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An ethnographic study of main events during hospitalisation: Perceptions of

nurses and patients

Article  in  Journal of Clinical Nursing · June 2012

DOI: 10.1111/j.1365-2702.2012.04083.x · Source: PubMed

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PATIENT DIGNITY AND SAFETY

An ethnographic study of main events during hospitalisation:

perceptions of nurses and patients
Christine Coughlin

Aim. To explore nurses’ and patients’ perceptions of care during main events of hospitalisation.
Background. Main events during hospitalisation such as admission, transfer to the operation room and preparation for dis-
charge have been identified as times when there is significant patient–caregiver interaction. It is during these interactions that
there is an opportunity for the nurse to have a positive influence on the patient’s satisfaction with care. The patient’s perception
of care has been studied but not qualitatively. Perceptions of care from the nurses’ perspectives have not been well studied. This
study explored the patient’s perception of care as well as the nurse’s perception of the care he provided.
Design. This study used an ethnographic methodology that included participant observation and unstructured interviews.
Method. The research was conducted in two phases. First, participant observation was chosen to observe and understand
nurse–patient and nurse–family behaviour. The second phase was an unstructured interview to elicit both the patient’s and the
nurse’s views about the care experience.
Results. Two major findings were the patient and the nurse had different perceptions of the care experience and the presence of
family or a support person influenced the patient’s perception of care.
Conclusion. The use of ethnography proved to be a valuable methodology for studying the interactions of patients, families and
nurses. Qualitative methods such as ethnography can yield significant findings on perceptions that are unable to be gleaned by
traditional quantitative methods but can serve to provide hypotheses for further study.
Relevance to clinical practice. This study suggests that to maintain quality and patient satisfaction scores, hospitals will need to
focus on the difference between the perceived care given and the perceived care received particularly during main events. The
role of families and visitors supports positive perceptions of care.

Key words: ethnography, main events, patient satisfaction, perception of care

Accepted for publication: 16 January 2012

primary nurses’ and patients’ perceptions of care delivery

Introduction
Consumers of health care today are becoming more cognizant
of and vocal about their rights and are demanding to be able
to influence their own care. Quality care surveys, outcome
measures of care, patient satisfaction surveys and physician
rankings are a few of the measures the sophisticated
consumer will be assessing in selecting health care services
(Isaac et al. 2010). The aim of this study was to explore
during main events of hospitalisation. Main events for this
study were identified as points of service delivery in which
intense customer–provider contact is experienced and were
preadmission, readmission, transport, discharge, transfer to
referring hospital and receipt of bill for service. It is at these
critical points in time that the patient and family may feel the
most vulnerable in the health care environment and during a
time when the patients and families have the least control. At

Author: Christine Coughlin, EdD, RN, Associate Professor, School of Nursing, Adelphi University, Garden City, NY 11530, USA.
Nursing, Adelphi University, Garden City, NY, USA Telephone: +1 516 877 4535.
Correspondence: Christine Coughlin, Associate Professor, School of E-mail: coughlin@adelphi.edu

