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Critical Care Nurse. 2009;29: 24-37 doi:10.4037/ccn2009241
Copyright © 2009 by the American Association of Critical-Care Nurses.
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Clinical Article
CE Article

Patients’ Perceptions of Nurses’ Skill

Peggy Rupp Wysong, RN, MSN, CCRN
 Evelyn Driver, RN, PhD

Peggy Rupp Wysong is a clinical nurse specialist in critical care at Goshen General Hospital, Goshen, Indiana.

Evelyn Driver (now retired) was a nursing research consultant at Goshen General Hospital and a professor of nursing at Goshen College, Goshen, Indiana, when this article was written.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

dotmore
To learn more about nurses’ competence, read "Competence and Certification of Registered Nurses and Safety of Patients in Intensive Care Units" by Deborah Kendall-Gallagher and Mary A. Blegen in the American Journal of Critical Care, 2009;18:106-113.[Abstract/Free Full Text] Available at www.ajcconline.org.

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Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click "Respond to This Article" in either the full-text or PDF view of the article.

Financial Disclosures
None reported.

This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:

  1. Identify the characteristics most often described by study participants as indicative of a skilled nurse
  2. Describe the relationship between patients’ descriptions of nurses’ skill and the 3 domains of skill in nursing practice
  3. Describe the extent to which nurses’ attributes identified by patients correspond to the 8 nurse characteristics in the AACN Synergy Model
  4. Discuss the application of the study findings to nursing practice

Corresponding author: Peggy Rupp Wysong, RN, MSN, CCRN, Clinical Nurse Specialist, Critical Care, Goshen General Hospital, 200 High Park Ave, Goshen, IN 46526 (e-mail: prupp{at}goshenhealth.com).

Satisfaction with hospital care is a topic of much interest, and many hospitals use some instrument to measure patients’ satisfaction. Public reporting of measures of patients’ perspectives of care are now available on the Internet.1 Press Ganey Associates, Inc,2 a leading vendor of tools to measure patients’ satisfaction, includes the item "skill of the nurses" on a questionnaire mailed to patients after discharge from the hospital. Although much information is available on patients’ satisfaction and perceptions of quality of care, and some information is available on patients’ perceptions of physicians’ skills, little information is available on patients’ perceptions of nurses’ skills.

Skill is defined as "the ability to use one’s knowledge . . . in performance; dexterity . . . in execution of physical tasks" and as "a learned power of doing something competently."3 In nursing practice, skill has 3 domains: interpersonal, critical thinking, and technical.4–11 It is not known what attributes patients use to determine whether a nurse is skilled. Is the observed technical skill of a nurse during procedures the main element that patients use to assess the nurse’s skill, or are other factors involved?

The American Association of Critical-Care Nurses (AACN) has developed the AACN Synergy Model for Patient Care.12 The core concept of this model is that the needs of patients promote the expected competencies of nurses. Eight nurse characteristics of concern to patients are described in this model. Further research is needed, however, on patients’ perceptions of nurses’ competency. The purpose of this study was to explore patients’ perceptions of nurses’ skill in a progressive care unit (PCU).


   Literature Review
Top
 Literature Review
Study Questions
 Methods
 Results
 Discussion
 Conclusion
 PRIME POINTS
 References
 
Several investigators have examined patients’ perceptions of physicians’ skill (Table 1Go). Patients with chronic obstructive pulmonary disease, AIDS, and cancer were asked about their perceptions of physicians’ skill at providing end-of-life care.13,14 Communication with patients was one of the top themes identified by patients as vital to a skilled physician and included listening skills, openness to questions, speaking with honesty and sensitivity, and an ability to discuss death and dying. Emotional support, accessibility, and continuity were other commonly identified themes for these patients. For patients with chronic obstructive pulmonary disease, a physician’s ability to provide patient education stood out as an area of importance. Additional studies15–18 of patients’ perceptions of physicians’ skill and quality of care also indicated that communication is an important aspect of the interaction.


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  		Table 1 Literature summary

 
Numerous researchers have examined patients’ satisfaction with nursing care in general terms, as well as patients’ perceptions of the quality of nursing care (Table 1Go). A review of the literature by Scandinavian researchers19 indicated that patients’ satisfaction with nursing care is influenced by the nurses’ technical competence, as well as by the interpersonal relations between the nurses and the patients.

