What can nurses learn from patient's needs and wishes when developing an evidence-based quality improvement learning culture? A qualitative study

Abstract

Background
Patient participation is fundamental in nursing care and has yielded benefits for patient outcomes. However, despite their compassionate care approach, nurses do not always incorporate patients' needs and wish into evidence‐based practice, quality improvement or learning activities. Therefore, a shift to continuous quality improvement based on evidence‐based practice is necessary to enhance the quality of care. The patient's opinion is an essential part of this process. To establish a more sustainable learning culture for evidence‐based quality improvement, it is crucial that nurses learn alongside their patients. However, to promote this, nurses require a deeper understanding of patients' care preferences.

Objective
To explore patients' needs and wishes towards being involved in care processes that nurses can use in developing an evidence‐based quality improvement learning culture.

Methods
A qualitative study was conducted in two hospital departments and one community care team. In total, 18 patients were purposefully selected for individual semi‐structured interviews with an average of 15 min. A framework analysis based on the fundamental of care framework was utilised to analyse the data deductively. In addition, inductive codes were added to patients' experiences beyond the framework. For reporting this study, the SRQR guideline was used.

Results
Participants needed a compassionate nurse who established and sustained a trusting relationship. They wanted nurses to be present and actively involved during the care delivery. Shared decision‐making improved when nurses offered fair, clear and tailored information. Mistrust or a disrupted nurse–patient relationship was found to be time‐consuming and challenging to restore.

Conclusions
Results confirmed the importance of a durable nurse–patient relationship and showed the consequences of nurses' communication on shared decision‐making. Insights into patients' care preferences are essential to stimulate the development of an evidence‐based quality improvement learning culture within nursing teams and for successful implementation processes.

Full text

Scand J Caring Sci. 2024;00:1–12.
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1
wileyonlinelibrary.com/journal/scs
Received: 31 October 2023
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Accepted: 24 February 2024
DOI: 10.1111/scs.13252
ORIGINAL ARTICLE
What can nurses learn from patient's needs and wishes
when developing an evidence- based quality improvement
learning culture? A qualitative study
JeltjeGiesen MSc, RN, Researcher1
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IlseTimmerman MSc, RN, Researcher2
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AnnickBakker- Jacobs Research Assistant1
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MarjoleinBerings PhD, Researcher3
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GettyHuisman- deWaal PhD, RN, Associate Professor1,4
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AnnekeVanVught PhD, RN,
Associate Professor5
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HesterVermeulen PhD, RN, Professor1,5
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2024 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.
1Radboud Institute for Health Sciences,
IQ Healthcare, Radboud University
Medical Center, Nijmegen, The
Netherlands
2Psychiatry Department, Radboud
University Medical Center, Nijmegen,
The Netherlands
3Radboudumc Health Academy,
Radboud University Medical Center,
Nijmegen, The Netherlands
4Surgical Department, Radboud
University Medical Center, Nijmegen,
The Netherlands
5Department on Health and Vitality,
HAN University of Applied Sciences,
School of Allied Health, Nijmegen, The
Netherlands
Correspondence
Jeltje Giesen, Radboud Universitair
Medisch Centrum, Radboud Institute
for Health Sciences, Scientific
Center for Quality of Healthcare (IQ
healthcare), Postbus 9101, Nijmegen
6500 HB, The Netherlands.
Email: jeltje.giesen@radboudumc.nl
Funding information
ZonMw
Abstract
Background: Patient participation is fundamental in nursing care and has yielded
benefits for patient outcomes. However, despite their compassionate care approach,
nurses do not always incorporate patients' needs and wish into evidence- based prac-
tice, quality improvement or learning activities. Therefore, a shift to continuous
quality improvement based on evidence- based practice is necessary to enhance the
quality of care. The patient's opinion is an essential part of this process. To establish
a more sustainable learning culture for evidence- based quality improvement, it is
crucial that nurses learn alongside their patients. However, to promote this, nurses
require a deeper understanding of patients' care preferences.
Objective: To explore patients' needs and wishes towards being involved in care
processes that nurses can use in developing an evidence- based quality improvement
learning culture.
Methods: A qualitative study was conducted in two hospital departments and one
community care team. In total, 18 patients were purposefully selected for individual
semi- structured interviews with an average of 15 min. A framework analysis based
on the fundamental of care framework was utilised to analyse the data deductively.
In addition, inductive codes were added to patients' experiences beyond the frame-
work. For reporting this study, the SRQR guideline was used.
