International Journal of Orthopaedic and Trauma Nursing (2012) 16, 136146

www.elsevier.com/locate/ijotn

A comparison between orthopaedic nurses and

patients perception of individualised care
Agneta Berg PhD, RNT (Professor) a,b, Ewa Idvall PhD,
RNT (Professor) b,c, Jouko Katajisto MSocSci (Senior Lecturer) d,
Riitta Suhonen PhD, RN (Professor) e,*

a
Section for Health and Society, Kristianstad University, Kristianstad, Sweden
b
Faculty of Health and Society, Malmo University, Sweden
c
Skane University Hospital, Malmo, Sweden
d
University of Turku, Department of Mathematics and Statistics, Turku, Finland
e
University of Turku, Department of Nursing Science, 20014 Turku, Finland

KEYWORDS Summary This exploratory study compares orthopaedic nurses perceptions of

Individualised nursing individualised nursing care with previously published orthopaedic patients percep-
care; tions. Orthopaedic nurses (N = 243) from one university, two central and two county
Orthopaedic nurses; hospitals working within in-patient care were surveyed using the Individualised Care
Quality of care Scale-Nurse (ICS-Nurse) in 2009 (response rate 74%, n = 180). The data were ana-
lysed using both descriptive and inferential statistics. About 60% of the nurses sta-
ted that it was very important that the care provided is individualised in comparison
with 86% of the patients as previously reported (p-value <0.001). The highest rated
assessment of individualised care was the clinical situation and the lowest the per-
sonal life situation which is in line with the patients experiences. This result dem-
onstrates the need of managers in healthcare organisations to redouble their efforts
in the implementation of individualised care by investigating nurses contemporary
beliefs about, and forces that hinder the provision of individualised nursing care.
c 2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +358 503042150; fax: +358 2

3338400.
E-mail addresses: Agneta.Berg@hkr.se (A. Berg), ewa.
idvall@mah.se (E. Idvall), jouko.katajisto@utu.fi (J. Katajisto),
riisuh@utu.fi, suhonen.riitta@kolumbus.fi (R. Suhonen).


1878-1241/$ - see front matter c 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijotn.2012.04.003
A comparison between orthopaedic nurses and patients perception of individualised care 137

Editors comment
We probably perceive we give the best possible care at all times, but this may not be the view of the
patient. Likewise we may feel that the lack of time we have with patients is perceived as poor care,
which again might not be the case. This study seeks to answer some of the questions related to
patients perception of care and how as orthopaedic practitioners we could improve the patients
experience by utilising the suggestions made by the author.
BS