When 40 patients in a private teaching hospital in California were asked what happened when a nurse was taking care of them, they almost exclusively described the interpersonal skills of the nurse, rather than the task that was being done.20 The 4 major subthemes of interpersonal skills were translating, getting to know you, establishing trust, and going the extra mile.

In a study21 in Iceland, nurses who were perceived as giving high-quality care were described by patients as kind, joyful, warm, polite, and understanding and as having clinical competence. Clinical competence, however, was considered the most important nurse caring behavior in another study22 from Iceland, in which "know how to give shots and IVs, know what they are doing, know when to call the doctor, and know how to handle equipment" were items with the highest scores.

In a study23 published in 2000, attributes of high-quality nursing care described by oncology patients that contributed to a sense of well-being included professional knowledge (both technical competence in performing tasks and experiential knowledge gained from caring for similar patients), continuity, coordination, attentiveness, partnership, individualization, rapport, and caring. In other research,24 oncology patients’ descriptions of nursing care yielded 4 major concepts: laudable (defined as commendable), caring (showing compassion, concern, and kindness), professional (holding the standards expected of a nurse in knowledge, skills, and demeanor), and outcomes (the affective, cognitive, or physical effects credited to nursing care).

In an investigation25 of parents’ perceptions of staff competency in a neonatal intensive care unit, parents of critically ill babies perceived competence as a range of caring behaviors rather than solely the performance of tasks or procedures. Being offered choices, style and quality of communication with staff, being made to feel they were not a burden, and being given a sense of being in control were caring behaviors that parents equated with staff competence.

The most important aspects of nursing care identified by postoperative patients in an Australian study26 were nursing attributes categorized as leading to a sense of being engaged with the patient and included an open dialogue; recognition of the patient as a unique individual; availability of the nurse; a friendly, warm personality; and having a gentle touch. The defining characteristics of good nursing care in another investigation27 mostly involved the demeanor of the nurses: gentle, calm, courteous, kind, attentive, available, empathetic, and reassuring. Although researchers have described nurses’ attributes that patients consider when judging nursing quality and good nursing care in general, little is known of patients’ perceptions specifically of the skill of nurses.


   Study Questions
Top
 Literature Review
 Study Questions
Methods
 Results
 Discussion
 Conclusion
 PRIME POINTS
 References
 
The purpose of this study was to answer 3 questions:

  1. What attributes do patients use to determine whether a nurse is skilled rather than unskilled?
  2. To what extent is the observed technical skill of a nurse during procedures a factor that patients use to assess the nurse’s skill?
  3. To what extent do nurses’ attributes identified by patients correspond to nurses’ characteristics in the AACN Synergy Model For Patient Care?


   Methods
Top
 Literature Review
 Study Questions
 Methods
Results
 Discussion
 Conclusion
 PRIME POINTS
 References
 
In this descriptive qualitative study, interview data and content analysis of themes were used to determine patients’ perceptions of nurses’ skill. Approval for the study was received from the appropriate institutional review board. The purpose of the study was explained to each eligible patient by the principal investigator (P. R.W.), and written informed consent was obtained from each participating patient before the interview. In order to ensure patient confidentiality, no patient-specific identifying information was collected or noted on the interview notes or on the audiotapes. The demographic data collected were not tied to any patient-specific identifiers.

Sample and Setting
Interviews were conducted with 32 patients in the PCU of Goshen General Hospital, Goshen, Indiana, a 123-bed community not-for-profit hospital in the rural Midwest. Patients were interviewed during an 8-month period from December 2006 through July 2007. This PCU is a 12-bed adult unit that admits patients with complex medical and surgical needs and also serves as the step-down unit from intensive care. Patients were eligible for the study if their length of stay in the PCU was 1 day or more, they were able to speak and comprehend English, and they were 18 years or older. Patients were ineligible if their hemodynamic status was unstable or they were confused or disoriented. A purposive sampling framework with intent of maximum variation in age and sex was used.28 Patients were selected until comments from different participants became redundant. Data saturation was reached when no new nurse attributes were mentioned.

Instrument
The interview guide was prepared by using semistructured open-ended questions and was used for field notes during the interview and for additional notes during the later review of audiotapes. This format ensured that specific questions were addressed, yet allowed participants to talk freely as they answered the questions in narrative fashion.28,29 The interview guide contained 6 scripted questions (Table 2Go), which were developed on the basis of the literature review13,14,21 and in consultation with a nurse researcher with a doctoral degree.