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Journal of Clinical Nursing, 22, 2327–2337, doi: 10.1111/j.1365-2702.2012.04083.x 2327
C Coughlin
this same time, their usual expectations about the quality of
care they will receive may not be met.
Review of the literature
During main events of hospitalisation, such as transferring
out of the intensive care unit, or experiencing the admission
assessment, nurses and patients both form perceptions of
their care. Perceptions of care regarding main events from
nurses’ perspectives have not been well studied. In a
qualitative study conducted by Wilkin and Slevin (2004),
nurses identified their experiences of caring. Knowing the
patient was seen as an important aspect in rendering care.
The nurses described their presence with the patient that
allowed for the emotional work of establishing a relationship.
The opportunity to know the patient was believed to occur
during main events of hospitalisation. In a systematic review
of the literature on studies of nurses’ perception of care,
Bassett (2002) found that nurses valued the interpersonal
aspects of the caring relationship and creating a strong
relationship with the patient. Watson (2003) identified
transpersonal caring as becoming liberating allowing the
practice of love and caring. This, she says, is the very nature
of our humanity.
Patients’ perceptions of care have been studied primarily
within the patient satisfaction literature and using the well-
known Press Ganey survey tool. The goal of the Press
Ganey survey is to assure that the voices of the patients are
heard in health care organisations (Press Ganey 2011).
Utilising data from the Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) to examine
patients’ experience with hospital care, Jha et al. (2008)
found a positive correlation between patient satisfaction and
high nurse-staffing levels. Their study’s findings underscored
the importance of nurse–patient staffing and the patient’s
perception of the interpersonal aspects of care. In another
study analysing patients’ perception of care and quality care,
the authors found consistency between patient experiences
and the technical quality of care (Isaac et al. 2010). To
further understand the patient experience, Dawood and
Gallini (2010) used discovery interviews in their qualitative
study. Two of the themes that emerged were care and
attentiveness. The patients who participated were positive
about the overall attentiveness of the nurses but stated that
the routine treatment aspects of the care ‘took too much of
the nurse’s time’, but communication aspects were found to
be important. The patients were more satisfied with
their care when nurses were responsive to requests or
communicated the reason the request could not be met
immediately.
2328
It is during main events that the patient’s need for care and
concern is the greatest. Prior research studies have noted that
there is a specific incident or occurrence that determines a
patient’s and family’s perception of satisfaction with care
(Rempusheski et al. 1988, Greeneich & Long 1993). As well,
the skill of the nurse in treatment was found to be another
important factor in patient satisfaction and outcome (Mayer
et al. 1998, Bozimowski 2011). However, most studies use
survey instruments, and such instruments have not captured
what patients verbally express about their care. A review of
survey instruments identified a considerable gap between the
content of and items on patient satisfaction surveys and what
some prior research has identified as important to patients
and families (Nelson & Neiderberger 1990).
The communication with patients and interaction of the
nurse and patient takes place both verbally and non-verbally
during key events and influences the perceptions of each.
Both nurses and patients describe a relationship that allows
for getting to know each other (Johnson & Smith 2006).
Henderson et al. (2007) also observed getting to know each
other as a key component in the nurse–patient interaction.
She described these nurse–patient interactions at the time
nurses were attending to patients’ physical needs. Patients
expected nurses to be responsive to their immediate needs
(Dawood & Gallini 2010). The importance of this relation-
ship has been well described by nurse theorists (Bassett 2002,
Watson 2003, 2005).
Theoretical underpinnings
This study relied heavily for a theoretical base on Watson’s
(1988) work and the process of caring as central to nursing.
The nurse provides care for the patient and also develops a
caring relationship with the patient to assess the needs and
expectations of the patient. The nurse intercedes on behalf
of the patient in the health care system when the patient is
unable to do so and spends time with the patient during
main events. It is during main events of hospitalisation that
the opportunity to develop the caring relationship occurs.
Watson (1988) explored the development of a nursing
theory that views the ways nurses connect with and serve
people. The nurse must connect with the patient and family
in a caring interaction to assist the patient and maximise
health. Thus, her theoretical framework describes this
caring relationship. Watson saw human care as a moral
ideal that transcends specific acts of an individual nurse and
produces collective acts of the nursing profession that have
consequences for human civilisation. She stressed that there
must be an underlying commitment to care and the desire
to care.
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Journal of Clinical Nursing, 22, 2327–2337
Patient dignity and safety
Further assumptions in Watson’s theory address caring as
the moral ideal of nursing in which the goal is protection,
enhancement and preservation of human dignity. She believes
all of human caring is related to intersubjective human
responses to health-illness conditions, a knowledge of health-
illness, environmental–personal interactions, a knowledge of
the nurse caring process, self-knowledge, and knowledge of
one’s power and transaction limitations (Watson 1988). As
the patient experiences caring from the nurse, so does the
nurse experience the care interaction with the patient and/or
family.
The patient’s perception of patient care and the nurses’
perception of care coexist in the phenomena of care delivery.
It is this perception of care that is significant during main
events of care delivery and is the focus of this present study.
Methods
Ethnographic method
As a research process, ethnography is the traditional
approach used by anthropologists as they describe people
living within a culture or subculture. As a method, it has
proven valuable for studying patient perceptions (Deitrick
et al. 2006). The findings from an ethnographic study not
only describe a culture but often identify questions for further