Introduction their patients individuality through general nurs-

The importance of individualised care has been
recognised as a useful goal for the provision of high
quality care by nurses (e.g. Teeri et al., 2006;
Dehn, 2007) and patients (e.g. Athlin et al., 1993;
Suhonen et al., 2008a). This has also been recogni-
sed in the Swedish Health and Medical Services Act
(1982:763). Although both nurses and patients have
highlighted the importance of being cared for as an
individual as individualised care is not always prac-
ticed (Barry et al., 2005; Teeri et al., 2006). In one
Swedish study, almost all of the patients stated
that it was very important to be treated as an indi-
vidual but only 59% experienced this type of care
(Berg et al., 2007). This may be because of the
complex nature of the concept of individualised
care and its management within modern health
care services.
Although a universally accepted definition of
individualised care remains elusive, there seems
to be a consensus which espouses the importance
of care provision tailored to meet individuals
needs which recognises each persons uniqueness
(e.g. Radwin and Alster, 2002; Thompson et al.,
2007). One definition of individualised care (Suho-
nen et al., 2005) takes into account patients per-
sonal characteristics in their clinical and personal
life situation and their decisional control over their
own care. Based on this definition the Individua-
lised Care Scale (ICS) was developed to measure
the level of individualised care provided by nurses
from the patients perspective (Suhonen et al.,
2005). The ICS, now re-named ICS-Patient, has
two dimensions; perceptions about how nursing
activities support patients individuality and per-
ceptions of the realisation of that individuality in
care provision. These dimensions include the rec-
ognition of the patients individual clinical situa-
tion, personal life situation and the decisional
control over their own care (Suhonen et al.,
2005). These same dimensions were used in the la-
ter development of the Individualised Care Scale-
Nurse (ICS-Nurse) (Suhonen et al., 2010a) which
captures the nurses views about how they support
ing activities and the extent nurses perceive the
care they provide to patients is individualised
(Suhonen et al., 2010a,b).
Studies conceptualising and measuring individu-
alised care from both nurses and patients per-
spectives have seldom been reported (Suhonen
et al., 2011a). Separately both patients (Suhonen
et al., 2008b) and nurses (Chappel et al., 2007;
Poochikian-Sarkissian et al., 2008; Suhonen et al.,
2010b) have provided assessments of individualised
care, indicating that, overall, individuality is pres-
ent in care provision. However, other studies have
revealed challenges and shortcomings in the provi-
sion of individualised care (e.g. Anderson et al.,
2003; Barry et al., 2005; Florin et al., 2005; Muntlin
et al., 2006). There is also evidence that nurses
perceptions of individualised care differ between
different healthcare organisations and specialities
(Suhonen et al., 2010b), between occupational
groups (Curry et al., 2000; Caspar and ORourke,
2008) and between cultures (Suhonen et al.,
2011b). Earlier published research also indicates
that nurses have a more positive perception of indi-
viduality in care than has been reported by patients
(Suhonen et al., 2010b), and this is also verified in
studies from similar topics such as, informed con-
sent (Schopp et al., 2003) and patient autonomy
(Scott et al., 2003).
The aim of this study was twofold: to report
orthopaedic nurses perceptions of the level of
individualised care they deliver and to compare
these results with patients perceptions about the
level of individualised care received, published
earlier (Berg et al., 2007).
Methods
Design and sample
This exploratory, descriptive, cross-sectional study
employed a comparative design. A consecutive
sample of 243 registered and licensed practical
nurses, working directly with patients in the
138
orthopaedic in-patient wards of university, central
county and county hospitals (n = 6) in the Southern
part of Sweden, provided the data for the study,
which was collected between 20th April and 29th
May 2009. The inclusion criteria applied were, that
the nurse (1) was Registered Nurse or Licensed
Practical Nurse, (2) participated in direct patient
care, (3) worked in the adult acute orthopaedic
surgical in-patient ward, (4) voluntarily partici-
pated in the study and (5) was able to indepen-
dently respond to the questionnaire in Swedish.
The sample size calculation was based on the
Burns and Groves (2005) sampling estimate for
use in statistical multivariate analyses which advo-
cates a sample size of 10 respondents per item of
the measure, for example, the ICS-Nurse. Since
the ICS-Nurse has a conceptual base of 17 items
(Tables 2 and 3) at least 170 completed question-
naires were required to complete the analyses sat-
isfactorily. Using a typical response rate of 70% in
hospital settings (e.g. Badger and Werrett, 2005;
Suhonen et al., 2010b) it was decided that around
240 questionnaires would be distributed.
The ICS-Nurse
The ICS-Nurse is a validated instrument originally
developed in Finnish. It is a bipartite questionnaire
designed to explore nurses perceptions of the le-
vel of individualised care delivered and is concep-
tualised into two dimensions. The ICS-A-Nurse
captures the nurses perceptions about how nurses
support patient individuality through general nurs-
ing activities and the ICS-B-Nurse captures their
perceptions about the extent nurses perceive that
the care they provide is individual. The ICS-A-Nurse
and ICS-B-Nurse is both 17 item, 5-point Likert-type
scales, grouped into three sub-scales: the clinical
situation (ClinA- and B-Nurse, seven items), the
personal life situation (PersA- and B-Nurse, four
items) and decisional control over care (DecA and
B-Nurse, six items). The items are scored from
1 = strongly disagree to 5 = strongly agree, with a
neutral midpoint. The higher the mean score the
higher the level of individualised nursing care.
In this study, the internal consistency reliability
(Cronbachs alpha) of the ICS-Nurse were 0.88 for
the ICS-A-Nurse (sub-scales 0.730.78) and 0.89
(0.770.82) for the ICS-B-Nurse demonstrating a
high degree of homogeneity. The Principal Compo-
nent Analysis (PCA) identified three factors which ac-
counted for 51.2% of the variance in the ICS-A-Nurse
and 58.5 in the ICS-B-Nurse supporting construct
validity. (Table 1.) The results of the PCA are similar
to those previously found (Suhonen et al., 2010a).
A. Berg et al.
ICS-Nurse translation
The English version of the ICS-Nurse (Suhonen
et al., 2010a) was translated, first into Swedish
by an authorised translator and then back-trans-
lated twice, independently by authorised transla-
tors, before being culturally and semantically
adapted (Sidani et al., 2010; Sousa and Rojjanasri-
rat, 2011) by two of the authors (AB and EI).
Nurse background data
The demographics requested were: age, gender,
highest education, occupation or job title, length
of experience in nursing care and the length of
experience in the current workplace. One question
about individualised care was added to this section
of the questionnaire.
How important is it for you that the care provided
is individualised?
Answers to this used the same 5-point scale used
in the ICS-Nurse.
Data collection and ethical considerations
The study was conducted according to the Swedish
law for human research (SFS, 2004) and according
to ethical standard procedures outlined in Beau-
champ and Childress (2009). Permission for the
data collection was obtained from the Head of
the Department in the hospitals. The first and
second author (AB and EI) held repeated informa-
tion meetings in each ward of the hospitals to pro-
vide all the nurses in the study wards with
adequate information about the study. All nurses
who fulfilled the inclusion criteria were then given
the ICS-Nurse questionnaire and an introductory
letter containing information about: the purpose
and nature of the research, the confidential man-
agement of personal information and their rights
to refuse to participate, at any time, without
retribution. Completed questionnaires sealed in a
prepaid, addressed envelope were returned by
mail and signified the participants informed
consent.
Data analysis
The data were analysed using the Statistical Soft-
ware for Social Sciences, SPSS 16.0 version. Firstly,
descriptive statistics, such as frequencies, per-
centages, means and standard deviations (SD) were
used to describe the respondents background
variables and study variables. In the analysis of
A comparison between orthopaedic nurses and patients perception of individualised care 139