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  		Table 2 Interview guide scripted questions

 
Procedure
Interviews were conducted by the principal investigator, a clinical nurse specialist with a master’s degree and experience in the PCU setting, thereby enabling her to respond with relevant prompts when needed. Interviews were conducted in patients’ rooms and were audiotaped; field notes were recorded manually during the interview. Follow-up prompts, probes, and reflective statements were used to clarify and expand patients’ comments. Additional use of reflection and rephrasing of the interviewer’s understanding of comments served as a form of member checking (validating the interviewer’s interpretation with the participant)28 to increase credibility of the data. Interviews were designed to last approximately 20 minutes; however, the length of the interview varied from patient to patient. Audiotapes of the interviews were reviewed, and field notes were amended and supplemented as necessary to capture direct quotes.

Data Analysis
Content analysis28 was performed to elicit common themes within a priori categories of the 3 domains of nurses’ skill as frequently cited in nursing literature: technical, interpersonal, and critical thinking.4–11 Because AACN guidelines are used as standards of practice in the PCU, data were then recategorized into domains by using the Synergy Model of nurse characteristics. Confirmability28 was addressed by using an independent review of the tapes and recording of themes by an experienced qualitative nurse researcher. The focus of the independent review was to discover omissions of comments and to verify placement of phrases into categories. All differences were discussed until consensus was reached about the final coding.


   Results
Top
 Literature Review
 Study Questions
 Methods
 Results
Discussion
 Conclusion
 PRIME POINTS
 References
 
A total of 15 men and 17 women, 30 to 96 years old, participated in the study. This mix of men and women is roughly equivalent to the typical population in this PCU.

Patients’ perception of a nurse’s skill focused more heavily on the interpersonal skills of the nurse than on technical skills. All 32 patients mentioned interpersonal skills of a nurse as a measure by which they judged whether the nurse was skilled or unskilled. The second most common category was critical thinking skills, cited by 30 patients (94%). Only 19 patients (59%) talked about the technical skills of a nurse as a measure by which they perceived a nurse was skilled. A total of 18 patients (56%) mentioned skills in all 3 domains.

Interpersonal Skills
Interpersonal skills, the "people skills" by which one establishes a connection with another person through verbal and nonverbal activities,6,11 were mentioned by every patient interviewed as a vital component of a skilled nurse (Table 3Go).


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  		Table 3 Attributes of nurses’ interpersonal skills identified as important by patients

 
Attributes of Skilled Nurses.
Patients described nurses who were friendly, caring, compassionate, kind, and good listeners as nurses who were very skilled. "A good bedside manner" was how one patient described the skills and qualities of his ideal nurse, adding "interested in me also as a person." Cheerful and happy and smiling were qualities several patients said gave them the impression that a nurse was skilled. "A friendly nurse seems like they know everything" were the words one patient used to describe the skill of the nurses who were the best at providing care.

Nurses who displayed confidence were also viewed as skilled nurses by many patients. The "confidence they display in the care they give you" and the nurses who "act as though they know what they’re doing" were examples patients gave of qualities of skilled nurses. "It’s just an observed level of confidence . . . if you feel someone has confidence in their job, then I guess that would demonstrate they are skilled." The nurse who "comes in the room and goes about her business with confidence" was described by one patient as a nurse whom the patient perceived as being very skilled: "I could just tell they were intelligent."

Several comments focused on nurses’ attitude toward their work. Nurses who gave the impression they liked their job were perceived as skilled nurses. "If they really like what they’re doing, they’ll do the job real well and people will recognize that." A nurse "should love her job," related another patient.

You can tell if they love their job, are called according to their purpose . . . are care-givers, they’ve been chosen . . . you can tell that in the extra time they take, talking, noticing I may be having a bad day . . . touch . . . making the extra effort, stopping by . . . it’s more than coming in and putting in your 8 to 10 hours doing what’s in your job description like a robot, it’s much more than that.

Other interpersonal skills and personal attributes that patients described as important included a nurse’s sense of humor; a nurse who was organized, not rushed, had a good memory; and a nurse who followed through when asked to do something. The nurse’s physical appearance was mentioned by 2 patients as a consideration when judging a nurse’s skill. "Nice, neat, clean . . . they smell so good . . . the colors they wear; bright, light colors" were descriptors one patient gave of the skills and qualities of an ideal nurse. Another patient described his ideal nurse as "clean-cut" (in the description of a male nurse). Age was cited as a factor by an elderly patient. If nurses were "middle-aged," he assumed "they’ve had a lot of experience" and therefore were skilled.