research on related topics. The ethnography method for this
study was based on the Bernard (1994) model.
Ethnography is considered both a process and a product. It
is a social act. The process is a method of inquiry that social
scientists employ to study human behaviour. Strategies used
in this method allow the researcher to collect phenomeno-
logical data, which can be utilised to view a particular aspect
of human life. The product of ethnography is a study that
describes a group of people (LeCompte & Preissle 1993). The
central focus in ethnography is culture, broadly defined as the
learned social behaviour or way of life of a particular group
of people. Ethnography provides knowledge that can assist in
understanding one’s own culture and those of others; it also
provides a basis for planned cultural change (Munhall 2011).
Bernard explains some methods for data collection and
analysis within his model. For example, he states that when
doing the unstructured interview, it is important to tell the
informant that the purpose is to learn from them, then to
keep the conversation focused on the topic but allowing the
informant to discuss his thoughts. He says that effective
probing is essential for unstructured interviewing. In data
analysis, Bernard is a proponent of expressing themes in the
form of a flow chart as a way of understanding one’s data. He
also believes that the researcher has to develop these themes,
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Journal of Clinical Nursing, 22, 2327–2337
Perceptions of care
state them with clarity and support them with quotations
from informants (Bernard 1994).
The present study was conducted in two phases. First,
participant observation was chosen to observe and understand
nurse–patient and nurse–family behaviour. The researcher
observed interactions of 10 dyads, primary nurses and their
patient, during this phase. Participant observation allowed the
researcher to look beyond statements of ideal behaviour and
observe behaviour directly so that the discrepancy between the
real and ideal behaviour could be described, assessed and
explained (Bonner & Tohurst 2002, Munhall 2011). In
participant observation, the study participants know the
researcher or ‘observer’ is present and is collecting data.
During this phase, the researcher becomes immersed in the
setting, which in this study was a nursing care unit.
Population and setting
The study was completed in an academic teaching hospital in
a major urban city in the northeast United States. The
hospital had approximately 1000 inpatient beds for diagnosis
and treatment of children and adults. Permission to conduct
the research study was obtained from the hospital’s Human
Subjects’ Review Committee. Informed consent was obtained
from the patients and the nurses who participated. The
observations took place on an inpatient unit for surgical
cardiac adult patients. The average length of stay for patients
on the unit is five days.
The second phase of data collection involved interviews.
Following the observation phase, the investigator interviewed
the patient and the nurse dyad who had already been
observed in main event interactions. The nurses were
considered as the ‘primary’ nurse for each patient. An
unstructured interview technique was chosen to elicit a
narrative flow that allowed the respondent to tell his/her
story without cues or directive questions (LeCompte &
Preissle 1993, Bernard 1994).
Patients were selected on the basis of their ability and
willingness to participate in the study; all participation was
voluntary. The criteria for patients’ inclusion were being
alert, cognizant of their surroundings and ability to under-
stand the directions of the investigator during the interview.
Final selection of patients for participation included a wide
range of ages and participants with differing levels of physical
stability. Ten patients were chosen who met the selection
criteria and were cared for by a primary nurse. The age range
of patients was 57–88. There were nine men, and only one
patient was non-Caucasian and was Hispanic. All patients
had prior hospitalisations, and four had inpatient experiences
at the hospital setting used for this study.
2329
C Coughlin
The two nurses, both women, who were observed and
interviewed in the study, were selected by the investigator
who conferred with the Education Specialist and the Clinical
Nurse Manager of the unit. These nurses were considered
‘expert’ as defined by Benner (1984, 2001). Expertise in
nursing has been well researched and described in the
literature (Benner et al. 1996, Benner 2001). Expert nurses
have passed the levels of: orientation, novice, advanced
beginner, competent and proficient phases of nursing
practice. Nurses at the expert level of practice are confident
and secure as professionals. Thinking, knowing and doing are
fused (Benner et al. 1996). In the present research setting, the
care delivery model was the Professional Practice Model of
Nursing (Clifford & Horvath 1990). In this practice model,
each patient is cared for by a primary nurse who plans and
directs the care for the patient. Either of the nurses was
assigned to all of the patients who participated in the study.
Data collection
During the observations, the investigator was in close
proximity to the patient and nurse. The investigator also
observed the nurse’s interactions with family members who
were present. Jottings or short notes were made during the
observations, and at the end of the observation, the
researcher went to a private office to write the full account
of the observation. This occurred frequently during the
observations to have as much recall as possible. While in the
clinical area, while observing, there was minimal participa-
tion by the researcher. However, if the nurse needed
assistance with positioning a patient or another patient
activity, the researcher assisted or participated. However, this
occurred infrequently; the role of the researcher was mainly
to observe the interactions of the nurse and patient.
Participant observation included the admission assessment,
which usually takes approximately 25 min at the patient’s
bedside. It is during this initial assessment on the unit that
the patient meets his/her primary nurse. This assessment was
the first observation of the nurse and the patient by the
researcher. The researcher also observed each patient during
at least two other main events during hospitalisation such as
discharge teaching or when a new treatment was initiated.
The data from the observations were not analysed prior to
the interviews. This was decided upon to minimise the effect
of observational data on the researcher’s interview data
collection. Data collected from the interviews and observa-
tions were analysed after all data were collected.