Results: Participants needed a compassionate nurse who established and sustained
a trusting relationship. They wanted nurses to be present and actively involved dur-
ing the care delivery. Shared decision- making improved when nurses offered fair,
clear and tailored information. Mistrust or a disrupted nurse–patient relationship
was found to be time- consuming and challenging to restore.
Conclusions: Results confirmed the importance of a durable nurse–patient re-
lationship and showed the consequences of nurses' communication on shared

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PATIENTS' NEEDS FOR AN EBQI- LEARNING CULTURE
BACKGROUND
The sustainability of the current healthcare delivery model
is questionable. Healthcare costs are increasing, and there
is a declining interest in working in the healthcare sec-
tor. To ensure that high- quality care remains accessible to
everyone, a transition to the delivery of appropriate care
is necessary [1]. This concept revolves around person-
centred care (PCC) organised close to the patient. In ad-
dition, the provided care is cost- efficient and focuses on
promoting self- management and prevention after curing
[2]. Nurses are the largest group of healthcare providers
and are vital in making the transition of care [3]. Evidence-
based quality improvement (EBQI) is an approach for
working towards the delivery of more appropriate care.
EBQI combines evidence- based practice (EBP) and qual-
ity improvement (QI) to ensure the right things are done
correctly [4, 5]. EBP is the problem- solving component to
improve healthcare delivery sustainably. It includes using
the best available evidence, the expertise of professionals
and patients' preferences [6]. QI focuses on implementing
change systematically, leading to better healthcare out-
comes for patients, professional development and increas-
ing system performance [7].
By developing an EBQI learning culture in nursing
teams, nurses can strengthen their care delivery founda-
tion. It supports them to reflect on their practice systemati-
cally [8]. When adjusting care, it is essential to take patient
preferences into account. To ensure treatment decisions
are made collaboratively and to promote PPC [9, 10].
Previous research shows that nurses recognise patients'
needs and can integrate them into new care approaches.
They can design and evaluate care processes while prior-
itising quality improvement subjects based on patients'
involvement. These competencies are essential for estab-
lishing an EBQI learning culture [11]. Nevertheless, it is
also known that nurses do not focus enough on encour-
aging patients to participate in care despite their compas-
sionate approach during care delivery [12]. To enhance
PCC delivery and improve care quality, the fundamentals
of care framework have been developed (FoCF) [13].
The FoCF encompasses three distinct dimensions
of care: the relationship, the integration of care and the
care context [14]. The first dimension, the relationship,
involves developing and maintaining trust, getting to
know and focusing on the patient being cared for and
anticipating their needs [14]. Nurses can establish a posi-
tive nurse–patient relationship by focusing on the patient
and developing and maintaining trust [15]. The second
dimension, the integration of care, includes physical, psy-
chosocial and relational aspects that all patients require
regardless of their clinical condition. It guides a PCC ap-
proach [13]. The third dimension, the FoCF, has been en-
riched with an outer layer called the context of care that
delineates the environment in which caregiving occurs.
This layer encompasses policy- and systems- level factors
that impact the nurse's capacity to establish a meaningful
connection with the person under their care and address
their fundamental needs cohesively [13] (Figure1).
Despite the development of the FoCF to support nurses
in providing more PCC, it is known that nurses still do not
focus enough on involving patients in quality improve-
ment or learning activities in daily practice [16]. More at-
tention is needed to promote patient- centred care (PCC)
and ensure high- quality care [17]. Therefore, this study
aims to explore patients' needs and wishes towards being
involved in care processes that nurses can use in develop-
ing an EBQI learning culture.
METHODS
Research design
Qualitative research was conducted to explore patients'
perspectives on developing a person- centred funda-
mental EBQI learning culture. A phenomenological ap-
proach with semi- structured interviews was used to gain
in- depth information and understand patients' needs and
wishes towards being involved in care processes [18]. The
study was designed by the primary project group consist-
ing of four health scientists with backgrounds in nursing
(HV, GHdW AvV, JG), an educationist (MB) and a re-
search assistant (ABJ). Two master- educated nurses with
a background in the hospital setting (IT) or community
care setting (MWV) were involved in creating the inter-
view guide, interviewing and data analysis. This was to
ensure that the interviewing researchers could relate to
decision- making. Insights into patients' care preferences are essential to stimulate
the development of an evidence- based quality improvement learning culture within
nursing teams and for successful implementation processes.