Attributes of Nurses Who Are Not Skilled.
A nurse who is viewed by patients as not skilled is one whose interpersonal skills are weak. Lack of confidence, timidity, rudeness, abrupt answers to questions, indecisiveness, and a "negative attitude" were examples of behaviors that led patients to believe a nurse was not skilled. In the words of one patient, "Some [nurses] need to present themselves better. They could be the most qualified nurse, but not have good people skills." One patient perceived a nurse’s nervous "body language, and stuttering, stammering around to a question" as indicative of an unskilled nurse. "Language skills . . . if I can’t understand someone because of an accent" was a factor one patient mentioned in her determination of whether a nurse is skilled or unskilled.

Several patients remarked that nurses who displayed negative emotions such as frustration were viewed as unskilled nurses. One patient described nurses she perceived as not skilled because of their "bad attitude" as follows:

If they let me know they’re having a bad day, whether with another nurse or another patient, that’s none of my business, nor should it be. Neither should I be talked to in a degrading manner because the nurse is having a bad day.

A "flip attitude . . . attitude they don’t want to be here" was an example one patient gave of an unskilled nurse, adding, "It makes me afraid to ask them to do anything." Another patient, in describing a nurse she thought was not skilled, stated the following:

I think the nurse was having an extremely bad day all around . . . it was a tense day . . . everybody seemed to be having a bad day . . . you could definitely feel it in the air . . . tension . . . the air was definitely charged.

Critical Thinking Skills
The second most common domain mentioned by patients in judging the skill of a nurse was critical thinking. Critical thinking in nursing is defined as a purposeful judgment associated with clinical decision making and problem solving, characterized by analysis, reasoning, inference, interpretation, knowledge, and open-mindedness.30,31 Critical thinking is manifest in clinical judgment when nurses make accurate decisions about a situation, what needs to be done, how soon, and why.32

Aspects of critical thinking skills important to patients in this study (Table 4Go) included the ability of a nurse to assess a situation and take appropriate action. One patient explained, "I had chest pain into my shoulder and immediately she arranged for an EKG." Another example given of a skilled nurse using critical thinking skills was one who used the information she collected from a patient and "insisted on setting the alarm on the bed and chair so I wouldn’t fall." She was "firm, concerned, paying attention to details . . . I appreciate that." One patient recalled a nurse who was concerned about "all the visitors I was getting because I wasn’t getting rest." The nurse put a note on the door to limit visitors, leading the patient to view that nurse as skilled. The nurse who uses "more than book smarts . . . common sense" is the description one patient gave of a skilled nurse.


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  		Table 4 Attributes of nurses’ critical thinking skills identified as important by patients

 
Indicators of a nurse’s critical thinking also include the ability to explain signs and symptoms of problems, complications, and reasons behind interventions, medications and diagnostic studies.33,34 The ability of a nurse to provide information and education to patients was an important consideration for patients. "Keeping me informed" was a common element described by patients, along with "helping me with questions," "able to research questions I might have," "able to offer advice and suggestions," "keeps telling me what’s going on," and "explains procedures and possible outcomes." Yet patients recognized that skill involves more than just giving information, that judgment and discretion are important attributes. One patient described an episode in which he experienced hypotension and tachycardia:
When things were shaky [the nurse] held back some [on giving information]. That was good, that was for my own benefit. She told me later, when I was out of the woods, but she didn’t tell me right then . . . best for me and for the family.

Education about medications was mentioned by 9 patients. "When they give me my medicine, they tell me what every pill is and what it’s for." One patient said, "Someone brought in information on my medicines I’m on here that explains the pros and cons. I appreciate that," and went on to say that the nurse "explained to me not only what it was for, but how it functions."

Technical Skills
Although mentioned by the majority of patients, technical skills, the "hands-on" performance of procedures,11 were the domain of skills mentioned the least. A total of 19 of the 32 patients (59%) identified instances involving technical skills (Table 5Go). The majority of these patients (n=15) described experiences with intravenous (IV) devices, injections, or blood samples as procedures used to determine a nurse’s skill. "Skill at various tasks," "operating machines like [IV] pumps," and "the way they . . . give me the shots" were descriptors patients used as they discussed the technical skills of nurses. A skilled nurse was one who could "stick me one time for the IV."


