
above and beyond the control variables of nurses’ gender,
education, job tenure and nurses’ perceptions of role overload
in the unit. These variables were chosen because the literature
has noted that they might have an impact on nurses’ health
(Ware et al. 1996) and because when job demands are high,
PCC behaviour might be less enacted by the nurse (Rose et al.
2007).
•
The study
Aim
The aim of the study was to assess the moderating effect of
caring orientation on the relationship of PCC to nurses’
physical and mental health.
Design
A cross-sectional study was conducted during 2007.
Participants
A random sample of registered nurses (RNs) working in the
Israeli public healthcare sector in in-patient units. Only
nurses working in hospitals in morning shifts and having
direct contact with patients were approached. Of the 400
solicited, 325 returned a completed questionnaire, giving a
response rate of 81%. A priori and post hoc power analyses
were conducted. A priori power analysis revealed that this
sample size assures an 80% power maximum with an error
rate of ±05 in estimating variable expectation (M = 70, and
SD = 16).
Data collection
Observational data
Observations have been described as one of the better
methods for assessing PCC because studies relying on nurses’
or patients’ retrospective self-report suffer from estimation
biases (Epstein et al. 2005). In the present study, observers
Patient-centred care and nurses’ health
recorded nurses’ PCC in the course of three distinct occasions, such as medication administration or discharge, each
averaging 20 minutes. A nine-item structured observation
sheet discussed by Schirmer et al. (2005) was used. The
measure consisted of nine evaluation criteria on a four-point
Likert-type scale (from 0 = not attempted to 3 = well done,
and a ‘not applicable’ option), and a space for comments
after the evaluation criteria (see Appendix). PCC was averaged across the nine evaluation criteria and across the three
observation instances. Analysis of the comments made in the
open space revealed that nurses’ actual behaviours could be
easily rated with the assessment tool. Only in negligible cases
(about 10 observations) did the observer note that the item
was not applicable to the given observation instance. The
scale has been reported as one of the most reliable and valid
scales in a comparative study of 15 existing measures of PCC
(Schirmer et al. 2005).
Undergraduate nursing students participated as observers
as part of their course requirements. The advantage of
employing them was that their presence was perceived by
nurses as a natural part of the unit environment, which might
have prevented bias. In addition, their objectivity could be
relied on, and they were familiar with best practice in PCC.
To ensure inter-rater reliability and validity, the observers
received 10 hours of training. This included: (a) observation
techniques in research, (b) a thorough study of PCC and
caring, and (c) participation in periodic meetings during the
observation period at which categorization dilemmas were
discussed and resolved by the group consensus technique.
Intra-rater reliability was moderate to high (r = 0Æ68–0Æ71
between the three observations).
Survey data
Data on caring, physical and mental health, and overload
were obtained through questionnaires distributed to nurses
on site by a research assistant.
Caring orientation was assessed by the 13-item Caring
Attributes Scale reported by Arthur et al. (1999), with a fivepoint Likert-type scale from 1 = disagree to 5 = agree.
The scale has been reported to be reliable and valid,
helping to create a picture of caring orientation of nurses in
various countries and cultures (Watson 2002). The items
reflect what caring means to respondents as nurses. An
example is ‘Caring is the central feature of nursing’. Cronbach’s alpha in the present study was 0Æ88.
Nurses’ health was measured by the physical and mental
health measures of the SF-36 health survey (Ware et al.
1996). The physical health component consisted of 10 items
on physical functioning, assessing respondents’ ability to
perform mild-to-intensive physical activities; four items on
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A. Drach-Zahavy
role physique assessing role limitations due to physical
problems; two items on bodily pain; and five items on
general health. The mental health component consisted of
five items on mental health, assessing psychological distress
and well-being; three items on role emotion, measuring role
limitations due to emotional problems; two items on social
functioning, assessing health limitations on social activities
with friends, relatives or neighbours; and four items on
vitality, assessing energy when compared with fatigue. The
scales were transformed to a 0–100 scale using a transformation formula where 100 represents best possible health
status. Cronbach’s a in this study was 0Æ83 and 0Æ85 for
physical and mental health respectively.
Control variables
To measure role overload, a six-item five-point Likert-type
scale (1 = very seldom, 5 = very frequently) adopted from
Beehr et al. (1976) was used. An example is ‘It often seems
like I have too much work for one person to do’
(a = 0Æ91).
average job tenure was 13Æ8 years (SD = 8Æ9). The majority,
48Æ4%, had a Bachelor’s degree, 46Æ8% were RNs without a
Bachelor’s degree and 4Æ7% had a Master’s degree. The
information available indicated that respondents did not
differ from the overall nurse population in terms of sex, work
duration and education.