KEYWORDS
appropriate care, community care, evidence- based quality improvement, fundamental care,
hospital, nurses, person- centred care
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GIESEN etal.
the patient and understand their situations. All partici-
pating researchers had experience with conducting and
analysing qualitative research. The standards for report-
ing qualitative research (SRQR) [18] were used for report-
ing the study.
Setting
The interviews were conducted between February and
March of 2022 in one university hospital from the city of
Nijmegen and one community care organisation in sur-
rounding of the City of Utrecht in the Netherlands. Both
settings were included to gain a broad understanding of
patients' preferences and because they often work to-
gether or exchange patients. Two departments in the uni-
versity hospital were purposefully selected to participate:
the orthopaedic department (16 beds), where profession-
als deliver treatment to support the musculoskeletal sys-
tem, and the traumatology department (16 beds), where
patients who had acute musculoskeletal injuries were
admitted. In addition, one nursing team from the com-
munity care organisation was selected, which provided
fundamental care to approximately 14 elderly patients at
home. In all settings, care was administered by bachelor-
educated nurses, vocational- educated nurses and nurse
assistants.
Participants
Experienced nurses from the participating departments
and the nursing team were informed about the study's
purposes and were involved in including participants.
These nurses assisted the interviewing researchers
with selecting and recruiting eligible patients. Criteria
to include participants were being >18 years old, able
to speak and understand Dutch, receiving care from
one of the participating nursing teams and being will-
ing to participate. Patients with cognitive impairment
or receiving palliative care were excluded. To ensure
a balanced sample, the interviewing researchers and
the leading researcher (JG) made the final selection of
participants based on the study criteria, patients' gen-
der and admitted department. The selected participants
were informed verbally by interviewing researchers and
FIGURE  Fundamentals of care framework (image obtained from https:// ilcca re. org/ the- frame work/ ). Content within the image
derived from Feo etal. [15]
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PATIENTS' NEEDS FOR AN EBQI- LEARNING CULTURE
through a written participant information form before
the interview. The research group aimed to include be-
tween 15 and 24 patients, as they expected to reach satu-
ration within this range [19].
Data collection
The leading researcher and the interviewing research-
ers developed a guide for the semi- structured interviews
based on the FoCF [14]. This guide was reviewed and ap-
proved by the entire research team. Three interview top-
ics were established: 1. kept updated about proposed and
ongoing care, 2. consulted regarding care and 3. given
opportunities to contribute to care decisions. To test the
interview guide, a pilot interview (by IT) with a hospi-
tal patient from the traumatology department was con-
ducted. No adjustments were necessary. All interviews
were carried out during morning shifts in a quiet room at
the hospital or the patient's home. During the study pe-
riod, the interviewing researchers reflected on their inter-
viewing technique with the leading researcher to ensure
they all were carried out in a uniform manner. The inter-
views were audio recorded and then transcribed verbally.
A member check by the interviewing researchers was per-
formed to ensure accuracy and validity. All participants
agreed to the summary of their interview transcripts. Data
collection and analysis were performed iteratively, allow-
ing for a dynamic and comprehensive understanding of
the patient's perspectives.
Data analysis
Two researchers (JG, IT) and an experienced research
assistant (ABJ) performed the data analysis. A con-
ceptual framework analysis [20] was utilised to deduc-
tively analyse the interview transcripts according to the
FoCF [14]. First, the analysing researchers familiarised
themselves by reading the hospital and community
care interview transcripts to get an overview of topics
and patterns [20]. The hospital interviews were coded
independently by IT and ABJ, and those from the com-
munity care by JG and ABJ. The codes were thoroughly
discussed until a consensus was reached. In case of disa-
greements, a third analysing researcher was consulted
for resolution. In addition, inductive codes were cre-
ated where participants' experiences extended beyond
the framework. This approach allowed the researchers
to analyse the data inductively and deductively and en-
sured no vital information was missed [21]. The induc-
tive codes were then categorised and linked to the FoCF
[14] (see Table1). Finally, rereading the interviews was
performed to verify that no data were missed. Data satu-
ration was achieved after conducting 14 interviews as no
new codes emerged from the data. To ensure the confir-
mation of the saturation [19], four additional interviews
were carried out. All coding took place with the support
of ATLAS.Ti version 9 and resulted in a thematic map.
Ethical considerations
All participants were properly informed about the pur-
pose of the study, that participation was voluntary, that
confidentiality and anonymity of recordings and tran-
scripts were assured and that participants had the right
to withdraw from the study at any given time without dis-
closure of a reason. The research ethics committee of the
Medical Research Ethics Committee of Arnhem Nijmegen
concluded that ethical approval was not required under
Dutch law (CMO no. 2021–13,317).