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  		Table 5 Forms of nurses’ technical skills identified as important by patients

 
On the other hand, "couldn’t get IV in right away," "jabbed me 4 or 5 times," and pushes IV "medicine in hard" were some statements patients made when describing an unskilled nurse. One patient said:
The nurse had the hardest time getting a needle into my veins. I just wanted to tell her to go and get someone else who knows what they’re doing. This was a nightmare! And that made me wonder if she really knew what she was doing.

Other aspects of technical skills mentioned by patients included preparing a patient for a procedure by shaving the site "quickly and efficiently," being "gentle" with any procedure or physical care, and ability to handle monitoring equipment with ease.

Patients’ perceptions of a skilled nurse involved in technical procedures often did not depend solely on the success of the procedure but also involved the interpersonal skills of the nurse and how he or she related to the patient while performing the procedure. The confidence displayed by the nurse during a procedure reassured many patients. A nurse who "explained what she’s doing and why" was perceived as skilled.

The ability of a nurse to listen, take seriously a patient’s complaint of discomfort, and respond with empathy were attributes that led several patients to view a nurse as skilled during the performance of a technical procedure. One patient described a nurse she viewed as unskilled as one in another area of the hospital who tried 4 times to insert a urinary catheter, an experience the patient found very painful. When the patient arrived in the PCU, a nurse again attempted to insert the catheter but stopped when the patient said it was too painful. The patient viewed that nurse as skilled, even though she was not successful in the procedure: "The nurse told me it was quite alright and she understood."

Other Comments
A few comments from patients did not fit in any of the 3 domains of the skill of a nurse. One patient stated that to judge the skill of a nurse, he asked how long the nurse had been in nursing: "What I have is pretty serious, and I don’t want someone messing with me that should be an apprentice." Another patient said he assumes the skill is there if the nurses maintain their license: "I have a lot of confidence that the testing that they have to go through would demonstrate their skill level." Yet another said that nurses who were visible "at their job" gave him the impression they were skilled. In contrast, another patient commented that nurses who gave him the impression they were not skilled were those who "just sit and chitchat" with each other.

Synergy Model
Patients’ descriptions of skilled nurses could be categorized into 7 of the 8 domains of the Synergy Model (see FigureGo). The descriptions fit the nurse characteristics of caring practices, facilitator of learning, clinical judgment, collaboration, advocacy/moral agency, systems thinking, and response to diversity (Table 6Go). Only clinical inquiry, which involves questioning and evaluating practice and providing informed practice through research utilization, was not recognized by any of the patients.


Figure 1
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  		Figure Number of patients (N = 32) with comments attributed to each domain of nurse characteristics as defined by the AACN Synergy Model for Patient Care.

 

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  		Table 6 Nurse competencies in the AACN Synergy Model for Patient Care identified by patients as important attributes for a skilled nurse

 
Caring Practices.
AACN12 defines caring practices as "nursing activities that create a compassionate, supportive, and therapeutic environment . . . with the aim of promoting comfort," including "vigilance, engagement, and responsiveness of caregivers." When the data were analyzed in context of the Synergy Model, the nurse characteristic of caring practices was the most important trait of a skilled nurse identified by the patients, and all 32 patients made comments in this category. One patient, who echoed the sentiments of many, described the most important characteristics of a skilled nurse as "caring, compassionate, concerned; those would be the 3 at the top of the list." Another patient described the skills of her ideal nurse as follows:
[A] gentle, caring, almost loving touch. You can feel that they are a healer . . . it’s more a nuance, a look in their eye. They love their jobs, they care about the people they’re taking care of.

One patient described the compassionate, therapeutic environment provided by a nurse as beginning with the first encounter: "When I came in, I was so cold; they came in with a warm blanket. That set the tone of the whole experience." As another patient thought about the qualities she would consider if rating the skill of the nurses on a questionnaire, she reflected, "I think it’s all about kindness. Make your patients feel comfortable, not scared and worried." Several patients stated that the ability of a nurse to "put my mind at ease" was an important characteristic of a skilled nurse. In the words of yet another patient, the nurse who "made me comfortable in being here . . . to me, that’s a good nurse."