Table 1 shows the means, SD s and range of the study
variables. Table 2 gives the inter-correlation matrix (Pearson)
for the study variables. Tables 3 and 4 present the results of
the hierarchical regression analyses for physical and mental
health respectively. In line with Kirk (1996), partial etasquared values are provided as indicators of sizes of the
effects. Kirk (1996) also recommended rules of thumb for
estimating effect sizes: small, medium and large effect sizes
for an F-statistic have partial eta-squared values of 0Æ01,
0Æ059 and 0Æ138 respectively. In addition, to support the
hypotheses, observed power values are also provided. In line
with Cohen (1992), an observed power of 0Æ80 is recommended.
Physical health
Ethical considerations
The study was approved by the appropriate institutional
review board. All participants gave informed consent to
participate after receiving a brief explanation of the research
aims, and being assured that the observational and survey
data would be used only for research purposes.
Data analysis
Following the advice of Cohen and Cohen (1983) for testing
moderating effects, we computed a hierarchical regression
analysis that regressed the health of nurses on its predictors;
the control variables of gender, tenure, educational level and
overload were entered in step 1. All main effects of the
proposed antecedents, namely PCC and caring, were entered
in step 2 to allow testing their effects beyond the control
variables. Finally, the two-way interactions of PCC and
caring were determined from cross-product terms, and added
to the regression equation after controlling for the effects of
the independent and the moderator variables (Cohen &
Cohen 1983). The statistical significance of the effects were
assessed at P = 0Æ05.
Results
Seventy-one per cent of the nurses were women, with an
average age of 37Æ48 years (SD = 8Æ81). Average length of
time working in the unit was 9Æ8 years (SD = 7Æ3), and
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As shown in Table 3, the control variables predicted 18% of
the variance in nurses’ physical health [F(4,325) = 17Æ61,
P < 0Æ05]. Whereas education level was positively and
statistically significantly associated with physical health,
overload was negatively and statistically significantly associated with it.
The main effects of PCC and caring (Model 2) accounted
for an additional 8% of the variance in physical health
[F(6,325) = 17Æ73; P < 0Æ001]. Whereas PCC was statistically significantly and negatively associated with physical
health, caring was statistically significantly and positively
associated with it. However, in contrast to our hypotheses,
no interaction effect of PCC behaviour and caring orientation
on nurses’ physical health was found. Hence, hypotheses
(a–d) were rejected for physical health.
Table 1 Means, standard deviations, possible and obtained range
of scores study’s variables
(1) Physical health
(2) Mental health
(3) Patient-centred
care behaviour
(4) Caring
(5) Overload
(6) Tenure
Mean
SD
Possible
range
Obtained
range
71Æ89
66Æ69
2Æ08
13Æ17
20Æ67
0Æ58
0–100
0–100
0–3
35Æ00–90Æ00
21Æ00–97Æ00
0Æ68–3Æ00
3Æ58
2Æ45
9Æ8
0Æ56
0Æ62
7Æ3
1–5
1–5
–
1Æ86–4Æ57
1Æ38–4Æ33
0Æ5–32
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Patient-centred care and nurses’ health
Table 2 Correlation matrix of study’s variables
(1)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Physical health
Mental health
Patient-centred care behaviour
Caring
Overload
Gender
Tenure
1Æ00
0Æ55**
0Æ11*
0Æ23**
37**
0Æ06
0Æ12*
(2)
(3)
1Æ00
0Æ12*
0Æ25**
52**
0Æ12*
0Æ21*
(4)
1Æ00
0Æ21**
21**
0Æ12*
0Æ08
(5)
1Æ00
0Æ04
0Æ06
0Æ04
1Æ00
0Æ08
0Æ18*
(6)
(7)
1Æ00
0Æ05
1Æ00
Note: n = 325; * P < 0Æ05; ** P < 0Æ01.
Dummy coded: 0 = male, 1 = female.
Table 3 Results of hierarchical regression analyses for testing the predictors of physical health
Model 1 (controls)
Variables
Gender
Tenure
Education
Load
PCC
Caring
PCC · caring
R2
d.f.