RESULTS
In total, 18 patients were included in the study. One pa-
tient refrained from participating for general reasons.
Ten men and eight women were interviewed, who had an
average age of 65 years (SD 13,81). The median length of
hospital stay was 3.5 days (range 2–12) at the orthopaedic
department and 15 days (range 5–84) at the traumatology.
All patients from community care received care for more
than 2 years. Hospital readmission rates varied between 0
and 30 times with a median of three pre- admissions. This
enriched the data because participants could add informa-
tion from previous experiences. The mean duration of the
interviews was 15 min and 7 sec (SD 6.1) (see Table2).
During the interviews, participants predominantly
discussed their needs and wishes about their relationship
with the nurses. They expressed how these needs were
either fulfilled or unmet, particularly regarding the psy-
chosocial (18 codes) and relational (16 codes) aspects of
nursing care in the dimension of ‘integration of care’. Also,
six codes about the dimension ‘relationship’ of the FoCF
were identified in the data analysis. Codes related to the
physical aspects of nursing care and from the dimension
‘context of care’ were excluded from the mind map and
description of the results because underlying information
did not contribute to answering the research question. To
better understand the interrelations among the codes and
their association with the dimensions of the FoCF, a mind
map was created to present the findings graphically (see,
Figure2). Furthermore, the codes in the results text have
been formatted in bold to enhance clarity and highlight
the discussed concepts.
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GIESEN etal.
TABLE  Coding table.
Original fundamental of care Themes Sub themes
Dimension 1: Relationship
Anticipate Anticipating patients’ needs
Evaluate a
Focus Focus on patient
Know Getting to know the patient
Trust Trust Technology
Caregiver
Dimension 2: Integration of care—Psychosocial needs
Being involved and informed Involved Decision making
Participating care
Patient's own control
Sufficient
Communication Communication Feedback
Dignity/Having values and beliefs considered and respected Dignity and respect
Education and information Informed Clear
Fair
Incorrect/in complete
Supportive/supported
Tailored
Emotional wellbeing Emotional Being too much
Support
Privacy Privacy
Dimension 2: Integration of care—Relational needs
Active listening Active listening
Being compassionate Showing compassion Kindness
Unkindness
Being empathic Showing empathy
Being present Present Point of contact
Standing up
Taking time
Engaging with patients Engaging with patient
Helping patients to cope Helping to cope
Helping patients to stay calm Helping to stay calm
Supporting and involving families and carers Families/carers
Working with patients to set goals Goal setting
Being consistentb
Dependenceb
Dimension 2: Integration of care—Physical needs
Comfort a
Eating and drinking a
Medication management a
Mobility a
Personal cleaning and dressing a
Rest and sleep a
(Continues)
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PATIENTS' NEEDS FOR AN EBQI- LEARNING CULTURE
Dimension 1: The relationship
In general, participants expressed a fundamental need
to trust their caregivers. Even if nurses displayed slight
variations in their approach, or if patients encountered
different nurses during their care, they wanted to experi-
ence a feeling of trust. Participants assumed that if some-
one holds the nurse's function, they could expect their
caregiver to be a professional. Participants expressed
trust in nurses' expertise, particularly when they had
positive prior experiences or when the nurse utilised sup-
portive technologies such as a medication scanner.
That nurses work differently does not bother
me. Because in the end, they all do what I
need, and if I ask for something, they do it
too. So, I do not care how they do it.
(P15- Community Care)
Participants wished to feel understood and cared for
by the nurses. They needed to know that the nurse
was aware of their current situation. It was comforting
for them to perceive that their patient records were re-
viewed, and relevant information had been transferred.
Seeing familiar faces and engaging in informal conver-
sations with nurses also contributed to this sense of con-
nection and understanding, as it indicates that the nurse
was getting to know the patient personally and priori-
tised their well- being. Furthermore, participants valued
nurses who focussed on and anticipated their needs.
Original fundamental of care Themes Sub themes
Safety a
Toileting needs a
Dimension 3: Context of care
Policy level
System level
aNo codes related to the research question.
bAdditional codes.
TABLE  (Continued)
TABLE  Demographic data of the included patients.