Patients talked further about the importance of nurses being engaged with them. "Interested in you as a person" and "able to bond with you" were descriptors patients gave for a skilled nurse. Several patients described the process of nurses engaging themselves with a patient by introducing themselves, greeting the patient by name, and showing a genuine interest in how the patient was feeling; these nurses were perceived as skilled nurses. Maintaining eye contact, using humor, and "not feeling rushed" were other qualities of skilled nurses described by patients as they discussed the nurses’ engagement with patients. On the other hand, nurses who were perceived as lacking a caring attitude and as not engaged were considered unskilled. One patient described nurses who were "not emotionally invested in what they’re doing" as an example of nurses who gave him the impression they were not skilled.

Patients also perceived nurses who demonstrated the caring practices of vigilance and responsiveness as skilled nurses. Nurses who were described by patients as "prompt," "anticipating my needs," "keeping track of what’s happening," and "at their job" were perceived as skilled. One patient eloquently described a vigilant nurse: "How intuitive they are . . . anticipating what could happen and watching for signs of that to occur . . . kind of like a mother with eyes in the back of her head."

Responsive nurses were nurses who listened, were attentive, and followed up on requests promptly. In the words of one patient, "They check me many times. When they say they’ll be back, they’re back before [the time due]."

Facilitator of Learning.
A total of 14 patients (44%) described a skilled nurse as one who assists in the facilitation of learning, making this nurse characteristic the second most frequently cited one by patients. The Synergy Model12 describes an expert nurse as one who facilitates patient learning by integrating patient education through out the delivery of care. Patients in our study stressed the importance of this nurse characteristic, especially as it related to patients’ learning about medications. Many patients described skilled nurses as those who "tell me what every pill is and what it is for" throughout the hospital stay, enhancing patients’ learning. Providing information on procedures was frequently mentioned as another important characteristic of a skilled nurse. "Explained things before doing them," "letting me know what’s going on," and "keeping me informed" were frequent comments from patients as they spoke of skilled nurses.

Clinical Judgment.
Comments from 13 patients (41%) were categorized in the realm of clinical judgment, described in the Synergy Model12 as including clinical reasoning and clinical decision making, critical thinking, and a global grasp of the situation. Patients used descriptors in this category to identify a skilled nurse as one who was "able to make decisions," had "common sense," and used "good judgment." One patient described a nurse who "had the ability to discern what needs to be done and what shouldn’t be done" as a skilled nurse. An example given by another patient of a skilled nurse’s clinical judgment was "If the IV was not working right," the nurse would be able to assess the situation correctly, know what the problem was, and would know "to go to another spot." "The knowledge of what’s going on . . . they had the information" was how one patient described nurses with a global grasp of his problems.

One patient related with great emotion an experience that occurred years before when her mother was a patient in another hospital, where our patient felt that a nurse did not use good clinical judgment and therefore was not a skilled nurse. As the patient’s mother was preparing to leave the hospital, the nurse removed the IV catheter:

She had tape that was holding the IV in, and the tape was tearing her skin. I asked the nurse to leave it, just cut it and leave it, and we would soak it off, take our time at home, but she continued to tear it and tear her skin. I have never forgotten that because I was so angry that they wouldn’t listen to me. She said, "I have to take this off." I thought, No you don’t. That tape’s not going to hurt a thing; leave it.

Collaboration.
A total of 4 patients (12%) mentioned the importance of collaboration, defined in the Synergy Model12 as working with others in a way that promotes each person’s contributions toward achieving optimal goals. One patient who described the care provided by skilled nurses stated, "I think it’s good they work as a team. I know they have their own patients, but if someone needs someone else to look at something, they come." Another patient described the importance of consistency between nurses, "The nurses all have been doing the same thing... gives me confidence in their care." When that same patient was asked if she could give an example of something a nurse might do that would make her question the nurse’s skill, she readily identified a lack of collaboration and communication as evident by a caregiver who asked her questions that had previously been asked and charted. Two other patients discussed collaboration as an important nursing skill as they described nurses who relay information to and from the physician, who listen to others on the caregiving team, and treat the team members with respect.

Advocacy/Moral Agency.
The Synergy Model12 places advocacy and moral agency within the same category. Included in the definition of this category is "working on another’s behalf and representing the concerns of the patient/family and nursing staff; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within and outside the clinical setting." Although none of our patients identified the nurse characteristic of moral agency, 2 patients described a skilled nurse in terms of advocacy. One patient described skilled nurses as those who would advocate for him "if I had a problem" and "try to figure out what to do . . . and follow up." Another patient described the advocacy role of nurses whom he considered skilled as those nurses who had the ability to research for him the answer to his questions.