F
Estimate (SE)
0Æ01 (1Æ54)
0Æ01 (0Æ10)
0Æ10 (0Æ90)
0Æ40** (1Æ12)
Model 2 (main effects)
g2
Observed power
0Æ01
0Æ01
0Æ02
0Æ14
0Æ07
0Æ06
0Æ53
1Æ00
0Æ18
4
17Æ61**
Estimate (SE)
0Æ03 (1Æ49)
0Æ02 (0Æ10)
0Æ11* (0Æ88)
0Æ42* (1Æ10)
0Æ22** (1Æ2)
0Æ15** (1Æ1)
Model 3 (interactions)
g2
Observed power
Estimate (SE)
g2
Observed power
0Æ01
0Æ01
0Æ02
0Æ14
0Æ07
0Æ06
0Æ53
1Æ00
0Æ98
0Æ85
0Æ03 (1Æ49)
0Æ02 (0Æ10)
0Æ11* (0Æ88)
0Æ43* (1Æ1)
0Æ18 (11Æ7)
0Æ17 (4Æ85)
0Æ04 (2Æ54)
0Æ26
7
15Æ18**
0Æ01
0Æ01
0Æ02
0Æ14
0Æ01
0Æ01
0Æ01
0Æ07
0Æ06
0Æ53
1Æ00
0Æ05
0Æ16
0Æ05
0Æ26
6
17Æ73**
PCC, patient-centred care.
*P < 0Æ05; **P < 0Æ01.
Table 4 Results of hierarchical regression analyses for testing the predictors of mental health
Model 1 (controls)
Variables
Gender
Tenure
Education
Load
PCC
Caring
PCC · caring
R2
d.f.
F
Estimate (SE)
0Æ02 (2Æ38)
0Æ03 (0Æ15)
0Æ02 (1Æ40)
0Æ46** (1Æ73)
0Æ22
4
19Æ53**
Model 2 (main effects)
Model 3 (interactions)
g2
Observed power Estimate (SE)
g2
Observed power Estimate (SE)
g2
Observed power
0Æ01
0Æ01
0Æ01
0Æ17
0Æ09
0Æ09
0Æ22
1Æ00
0Æ01
0Æ01
0Æ01
0Æ18
0Æ01
0Æ06
0Æ08
0Æ16
0Æ19
1Æ00
0Æ14
0Æ98
0Æ01
0Æ01
0Æ01
0Æ17
0Æ01
0Æ03
0Æ06
0Æ07
0Æ22
0Æ13
1Æ00
0Æ42
0Æ83
0Æ82
0Æ02 (2Æ34)
0Æ05 (0Æ15)
0Æ01 (1Æ37)
0Æ48** (1Æ71)
0Æ05 (1Æ89)
0Æ21** (1Æ79)
0Æ27
6
20Æ71**
0Æ02 (2Æ34)
0Æ06 (0Æ15)
0Æ01 (1Æ35)
0Æ45** (1Æ71)
1Æ50** (1Æ87)
0Æ39** (2Æ48)
1Æ54** (3Æ90)
0Æ32
7
24Æ71**
PCC, patient-centred care.
*P < 0Æ05; **P < 0Æ01.
Mental health
As shown in Table 4, the control variables predicted 22% of
the variance in nurses’ mental health [F(4,325) = 19Æ53;
P < 0Æ05]. Of the control variables, only overload was
negatively and statistically significantly associated with
mental health. The main effects of PCC behaviour and caring
orientation (Model 2) accounted for an additional 5% of the
variance in mental health [F(6,325) = 20Æ71; P < 0Æ001].
Only caring orientation was statistically significantly and
2009 The Author. Journal compilation 2009 Blackwell Publishing Ltd
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A. Drach-Zahavy
positively associated with mental health. Consistent with our
hypotheses, an interaction effect of PCC and caring on
mental health was found (Model 3). The interaction effect
accounted for an additional 5% of the variance in mental
health (F = 24Æ71; P < 0Æ001).
The interaction effect is shown in Figure 2. For nurses
exhibiting high PCC mental health was statistically significantly higher in those with a high caring orientation than in
those with a low one. Note that those with a high caring
orientation who exhibited high PCC had the highest mental
health scores in our sample, indicating support for hypothesis (a). Also, nurses with a low caring orientation who
exhibited high PCC had the lowest mental health scores in
our sample, indicating support for hypothesis (b). As for
those who showed low PCC behaviours, no statistically
significant mental health differences were found between
those with high and with low caring. However, nurses with
high caring orientation who exhibited low PCC showed
statistically significantly lower mental health than those with
high caring orientation who exhibited high PCC. This
finding supports hypothesis (c). Finally, regarding hypothesis
(d), mental health in low caring-oriented nurses who
exhibited low PCC was statistically significantly higher than
in low caring-oriented nurses who exhibited high PCC.