Participant Age Gender Setting
Length of stay/Time
receiving care
Pre- admissions
(n)
Interview duration
(min)
P1 63 Man Traumatology 84 days 0 15.36
P2 41 Woman Traumatology 16 days 0 14.24
P3 55 Man Orthopaedics 2 days 2 15.17
P4 42 Woman Traumatology 13 days 3 14.24
P5 68 Woman Orthopaedics 2 days 3 15.27
P6 78 Woman Orthopaedics 2 days 30 22.42
P7 57 Man Traumatology 16 days 7 26.51
P8 54 Man Orthopaedics 5 days 10 21.13
P9 81 Woman Orthopaedics 6 days 2 20.59
P10 54 Woman Orthopaedics 12 days 5 16.36
P11 67 Man Traumatology 14 days 0 15.18
P12 63 Woman Traumatology 5 days 5 21.01
P13 74 Man Community care NP NA 13.10
P14 79 Woman Community care >5 years NA 12.40
P15 85 Woman Community care 3 years NA 12.19
P16 82 Man Community care >5 years NA 7.56
P17 55 Man Community care >5 years NA 8.59
P18 80 Woman Community care 2 years NA 6.05
Abbreviations: NA, Not applicable; NP, Not provided; P, Patient.
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GIESEN etal.
They appreciated when nurses were present and asked
proactive questions about their requirements. While par-
ticipants understood that nurses may be unable to solve
all their problems, they found it helpful when nurses
inquired about any concerns and provided information
about all available options.
That patients are heard; safety is offered
and that they are proactive. So, nurses think
along, see things coming in advance, and act
accordingly.
(P8- Hospital- Orthopeadics)
Dimension 2: Integration of care
Psychosocial fundamentals of care (care
recipients' needs and outcomes)
Participants needed emotional support from nurses to
establish person- centred care. This became apparent from
the positive experiences reported by participants, who
found that being involved in conversations with nurses
contributed to their emotional well- being. In addition,
it provided them with a sense of being supported by the
nurse. Some participants specifically emphasised the need
to receive comforting conversations when feeling anxious.
Similarly, patients in community care settings underlined
the importance of meaningful discussions with a trusted
nurse. However, some patients were aware of the nurses'
busy schedules and, thus, were hesitant to burden them
with excessive demands for time and attention and were
afraid of being too much.
I had a confidential conversation with […]. I
could trust her to keep her mouth shut and
could discuss everything with her. I do not
want to talk to everyone about everything.
(P13- Community Care)
Communication was experienced as an essential need
for participants. In information sharing or overall com-
munication, most participants mentioned the impor-
tance of maintaining a professional attitude among
nurses in verbal and non- verbal communication.
They felt honestly heard when nurses actively lis-
tened without interrupting or speaking on their behalf
and not filling in for them. This also gave participants
FIGURE  Mind map of needs and wishes of patients.
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PATIENTS' NEEDS FOR AN EBQI- LEARNING CULTURE
a feeling of being respected. Moreover, participants
appreciated the opportunity to provide feedback to the
nurses, and they were pleased with the positive recep-
tion of their input.
I am not a number. Maybe I am just a patient
and a patient number on paper, but I do not
want to feel that way here. I do not want to be
a number.
(P5- Hospital- Orthopeadics)
Several participants who shared their experiences of fac-
ing privacy issues highlighted the significance of pri-
vacy. The lack of privacy was particularly evident in
multi- person rooms, where patients experienced limited
personal space, especially when they were seriously ill
or required assistance with toileting while in bed. Such
situations impacted the patient's dignity, humanity and
feeling of being respected. To address these privacy
concerns, it was beneficial for patients to be taken care of
by the same nurse consistently. In addition, it helped if
they closed curtains properly to help create more privacy
during sensitive moments. Additionally, it was crucial for
healthcare professionals not to engage in conversations
across multi- person rooms but rather to converse with pa-
tients at their bedside.
Nurses do not come to your bed. They stand
behind the computer and then go past every-
one in the room. I do not like that.
(P6- Hospital- Orthopeadics)
Most participants expressed a strong desire to be well in-
formed, and they reported positive experiences with the
information provided by the nurses. Patients emphasised re-
ceiving clear and fair information tailored to their needs.
Clear information was crucial because it eliminated ques-
tions and alleviated anxiety.
As a patient, you need clarity […] a feeling
that they have it all figured out.
(P4- Hospital- Traumatology)
For example, this consists of sufficient explanation of
the proposed nursing care, including the how, what and
why of the treatments or procedures. In addition, partic-
ipants highly value fair information, and nurses must
share their knowledge and information about their
medical situation without withholding any relevant
information. Participants also mentioned that nurses
could meet their needs for tailored information by pro-
viding information in a way anticipated most practi-
cal and preferred by the patients. Tailoring information
increased clarity and comprehension. Furthermore, in-
formation was perceived as supportive when it met the
wishes and requirements of the participants, not only
in terms of content but also in the manner of delivery.