Immediately prior to the patient’s discharge, the investiga-
tor interviewed the patient to elicit his/her perspective on the
care received. The interviews were conducted in a private
2330
space to ensure confidentiality. At the end of each interview,
selected demographic information was obtained from each
respondent. Each nurse was interviewed separately to ascer-
tain her perspective on the patient’s satisfaction with the
hospital experience. One nurse was interviewed six times as
she was assigned to six patients in the study; the other nurse
was interviewed four times. The subject of each interview
was the care of one specific patient.
The overall question for each interviewee was an open-
ended one that focused on the present hospital experience
and the care delivered. The investigator allowed a free flow of
information but directed the conversation so that the infor-
mation remained focused on the personal experience of the
patient, family or the nurse. The investigator used relevant
probes to ensure that the information collected was specific to
the study’s focus. At the end of the interview, the investigator
summarised the content and reviewed it with the informant
for feedback and validation.
Methodological rigour
The researcher throughout the study ensured methodological
rigour in several ways. First, regarding trustworthiness and
credibility, there was prolonged engagement in the field. Both
observations, participant observation and interviews, were
utilised. Auditability was ensured with the recorded paper
trail in which the movement from phrases to categories to
themes was evident. The bias of the researcher was attended
to in several ways, especially because she was a director of the
cardiac care centre in this large teaching hospital. First,
methodological notes were taken that addressed my presence
and any issues that could affect the data collection. The
researcher, while known to the ‘informants’ (nurses) as is the
case in many ethnographic studies, remained objective
through the data collection. A constant thoughtful process
in reviewing the observations, for example, assisted with as
much objectivity as is possible. The researcher bracketed her
own perceptions early on, prior to the commencement of the
study, thus was aware of the potential of preconceived
notions. To further ensure objectivity and minimise bias, the
data from the observations were not analysed prior to the
interviews. This decision was made to minimise a possible
effect or influence of observational data on the researcher and
thus the next phase, the interviews. The instrument for this
study, the researcher, was reliable in that she remained
constant and was the only one conducting the interviews and
completing the observations. For validation, the investigator
summarised the interviews at the end with each participant to
be sure of the meaning of the recorded content. Because
ethnography is a descriptive and not interpretive process, the
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Journal of Clinical Nursing, 22, 2327–2337
Patient dignity and safety
method used for this study (Bernard 1994) does not address
the need for member checking of the final product or final
thematic analysis.
Data analysis
This study was inductive in methodology and utilised only
qualitative data collection and analysis. All interviews were
examined by reviewing each nurse transcript with the related
patient’s transcript so that the nurse’s perception of care of a
specific patient was examined with that same patient’s
perception of the care experience. Following this, all of the
nurse interview data and all of the patient interview data
were examined as an aggregate. Content analysis of the
qualitative data (phrases)was undertaken using Bernard’s
(1994) overall method of moving from interview data phrases
to themes but more specifically a process such as the one
outlined by Krippendorff (1980) in which he addresses how
to progress from verbatim transcripts and phrases to themes.
First, for the patient data, phrases were highlighted that
represented significant content related to the study’s aims.
These initial identified codes represented categories related to
main events, caring, advocacy, visitors, tests and treatments.
Those ‘similar’ coded phases were then reduced into catego-
ries; these were then conceptualised as overall themes (see
Table 1 Patient themes and subthemes
Positive themes Negative themes
Care issues
Waiting
Neglected
Frightened
Patients have no control
Waking up at night
Responsive
Competent
Explained everything
Team work
Environmental issues
None Bed hard
Noise
Food tasteless
So many people
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Journal of Clinical Nursing, 22, 2327–2337
Perceptions of care
Table 1). Two main themes emerged from these categories:
those containing subthemes relating to what the researcher
termed as environmental issues and the other to care issues.
Because there were both positive and negative responses to
the interview questions, these were then separated into
positive and negative aspects of each category (see Table 1).
The researcher used the same process of analysis for the data
collected from the nurse interviews. Table 2 outlines the
themes that emerged from the nurse interviews.
Observational data collected and described in writing and
in detail in the investigator’s notes were analysed for themes
using the same content analysis method. A comparison of
interview themes and observation themes was then under-
taken resulting in the emerging of new themes or overarching
main findings.
Study results
The study results indicated that the nurse’s perceptions of care
and the patient’s perceptions differed. Table 3 identifies the
main events that occurred and the patient’s perception of care
and the nurse’s perception of care. The perception of care
differed in eight of the ten nurse/patient interviews. In only
two nurse–patient dyads (interviews) was the perception of
care the same. Of note, when the patient had a family member
Associated subthemes
Waiting for surgery, timing for tests
and procedures
Forget when ask for something, slower
response than in ICU, too short staffed
Anxious, worried about getting medications,
worried about swollen feet
Don’t listen to patient tell about self,
patients not allowed to voice complaints
Disturbed at night, bathed at night
Available, needs anticipated, better at night,
attitude better at night
Follow-up, nurses specialised, felt safe,
comfortable, competent in doing dressing
Answered questions, brought written material,
teaching, prepared family for patient moves,
peace of mind, prepared to go home.
Everybody watches
Pillows not good
Noisy at night, noisy equipment
Food awful, not cardiac
Disappointed, very difficult
2331
C Coughlin