Systems Thinking.
Systems thinking is the category of nurse competency that encompasses the body of knowledge and tools that allow a nurse to manage system resources for patients. Expert nurses anticipate the needs of patients through the continuum of care and act to find resources to meet patients’ needs.12 One patient’s comments fit in this category, as he described the nurse who was aware of the hospital’s resources and helped him "find a better way at paying bills" through referral to the hospital’s financial counselor. This same patient described a nurse who helped him find resources in the community and obtained a list of low-cost medications from a local pharmacy.

Response to Diversity.
The nurse characteristic of response to diversity encompasses the sensitivity of nurses to recognize individual differences, including cultural, spiritual, and ethnic differences, and to include these differences in the provision of care.12 One patient’s comments fit the category of response to diversity. This patient, after reflecting on the skills of the nurses who delivered the best care, spoke about a nurse’s sensitivity to his spiritual needs, "Being a man of faith, [it was helpful that] she prayed with me." He further described this nurse as having "a holistic mind-set."

Other.
Of interest, although technical skills are not specifically included in the Synergy Model of nurse competence, the majority of patients (59%) mentioned technical skills of a nurse as a measure by which they perceived the nurse as being skilled. A nurse who demonstrates proficiency at giving injections, starting infusions, preparing patients for procedures, and handling monitoring equipment is deemed skilled by many patients. In addition to the comments related to technical skills, comments of 3 patients were outliers in the Synergy Model. These comments were related to patients’ assumptions that skill is present as long as a nurse maintains his or her license and that a nurse’s age and the number of years a nurse has worked correlate with the skill level of the nurse.


   Discussion
Top
 Literature Review
 Study Questions
 Methods
 Results
 Discussion
Conclusion
 PRIME POINTS
 References
 
Interpersonal Skills, Critical Thinking Skills, and Technical Skills
Our results suggest that patients’ perceptions of a nurse’s skill are largely a component of the interpersonal skills of the nurse, rather than purely the technical skills. These findings are consistent with those of several previous studies19–21,24,26,27 in which patients’ perceptions of overall quality of nursing care were examined and with findings of studies13–18 that showed the importance of communication in patients’ perceptions of physicians’ skill. Our results also indicate that nurses’ critical thinking attributes were recognized by patients as an important component of nursing skill; the nursing roles of clinical decision maker and provider of patient education were major elements. Fewer patients discussed technical skills as a measure of a skilled nurse, a domain identified as a primary measure of nursing quality in 2 studies.22,23

Interpersonal Skills.
Of interest, every patient identified interpersonal attributes of a nurse as a component the patient used to describe a nurse’s skill. A friendly, happy, smiling nurse was perceived as a skilled nurse, yet these attributes have no direct relationship to the quality of a nurse’s clinical expertise. This perception could be attributed to the halo effect, the "tendency of observers to be influenced by one characteristic in judging other unrelated characteristics."28 Although many nurses who are skilled clinically and technically may also have strong interpersonal skills, a nurse who is perceived as friendly and cheerful could be woefully lacking in clinical and technical skills. Because so many nurse attributes that patients identified have no direct relationship to the quality of a nurse’s expertise, radical differences could exist between a patient’s perceptions and the reality of a nurse’s skill.

Language Skills.
One patient’s comments were related to language skills, an important issue because so many international nurses are now employed in the United States. Language barriers are cited by nurses and employers as the most significant challenge for foreign nurses working in the United States.35 Difficulty in communication due to language skills raises questions about possible patient care and safety issues. Because of the importance of communication, this topic warrants further detailed exploration.

Synergy Model
An additional finding of our study is that patients’ perceptions of a nurse’s skill fit with 7 of the 8 nurse characteristics of the Synergy Model. This model describes nursing practice based on the needs and characteristics of patients.12 In the Synergy Model, 7 patient characteristics and 8 nursing competencies are described; optimal patient outcomes occur when patients’ needs and nurses’ competencies are matched. The 8 nurse competencies in the model are clinical judgment, advocacy/moral agency, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitator of learning. The nursing competencies of the Synergy Model are recognized by the AACN Certification Corporation as components in addition to clinical knowledge and judgment that make up critical care nursing. These competencies are included in the exams for progressive care certified nurse and critical care registered nurse, under the category of professional caring and ethical practice.12 In Core Curriculum for Critical Care Nursing, Molter36 notes that further research is needed on the perspectives of health care consumers of the components of the Synergy Model. Thus, it is of interest that the characteristics of skilled nurses identified by patients in our study do fit within this model. Only the nurse characteristic of clinical inquiry, which occurs outside direct interactions with patients, was not mentioned by any of our patients.