On the other hand, when patients' need for clear and
fair information was not met, whether due to incom-
plete or incorrect information, it seriously harmed
trust in the nurses.
A nurse that tells lies shouldn't come into my
house. I can figure them out in five minutes.
(P14- Community care)
Participants needed the opportunity to participate and be
actively involved in their care. Participants felt heard and
valued when given the chance to participate in the decision-
making process and were supported. However, a few par-
ticipants described their experience of decision- making as
not possible, primarily because they were not consulted or
included in the process.
As a patient, that gives you the feeling that
you can participate, and that gave me the feel-
ing of belonging.
(P6- Hospital- Orthopeadics)
Several participants strongly wished to actively participate
in nursing care, believing it promoted their self- reliance
and sense of empowerment. They engaged in nursing
care by providing instructions or expressing their care pref-
erences. Participants felt in control when they were well-
informed about their current and future care and involved
in decision- making.
I am a huge supporter of letting people keep
their control. Make sure you inform your pa-
tients sufficiently.
(P12- Hospital- Traumatology)
Relational fundamentals of care (care provider's
actions)
Participants wished that nurses showed compassion by
kindly letting them know they cared about the patient.
For example, by asking about an upcoming procedure
and wishing the patient good luck or doing something
extra. Some participants found all nurses to be kind and
compassionate. Others found it more diffuse and liked
it when nurses actively asked if a patient needed more
help. The participants experienced that some nurses were
more practical in their care, and others showed more
empathy. Nevertheless, most participants needed the
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9
GIESEN etal.
nurses engaged them actively. They wished to be seen as
complete people and not just as a disease or a care prob-
lem. Participants who experienced such a relationship
felt safe and heard.
That they can connect, build and give trust.
That I am besides the disease also a feel
human. It gives the feeling to be comfortable,
safe and heard.
(P11- Hospital- Traumatology)
The participants' responses to unkindness from caregiv-
ers varied in two ways. Some participants reported feeling
anger in response to unkind treatment. Others avoided
further care interactions, attempting to distance themselves
from potentially harmful experiences and being reluctant to
discuss them.
The nurse said: “You can do that.” Then I was
thinking, you do not feel what I feel. No, I
cannot do it and will not do it either. I cannot
even get out of bed.
(P5- Hospital- Orthopeadics)
The presence of a nurse who offers human attention was
essential for almost all participants, as it provided them with
a sense of security. It was particularly beneficial when the
nurse was familiar with the participants and readily avail-
able as a point of contact.
I only have to nod, and they are there to help
me. They told me if there was anything I
needed, I should ask for it.
(P1- Hospital- Traumatology)
Participants greatly appreciated it when nurses stood up
for them. Both participants and their relatives valued this
support. When nurses took the time and were present,
avoiding the impression of being rushed, the patients felt
that they genuinely mattered and were cared for. However,
when nurses spoke from behind a computer or were
wearing masks, this created a sense of distance. Feeling
dependent on nurses is challenging for participants, and
it takes time to adapt to this vulnerability. Especially in
urgent situations and when immediate help is required,
any delays in assistance lead to feelings of neglect.
Participants understood that nurses have busy schedules,
and consistent completion of tasks or communication
with them was essential to reassuring and making them
feel supported. Uniformity in the way nurses performed
was crucial for participants. When tasks were done differ-
ently, it caused confusion, insecurity and feelings of un-
sure of what to expect.
It would be more convenient if they finish
one thing and then (start) the next. So, every
patient gets care in time.
(P10- Hospital- Othopeadics)
Participants needed a nurse to inform family or caregiv-
ers especially if they could not actively participate in their
care. Then, participants needed a nurse to inform family or
caregivers about their maintenance, critical situations or
essential updates. Nurses' functional listening skills played
an important role in making participants feel heard and val-
ued, which fostered shared decision- making. Conversely,
most participants felt insecure when nurses failed to listen
actively or dismissed a patient's concern. For the majority
of the participants, the lack of a nurse to act in a consistent
way often led to feelings of insecurity. This feeling intensi-
fied when nurses started a discussion or refused to provide
care in a specific manner.
Sometimes a nurse asks me about my care
preferences. When I say: “do not know”. They
can get irritated and say a need to answer,
because they think it is standard answer of
mine. This frustrates me because I really do
not now it.