Table 2 Nurse themes and subthemes

Nurse themes Associated subthemes

Positive Negative

Care issues
Connecting to Knowing patient well, knowing
patient patient as individual, trusting
relationship, give patients
some control
Teaching Explaining, answering questions,
patient/family receptive to teaching
Smiling Laughing, good times, talking
Interaction Knowing the family, inclusion,
with family teaching family
Making Reassuring, touching
comfortable
Listening Waiting
System issues
Frustration Changing patients, miscommunication
to patients from physicians, not enough
time to teach patients
Emotional issue
Inappropriate Calling nurse to meet son
behaviour

Table 3 Main event and patient and nurse perception of care

Patient Main event Perception of care (patient) Perception of care (nurse)

JM Admission, surgery Very difficult, difficult Built trusting relationship, fulfilled

delay, test his needs
JR Admission, preparation Care was good, better in ICU, Really cared for this patient, liked
for discharge response on floor slower interactions with family when teaching
WM Admission Competent, sense of progress Not enough time, able to help him
MK Admission, waiting Too many people, concerned Teaching went well, good interaction
for surgery with preoperative antibiotics
MA Admission, blood Happy that blood finished Needed to know patient better,
transfusion on time admission went badly
FC Admission, surgery delay, Everything since OR day has Good relationship with spouse, had
Immediate post-op night, been good, family felt comforted good time caring for patient, was
moving to another room, that nurse was with patient, able to know patient and wife well,
moving out of ICU everyone worked as a team, felt good care was given
nurse prepared patient and
family for moves
AG Dressing change, discharge Felt wife well prepared to care Routine care, good teaching the whole
teaching for patient at home, nurse family, needed more time
competent and explained
everything
JS Admission Felt needs were anticipated Patient not responsive, frustrated
when refused help
EG Admission, dialysis Everything went smoothly Patient open, more receptive than
last time
VO Walking, medication Some nurses give patient no Care went well, patient receptive,
administration, test control, let patient tell any nurse would have been all right
about himself