Nevertheless, the mental health of these nurses was statistically significantly lower than that of nurses with high
caring who exhibited high PCC. Hence, for mental health,
hypothesis (d) was rejected.
Discussion
Study limitations
The research was cross-sectional, and so causal inferences
could not be drawn. The health data were gathered at the
same point in time as information on other variables in the
hypothesized model; a longitudinal design would have made
it possible to collect data on subsequent health, and provided
stronger evidence of a directional relationship between the
variables.
Second, although a multi-method strategy for data
collection was used, the self-report measure of physical
and mental health might be subject to bias. Regarding
nurses’ health, Wright and Cropanzano (2000) argued that,
for any number of reasons, self-report measures are and will
continue to be an important information source in research.
However, non-self-report measures, such as objective health
indicators (e.g., cholesterol level), as well as health behaviours, merit closer scrutiny in further research (Wright &
Cropanzano 2000).
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Discussion of results
The question that triggered this study was whether engaging
in PCC impairs or improves nurses’ health. This concern is
undoubtedly timely, given that PCC is becoming more and
more the ‘industrial religion’ of the 21st century in healthcare
organizations. For these to survive, their operatives are
required to interact with customers and to assure high-quality
care; however, this issue has addressed only sparsely and
indirectly in the stress literature (Dormann & Zapf 2004).
The handful of studies probing this issue so far has focused on
investigating such questions as whether the structure of
interactions with patients (e.g., number or length of interactions) or the content of the interaction (e.g., severity of
patients’ problems to be solved) is related to health hazards.
The adverse effects demonstrated in these studies were often
smaller than for other stressors, such as time pressure (see
Schaufeli & Enzmann 1998), leading these researchers to
conclude that health hazards are not particularly related to
providing PCC.
This study shows that the answer is more complex, and
that this quandary might be better resolved by considering
PCC in the context in which it occurs, particularly nurses’
physical or mental health or high caring orientation. As for
nurses’ mental health, interacting with patients and giving
high PCC per se did not lead to mental health deterioration.
However, this is not a good enough reason for dismissing
nurse–patient encounters as sources of stress and health
impairment. As the findings indicate, mental health was
improved under compatible conditions of high caring and
high PCC, and worsened under incongruent conditions.
Moreover, the findings help to demonstrate that these
relationships remain determinants of mental health when
another relevant stressor, workload, are controlled for.
Interestingly, the incongruent condition of a nurse exhibiting
high caring and providing low PCC did not have a more
detrimental effect on mental health than the congruent
condition of a nurse exhibiting a low caring orientation and
providing low PCC. This finding suggests that giving low
PCC does not affect mental health, regardless of the nurse’s
caring orientation.
As for physical health, engaging with PCC harmed
nurses’ physical health. It seems that the intensive encounters with patients and their families characterizing nurses
engaging in PCC had an effect on their physical health
(McArdle et al. 1995, Rose et al. 2007), regardless of their
caring orientation. This finding suggests that, at least with
regard to their physical health, nurses cannot expect their
investment in PCC to be rewarded solely by patients’
gratitude. Emotional investments in patients frequently
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JAN: ORIGINAL RESEARCH
What is already known about this topic
• The nurse’s job is characterized as a high-risk occupation due to a variety of physical and mental health
hazards present in the work environment.
• Nurses are required to give patient-centred care, and
this creates challenges for its implementation.
Patient-centred care and nurses’ health
in the job (Kobasa & Maddi 1977). Nurses’ sense of
psychological hardiness was recently found to be a potent
predictor of nurses’ physical health (Jackson et al. 2007).
Future researchers should further explore the relationships
among caring orientation, nurses’ physical health and
hardiness.
Implications
What this paper adds
• Giving patient-centred care per se does not affect
nurses’ mental health, but the relationship of patientcentred care behaviour and nurses’ mental health is
moderated by the nurse’s caring orientation.
• Giving patient-centred care is associated with impaired
physical health.
• Possessing a caring orientation improves nurses’
physical health.
Implications for practice and/or policy
• Caring orientation programmes focusing on the nurse’s
personal meaning of being a nurse, identification of
caring values and assimilating caring values into their
professional identity should be developed.