(P16- Community care)
Participants wished nurses would engage with them based
on their ability to perceive the patient's needs and respond
accordingly. For instance, recognising cues for reassurance
and providing them when needed is highly valued by pa-
tients. Honesty from nurses is appreciated, as participants
tended to contemplate all available options, even those that
may evoke concerns. Supportive and understanding nurses
help patients cope with and overcome these insecurities,
ultimately fostering calmness in participants.
Just tell me honestly how it is. Otherwise, I
will start thinking and make assumptions. I
will create a whole ghost story in your head.
That is the last thing I want because I have
enough to worry about.
(P4- Hospital- Traumatology)
DISCUSSION
This study explored patients' needs and wishes towards
being involved in care processes that nurses can use in de-
veloping an EBQI learning culture. The analysis, utilising
the FoCF framework, underpins the essence of the nurse–
patient relationship, emphasising the need for patients to
entrust the nurses providing care. Patients expressed their
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10
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PATIENTS' NEEDS FOR AN EBQI- LEARNING CULTURE
desire to be involved in their care process, requiring clear,
fair and tailored information to facilitate shared decision-
making. Furthermore, the approach used by the nurse
was found to be crucial in ensuring patient involvement
and the delivery of tailored information. For example,
considering how a patient wishes to be informed about
care changes can contribute to successful implementa-
tion. With this knowledge, nurses can make informed
choices regarding care topics to transform care and adopt
suitable approaches for implementing care changes.
For participants in this study, one crucial patient need
in the nurse–patient relationship is to trust the nurses
who provide care. Trust is critical for the nurse–pa-
tient relationship and is the cornerstone of nursing [22].
Participating patients naturally entrust nurses, viewing
them as skilled care professionals with the necessary
knowledge. This is also confirmed by Dinç & Gastmans
[23], who state that patients have a pre- existing sense of
trust linked to their familiarity with the healthcare system
and past interactions with hospitals and healthcare pro-
viders. Furthermore, patients demonstrate confidence and
initial trust in nurses due to nurses' extensive education
and professional experience [23]. However, if faith is com-
promised during the admission process or by a previous
occasion, patients may exhibit resistance and rebuilding
the relationship demands considerable time and effort. It
is known that trust is hard to rebuild [24]. To overcome
mistrust among patients, it is essential to engage in open
conversations about their health outcomes and acknowl-
edge their expertise regarding their life situation [25].
Therefore, nurses should pay attention to establishing the
best possible nurse–patient relationship when developing
an EBQI learning culture to drive change in healthcare.
Earning trust from participating patients requires
nurses to provide clear, fair and tailored information.
This approach allows patients to feel actively engaged in
their care, empowering them to participate in decision-
making and gain control over their care process. This
complies with the principles of the person- centred nurs-
ing framework of Mc Cormack etal [26] that focus on
attributes of the nurses (perquisites), the context of care
(care environment), care activities (person- centred pro-
cesses) and results of effective person- centred care (ex-
pected outcomes). In addition, Jerofke- Owen etal. [10]
state that obtaining, dealing with, understanding and
employing information is an essential catalyst of patient
engagement, involvement and participation. However,
when providing information regarding ongoing care or
care changes, nurses must remember that patients can
not read the nurses' minds. This aligns with patient ex-
periences with physicians, indicating that patients may
be unaware of what they do not know and, therefore, re-
quire personalised information to make informed health
decisions [27]. Our findings indicate that delivering tai-
lored information challenges the nurse to estimate pa-
tients' wishes and provide this properly. The study by
Rørtveit etal. [28] aligns with the earlier points, affirm-
ing that building and nurturing trust are interconnected
with effective communication. Nurses must demon-
strate openness, competence, practicality, interest, con-
cern, confidence and a willingness to share control. By
teaching healthcare professionals how to recognise sig-
nals that the patients do not feel heard, communication
can be improved and trust built [29].
Nurses should consider patients' needs when work-
ing on EBQI and giving information. Having a friendly
approach with patients and showing compassion and
empathy during interactions is essential. However, this
is also challenging given that medical- technical skills
are still valued more highly when assessing the qual-
ity of care [30]. In addition, previous studies have re-
vealed that nurses face challenges communicating with
patients due to their busy schedules, frequent interrup-
tions and desire for more time to engage in meaning-
ful patient conversations [31]. In addition, nurses need
to know their patients, take time, empathise with pa-
tients and create a safe and trusted environment [32].