Ó 2012 Blackwell Publishing Ltd

2332 Journal of Clinical Nursing, 22, 2327–2337
Patient dignity and safety Perceptions of care

or visitor present, the perceptions of care were positive;
however, they were negative when the patient had no visible
family member or other visitor present (Table 4).
Patients’ perception of care
Several themes emerged from the interviews. The positive
themes included a view of competence on the part of the nurse
and other employees, team work of the staff, responsiveness
and availability of the staff and that the nurse explained
everything. There were also negative themes that emerged and
primarily focused on basic needs. They concerned noise,
tasteless food or incorrect food, uncomfortable bedding and
being disturbed at night. The patients identified these issues,
and these were in stark contrast to those of the nurses. For
example, one patient discussed the bad attitude of a night
worker and also suggested that it would be best for a heart
hospital if the response time could be improved. Another
patient commented that the response time was slower than in
the ICU. A third patient mentioned feeling neglected because
the nurses were too busy. Several patients expressed anxiety
about receiving medications, treatments or physical symptoms.
The patients’ voiced perceptions of care were not evident
during the participant’s observation. For example, it was
observed that the response time was very quick. The patient
that voiced the most concern about the nurse’s response was in
a four-bedded room, and the nurse was always stationed in the
room. It was observed that the nurse anticipated the patient’s
needs and the patient rarely needed to use his call bell. The
patient’s anxiety about receiving medications was also not
evident by observation alone.
Nurses’ perception of care
The two nurses who cared for the ten patients in this study
identified themes that were both positive and negative. Both
Table 4 Presence of visitor and perception of care
Spouse/family/ Overall
significant Presence of perception
Patient Nurse Sex other visitor of care
nurses stated that interactions with the family were very
important. The positive themes that emerged from the
interviews of the nurses centred on teaching, including the
family and knowing the family, reassuring the patient and
connecting to the patient. For example, they expressed a need
to include the family in teaching and stated that the care was
improved if the family was known to them. They both
mentioned that knowing the family allowed them to under-
stand the patient better and that not knowing the family was
a frustration.
The two nurse participants placed importance on the care
of the family. They both identified the need to include the
family in teaching. Both nurses also mentioned the impor-
tance of listening to the patient and found connecting to the
patient to be a positive experience. One nurse said she needed
to know her patients as individuals and build trusting
relationships. The negative themes that emerged from one
nurse’s interview data were a frustration when she did not
have enough time to know the patient and when she failed to
get to know the family. Both nurses mentioned that they were
also frustrated when they had to change their assignment of
patients.
One nurse participant mentioned her concern with mis-
communication from physicians to patients. One of the
patients had come into the hospital on Friday for a procedure
on Monday. The patient needed to have a blood transfusion
prior to having the procedure. The primary nurse explained
to the investigator that the patient was very upset because he
expected the blood to be ready when he was admitted. The
nurse attempted to go over the procedure with the patient.
Later, outside the room, she expressed her frustration to the
researcher when she stated, ‘I wish the doctors would be
realistic when explaining to patients what to expect when
they are admitted’. She stated that ‘The patient was focused
on the blood; he felt that it took too long, he kept calling for
me to check and was surprised when it finished on time’.
Nevertheless, the researcher observed expert nurses giving
quality thoughtful care. The nurses appeared comfortable
and confident giving care to this population of patients.

JM CF M Yes No Negative
Study limitations
JR JL M Yes No Negative There is always a consideration of authenticity when
WM CF M Yes Yes Positive
observers know they are being observed and there is no
MK JL M Yes No Negative
MA JL M Yes Yes Positive way to avoid this influence on actions. While bracketing was
AG CF M Yes Yes Positive utilised, the past experiences of the researcher as a clinical
FC JL M Yes Yes Positive director in the cardiac setting could bias findings, but the
JS JL M Yes Yes Positive utilisation of many types of rigour ensured attending to bias.
EG JL F Yes Yes Positive
The sample was limited to ten patient informants and two
VO CF/JL M Yes No Negative
nurse informants in one setting and in no means should the