• To achieve enduring effects, training programmes
should be supported by an organizational climate
focused on the core values of caring.
have to be balanced by the organization for which nurses
work (Schaufeli et al. 1996, Zapf 2002), perhaps in the
form of a supportive climate, benefits, recognition and
other rewards. Further studies are needed to examine why
the fit/misfit hypothesis was not supported for physical
health, i.e. if this was an artefact of the present study, or if
it is valid across settings and contexts.
On the other hand, high caring proved a potent enhancer
of physical health. This finding is interesting, and might
suggest that a nurse’s caring orientation is not only
beneficial for their patients, but also immunizes the nurse
against the deterioration of physical health. A meta-analysis
of 130 empirical studies showed that caring was associated
with a sense of accomplishment, satisfaction and fulfilment
in nurses (Swanson 1999). Nevertheless, to the best of my
knowledge, this is the first study suggesting that a caring
orientation is also associated with physical health. Perhaps a
caring orientation is associated with hardiness, giving a
nurse a higher sense of control, commitment and challenge
The findings carry a promising message for managers who
are trying simultaneously to satisfy the needs of internal
(nurses) and external (patients) customers. These customers’
perspectives need not necessarily be contradictory; rather,
fostering a high caring orientation should help in manoeuvring between the contrasting perspectives in the attempt to
obtain superior PCC for patients and good health outcomes
for nurses. Most previous research has linked caring
orientation to nurses’ behaviours towards patients (Watson
2002). The present findings show promising insights,
indicating that focusing on caring may help to ‘win both
ways’, namely to achieve nurses’ good mental health as
well as high PCC, and to achieve good physical health
(regardless of PCC behaviours).
The question of how to elicit high caring then emerges.
To foster nurses’ caring orientation, caring training and
orientation programmes should be developed. These programmes should concentrate on the personal meaning of
being a nurse, identification of caring values and assimilating caring values into one’s professional identity (Wear &
Zarconi 2008). Unfortunately, cumulative evidence with
training programmes has indicated that their effects fade
soon after the training period ends. For example, Epstein
et al. (2005) noted that in the context of healthcare
systems, driven by technology and beset by productivity
pressures and financial concerns that threaten their survival, caregivers may be limited in their enduring caring
orientation.
To achieve enduring effects, training programmes should
be supported by job restructuring efforts. These efforts
should focus on attempts to broaden the scope of the nursing
role beyond physical care, for example by focusing on PCC
behaviours in performance appraisals, and as criteria for
promotion and rewards. Nursing managers should establish
an operative definition of PCC that will encompass the
essential requirements at the candidate recruitment stages.
This would possibly require a combination of education and
experience, aligned with personal skills such as communication skills, and power sharing. Moreover, nursing managers
should act to remove obstacles to the implementation of PCC
and resources should be directed to training and improving
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1471
A. Drach-Zahavy
nurses’ caring skills. Together, these efforts would help in
maintaining an organizational climate focused on the core
values of caring.
Conclusion
Nurses’ health is a recurrent issue, which may not be solved
by merely emphasizing – or limiting – the requirement to give
PCC. Factors such as caring orientation, whether it facilitates
professional image, skill use or knowledge, must be taken
into account. Moreover, talking of physical health or of
mental health makes a difference. This study promotes our
understanding of how to improve the mental health of nurses
engaging in PCC. The findings showed that the mental health
outcomes of providing PCC critically depend on the prevalence of caring orientation. As for physical health, the
question of how to enhance both PCC and nurses’ physical
health remains unsolved. Nevertheless, the findings point to
the importance of taking into account nurses’ caring for
improving their physical health.
Funding statement
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the author.
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Appendix
Evidence of patient-centred behaviour
1.
2.
3.
4.
5.
6.
7.
8.
9.
Score
NA
Elicits concerns, fears and expectations from patient
Expresses empathy for patient’s concern(s) and/or dilemma(s)
Clearly presents the evidence in understandable terms (avoiding medical jargon)
Checks with patient for understanding and invites questions
Elicits patient’s preferences regarding decision making
Assess the patient’s readiness for change (if appropriate)
Provide recommendations
Allows the patient time to consider options
Summarizes the discussion, decisions and next steps
Scoring key: 3 = well done
2 = Addressed incompletely or awkwardly
1 = Attempted but not accomplished
0 = Not attempted (missed opportunity)
NA = Not applicable in this encounter
Comments:
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