Participants also express the need for informal conver-
sations and meaningful interactions. Therefore, nurses
should be aware of behaviours, such as withholding
information, rushing through interactions or speak-
ing unkindly, which can undermine trust and damage
the nurse–patient relationship. This is confirmed by
the study by Tobiano etal. [33] which states that how
nurses communicate can hinder patient participation,
like when patients feel not listened to.
Finally, establishing a solid relationship with patients
is a prerequisite to showing (nursing) leadership and facil-
itating patient participation. Nurses demonstrate leader-
ship by deliberately building relationships with patients,
leading to improved patient participation and positive
experiences in healthcare [32]. These insights hold signif-
icant importance for nurses as they work towards imple-
menting transformative changes and cultivating an EBQI
learning culture, ultimately enabling them to deliver ap-
propriate patient care.
Strengths and limitations
The study's strength lies in providing valuable insights into
patients' needs and preferences regarding person- centred
fundamental care. Incorporating patients' perspectives
is crucial in developing an EBQI learning culture within
nursing teams and working towards more ‘appropriate
care’. The findings indicate that excluding patients from
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|
11
GIESEN etal.
implementing care changes hampers the success and sus-
tainability of such changes.
One limitation of the study is the relatively short du-
ration of the interviews (mean 16 min). This brevity was
necessary to consider the patients' well- being and atten-
tion span. Second, we have asked patients what they need
when implementing care changes. Additionally, asking
patients about their needs during care changes posed a
challenge, especially when they had not experienced such
changes or were unaware of them. Nonetheless, they were
able to articulate their requirements regarding their care
and interactions with nurses, which can be invaluable in
transforming care practices. Furthermore, it is essential to
acknowledge that this study only included patients from
hospital and community care settings due to the project's
scope. Finally, a reflective approach using interviews was
employed in this study. Combining these with a natural-
istic approach, like observations or patient diaries, could
yield more favourable outcomes in addressing patients'
needs [11]. Therefore, additional research is necessary to
confirm results and validate the generalisability of the re-
sults in other healthcare settings.
CONCLUSION
Patients need compassionate and attentive nurses who
build and maintain a trusting relationship. Nurses should
offer fair, clear and tailored information to actively in-
volve patients in the care delivery. Meeting these needs
and wishes contributes to the development of an EBQI
learning culture within nursing teams and promotes the
delivery of person- centred fundamental care. Which fi-
nally will result in the delivery of more appropriate funda-
mental care and make nursing care future proof.
AUTHOR CONTRIBUTIONS
Jeltje Giesen: Conceptualization, methodology, investiga-
tion, formal analysis, writing —original draft, writing—re-
view & editing, supervision. Ilse Timmerman: Investigation,
formal analysis, writing—original draft, writing—review
& editing. Getty Huisman- de Waal: Conceptualization,
methodology, formal analysis, writing—review & ed-
iting, funding acquisition, project administration, su-
pervision. Annick Bakker- Jacobs: Conceptualization,
methodology, formal analysis, writing—review & editing.
Marjolein Berings: Conceptualization, methodology, writ-
ing—review & editing, supervision. Anneke van Vught:
Conceptualization, methodology, writing—review & ed-
iting, supervision. Hester Vermeulen: Conceptualization,
methodology, writing—review & editing, funding acquisi-
tion, supervision.
ACKNOWLEDGEMENTS
We would like to thank MWV for her help in conducting
the interviews. Additionally, we wish to thank all partici-
pating organisations and patients who participated in this
study.
FUNDING INFORMATION
This paper is part of the Improve! project that focuses on
creating an evidence- based quality improvement (EBQI)
learning culture in nursing teams in the hospital and com-
munity care settings. The Improve! project is funded by
ZonMw (dossier no. 80- 83900- 98- 854).
CONFLICT OF INTEREST STATEMENT
The authors declare that they have no conflict of interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are avail-
able on request from the corresponding author. The
data are not publicly available due to privacy or ethical
restrictions.
ORCID
Jeltje Giesen https://orcid.org/0000-0001-6768-0838
Hester Vermeulen https://orcid.
org/0000-0003-1905-2890
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How to cite this article: Giesen J, Timmerman I,
Bakker- Jacobs A, Berings M, Huisman- de Waal G,
Van Vught A, et al. What can nurses learn from
patient's needs and wishes when developing an
evidence- based quality improvement learning
culture? A qualitative study. Scand J Caring Sci.
2024;00:1–12. https://doi.org/10.1111/scs.13252
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