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Journal of Clinical Nursing, 22, 2327–2337 2333
C Coughlin
findings be considered generaliseable. However, the study
results should be considered within these limitations.
Discussion
The results from this study provide some support for prior
research findings and highlighted some noteworthy new
findings. First, this investigation’s findings support the work
undertaken by Rempusheski et al. (1988) and by Long and
Greeneich (1994) concerning perceptions of care during main
events. Rempusheski et al. identified that the family’s critique
of patient care in the intensive care unit may solely be based
on the interactions between the nurse and family. Long and
Greeneich (1994) identified risk points or main events, which
may result in increased or decreased patient satisfaction. In
the present study, family involvement, although not clearly
labelled as family–nurse interactions, influenced patients’
positive perceptions of their care. Risk points in this study
(main events), as in the Long and Greeneich study, did
influence patient satisfaction. One event in particular was
noted by a patient as a troublesome time: during the
admission procedure in which patients were admitted and
immediately sent to the operating room.
In another study, Greeneich and Long (1993) identified
that complaints or satisfaction is often centred on one event.
This was also evident with one patient in the present study
and his focus on one event, blood transfusion. He was
observed to be anxious and concerned with the starting of the
transfusion as well as the progress of the transfusion. The
patient discussed the blood transfusion during the interview.
He mentioned that he was happy when the blood finished on
time. Two other patients in the study focused on one event,
that of being awakened at night. These events seemed to
influence the patient’s overall perceptions.
There is no recent literature since Spicer et al.’s (1988) in
their classic work identified main events as points of delivery
service where intense consumer–provider contact is provided;
such points were identified in this study. Each event involved
the patient’s interaction with either the hospital personnel or
the hospital system. Surgical delay, treatments such as
dialysis, blood transfusion, cardioversion, medication admin-
istration and dressing change are some of the main events
that were noted in this study. In each of these situations, there
was a consumer–provider contact. Complaints, for example,
about the size of the patient room would not be considered a
consumer–provider contact event.
Vosburgh (1988) worked specifically with cardiac patients
and families in attempting to enhance consumer–provider
communication. In her work, extended visiting hours were
perceived by the nursing staff as a burden. However, family
2334
visits by observation in the present study indicated that
patients who had a visitor present most of the time viewed the
hospital experience as positive. Patients who did not have a
visitor present for long periods of time viewed the hospital
experience overall as negative. This finding is demonstrated
in Table 4. A perceived burden by the family and staff can be
translated into a positive experience for the patient. Thus,
extended visiting hours need to be evaluated by perceptions
of, and effect on, all those involved. The nurses in the present
study, while the unit was not involved in ‘extended hours’,
did see the family visits as useful to their care. Gerteis (1993)
identified the importance of meeting the needs of the entire
family for hospitalised patients.
In a study undertaken by Chesla (1996), some nurses
claimed that technical care they were required to provide
limited the possibility of learning from a patient’s family. The
study was conducted in a critical care environment. However,
in the present study, on a unit that utilised telemetry, both
nurses stated that the presence of family greatly enhanced the
care they could give to the patients. They mentioned needing
to know the family and including the family in discharge
teaching.
The present study also identified that most important to the
patient were their basic needs. This finding is supported by
other research (Redman & Lynn 2005). Understanding the
patients’ concern about basic needs is important for the
caregiver to identify. Such needs include a quiet environment.
This is not only a challenge for the caregiver but is an issue that
should be addressed by hospital administration. Four patients
in this study mentioned the noise. And in fact, two patients
stated that the televisions should not be on during the night.
The Institute of Medicine (IOM) emphasised that care should
be patient-centred, focused on the patient’s experience of
illness (IOM 2001). Gerteis et al. (1993) identified ways of
creating a hospital environment that is pleasing and quieter for
patients. They conducted a national survey of over six
thousand patients and concluded that physical comfort that
included pain control, basic nursing care and the hospital’s
physical environment is important to patients. In the physical
environment, they included noise control.
Other consumer-oriented groups have addressed ways to
reduce noise. A survey conducted by the Picker/Common-
wealth Program for Patient-Centered Care identified multiple
ways of reducing noise and improving the ambiance of
hospitals (Gerteis et al. 1993). They recommended abandon-
ing the use of overhead speakers for paging personnel, using
musical sounds for alarms to make them less frightening, and
the use of carpets and fabrics to reduce noise. This investi-
gation found patients complained specifically about squeaky
wheels on equipment.
Ó 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 2327–2337
Patient dignity and safety
The responsiveness of the nurse was mentioned by some
patients in the interviews although not observed by the
investigator. One patient compared the response time to be
slower than when in intensive care. In a large study, in four
US hospitals, on ‘call light’ responsiveness, Tzeng and Yin
(2010) found that patient satisfaction was related to their
perception of the nurses’ responsiveness to the call light, if
their problem was then resolved and if the nurses answered
the call in person.
In summary, the findings from this investigation supported
the main event phenomena identified by other researchers. As
well, the analysis of data described instances in which
patients’ perception of care and nurses’ perception of care