Our data suggest that the Synergy Model is more closely aligned with patients’ perceptions of a nurse’s skill than are the skill domains (interpersonal, technical, and critical thinking skills) more commonly referenced in nursing. The most important nurse characteristic from a patient’s perspective is that of caring practices; all of our patients made comments attributed to this domain. As we listened to patients’ comments on the audiotaped interviews, this theme of caring practices was quite evident; every patient described a skilled nurse as one who through verbal and nonverbal communication established a relationship of caring. Facilitator of learning and clinical judgment are other characteristics from the AACN model important to patients as they consider nursing skill. Collaboration, advocacy, systems thinking, and response to diversity, although identified by our patients, were mentioned less often.

Although the Synergy Model does not specifically address technical skills of nurses, the majority of patients (59%) did mention technical skills as a domain they consider when assessing a nurse’s skill. Our data also suggest, however, that even when patients discuss technical skills as a measure of a nurse’s skill, it is not always the successful performance of a procedure that gives patients the impression a nurse is skilled, but often the caring practices that a nurse shows while performing the technical task.

Limitations
This study has several limitations. Patients were interviewed in the facility in which the interviewer was employed. Although patients were assured of confidentiality of information and that their care would not be affected in any way by participation or lack of participation in the study, the presence of a hospital employee conducting the interview may have biased and limited some patients’ comments. Most of the patients interviewed were highly complimentary of the nursing care received at Goshen General Hospital, which has achieved recognition as a magnet hospital. We think that if the interviews were repeated within this setting at a different time, similar results would be obtained; however, similar results might not be obtained in other PCU settings.

A further limitation is that the patients studied were located in 1 nursing unit in 1 hospital in the rural Midwest, reflecting the main population mix of this area. In addition, only English-speaking patients were included in the study, resulting in a mostly homogenous sample that was not necessarily reflective of the typical patient mix. Geographic or cultural differences important to patients’ understandings of a nurse’s skill may be different elsewhere in the United States. It would therefore be beneficial to replicate this study with different populations of patients.

Recommendations
Because the data suggest the important roles of strong interpersonal skills and caring practices in patients’ perceptions of a nurse’s skill, expanded training in communication skills for nurses would be beneficial. Although technical skills are generally the ones that are validated in many hospitals in yearly skills laboratories, a method for validating nurses’ interpersonal skills, critical thinking skills, and caring practices should also be used. Peer review, scenarios, and role-playing are methods of validating interpersonal and critical thinking skills, as well as caring practices.5,7,9 Certification through AACN is another method of validating a nurse’s knowledge and skill in the realm of caring practice.12

Other recommendations for further research include replicating this study with attention to specific age groups to ascertain differences in perceptions of nurses’ skill according to the age of the patient. In addition, further research could be done to study patients’ preconceived images of nurses’ skill, and whether those images are based on previous exposure to nurses or are images perpetuated by the media.


   Conclusion
Top
 Literature Review
 Study Questions
 Methods
 Results
 Discussion
 Conclusion
PRIME POINTS
 References
 
Our findings indicate that patients’ perceptions of a nurse’s skill are largely a component of the interpersonal skills, critical thinking skills, and caring practices of the nurse, rather than the nurse’s technical skills. Patients’ comments related to nurses’ skill fit well with the Synergy Model, particularly the nurse characteristics of caring behaviors, facilitator of learning and clinical judgment. These results support the importance of the acquisition of strong interpersonal skills, critical thinking skills, and characteristics of caring practices for nurses and add to the knowledge of patients’ perceptions of nursing care.


   PRIME POINTS
Top
 Literature Review
 Study Questions
 Methods
 Results
 Discussion
 Conclusion
 PRIME POINTS
References
 


   References
Top
 Literature Review
 Study Questions
 Methods
 Results
 Discussion
 Conclusion
 PRIME POINTS
 References
 

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