clearly differed. Nurses in this study were focused on the
future for the patient, home care, discharge planning,
medication routines at home and other perceived future
concerns. Patients were frequently focused on the daily basic
concerns of being a patient in a hospital, sleeping through the
night, the quality of the food and environmental issues. For
three of the patients, their length of stay was longer than
expected providing the nurse more opportunity to interact
with the patient and the family. This seemed to influence the
patients’ perceptions in that for these three patients the
perception of care was the same for the nurse and the patient.
Study implications and recommendations
In this study, nurses’ perceptions were often different from
the patients’ perceptions. The patients’ perceptions described
through interview were not ones observed by the researcher;
this would suggest that it is important for the nurse to ask the
patient about the care. The nurse’s interactions with the
patient should include frequent inquiries as to the patient’s
feelings about the care especially basic needs such as reduced
noise in the hospital environment.
When the nurse had more opportunity to interact with the
family and a longer period of time caring for the patient, as in
three of the case, the nurses’ and patients’ perceptions were
the same. As hospital length of stays is dramatically
decreased, the opportunity to know patients and their
families in any significant way is decreased, making it even
more imperative to find ways to interact with and include
families in any care of the patient. Additionally, both nurses
said that the presence of family members helped them to
provide better preparation for discharge to home.
A noteworthy finding in the present study was that the
patient’s perception of care was consistently positive if the
patient had a visitor present most of the time and consistently
negative if the patient was alone most of the time. This
occurred even if the nurse stated her perception that the care
Ó 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 2327–2337
Perceptions of care
was good and she had met the patient’s needs, and further, it
was observed that the patient was not ‘waiting’ for care. This
aspect of family and visitor impact on care needs to be further
explored. Nurses in this study were focused on the future for
the patient, that is, home care, discharge planning and
patients were frequently focused on the daily basic concerns
of being a patient in a hospital such as sleeping through the
night, quality of the food and environmental issues. As well,
responsiveness of the nurse to the patients’ call bell or light
should be emphasised in providing patient care. Therefore,
hospitals should continue to focus on meeting the patient’s
perception of care and not hospitals’ expectations of care. To
maintain quality of care and high patient satisfaction scores,
hospitals will need to focus on the difference between the
perceived care given and the perceived care received. Thus,
survey instruments need to be supplemented with patient
narrative questions, even if brief, on patient care and
satisfaction.
An important recommendation for nursing is the replica-
tion of this study with different types of participants: more
women patients, those with other diagnoses, and patients
who are more ethnically diverse. Because nine of the patient
participants in this study were men, it would be important to
replicate the study to identify whether perceptions of care
differ by gender. Cultural differences in perceptions of care
also need to be investigated in a future study. As well,
different types and levels of nurses’ experience and skills were
not a consideration in this study and should be included in
future studies about patients’ and nurses’ perceptions of care,
especially because some studies have identified this as an
influencing factor for patient satisfaction. Hypotheses from
this study’s findings, for example, those involving the
importance of family members in care and the significance
of patient comfort should be developed and tested. The
difference between nurses’ and patients’ perceptions of care
while evident in the current literature should continue to be
investigated and especially through quantitative methods.
Conclusions
It is important to investigate patients’ perceptions of care and
to develop surveys that include such important comfort
factors for them as food, noise and waiting times. The use of
ethnography proved to be a valuable methodology for
studying the interactions of patients, families and nurses.
Families and visitors have a key role in the perception of
patient satisfaction with care, and these roles need further
study as they can influence a positive hospital stay. Qualita-
tive methods such as ethnography can yield significant
findings on perceptions that are unable to be gleaned by
2335
C Coughlin

traditional quantitative methods. Such findings from quali- members had a positive influence on the care they provided
tative studies such as this can serve to generate hypotheses for and enabled them to better know the patient.
further study. Nurses may use these findings as a basis for future research
that will provide and expand knowledge on patient satisfaction.

Relevance to clinical practice

Acknowledgements
Two of the major findings, the patients’ and the nurses’
different perceptions of the care experience and the presence The author of this study would like to express her gratitude
of family or a support person’s influence on the patient’s to Jane White, PhD, Associate Dean for Research, School of
perception of care, have relevance to clinical practice. The Nursing, Adelphi University for her review of and suggestions
patients’ perceptions described through interview were not for an earlier draft of this manuscript.
ones observed by the researcher; this would suggest that it is
important for nurses to ask the patient about the care
Contributions
experience. The nurse’s interactions with the patient could
include inquiries as to the patient’s feelings about the care Study design: CC; data collection and analysis: CC and
especially basic needs such as reduced noise in the hospital manuscript preparation: CC.
environment.
The study also supports encouraging and supporting family
Conflicts of interest
visiting as the patient’s perceptions of care were positive
when the presence of family or a support person was None.
observed. The nurses believed that the presence of family

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