Table 1 Factor loadings for the ICS-Nurse-A and ICS-Nurse-B.

Content of the item Commonalities Factor loadings ICS-A Commonalities Factor loadings ICS-B
I II III I II III
(I) Clinical situation
1. Feelings 0.582 0.673 0.012 0.358 0.489 0.620 0.258 0.193
2. Needs for care 0.666 0.808 0.084 0.083 0.495 0.630 0.059 0.309
3. Responsibility for 0.207 0.375 0.257 0.018 0.649 0.071 0.169 0.785
care
4. Changes in 0.416 0.063 0.074 0.638 0.564 0.690 0.048 0.293
conditions
5. Fears and anxiety 0.538 0.253 0.060 0.686 0.702 0.827 0.070 0.117
6. Effects of the illness 0.598 0.429 0.286 0.576 0.722 0.770 0.361 0.015
7. Meaning of the 0.491 0.500 0.372 0.321 0.686 0.753 0.340 0.056
illness
(II) Personal life situation
8. Activities in daily life 0.390 0.472 0.315 0.260 0.692 0.218 0.801 0.059
9. Hospital experience 0.482 0.428 0.543 0.063 0.637 0.117 0.759 0.217
10. Everyday habits 0.539 0.169 0.660 0.274 0.702 0.208 0.810 0.055
11. Family in care 0.611 0.356 0.687 0.111 0.454 0.011 0.575 0.352
(III) Decisional control over care
12. Understandably 0.466 0.068 0.401 0.548 0.473 0.407 0.011 0.554
instruction
13. Want to know 0.584 0.373 0.656 0.121 0.477 0.178 0.263 0.613
14. Personal wishes 0.548 0.127 0.699 0.207 0.569 0.441 0.474 0.387
15.Decision-making 0.584 0.236 0.703 0.187 0.652 0.327 0.381 0.633
16. Express opinion 0.509 0.053 0.621 0.347 0.511 0.523 0.296 0.388
17. Want to wash 0.498 0.098 0.621 0.321 0.467 0.152 0.638 0.194

Rotated eigenvalue 5.988 1.499 1.222 6.755 1.907 1.279

Percentage of 35.2 8.8 7.2 39.7 11.2 7.5
explained variance
Cumulative percentage 35.2 44.0 51.2 39.7 50.9 58.5
of total variance
explained
Extraction method: principal component analysis. Rotation method: Varimax with Kaiser normalisation.

the ICS-Nurse data a total of eight sum-variables
(ICS-A-Nurse, ClinA-Nurse, PersA-Nurse, DecA-
Nurse, ICS-B-Nurse, ClinB-Nurse, PersB-Nurse,
DecB-Nurse) were computed by counting the item
responses for each sub-scale and then dividing this
by the number of items in the sub-scale to provide
the sum-score for each scale.
Secondly, the distributions of the sum-variables
were examined. Distributions differed significantly
from a normal distribution, according to Shapiro
Wilks-tests, and so non-parametric tests were
used. Nurses and patients responses at the sum-
score level were compared using the MannWhit-
ney U-test (chi-square statistics v2 with a p-value)
and nurses and patients answers to the additional
background question, the importance of individua-
lised care, were examined using cross-tabulation
and Pearsons chi-square statistics with p-value.
When interpreting the results of the ICS-Nurse a
mean score >4.5 was required to designate a high
level of individualised care. In order to examine
the underlying structure for the Swedish version
of ICS-Nurse an explanatory Principal Component
Analysis (PCA) with Kaisers normalisation and Vari-
max rotation was computed for both dimensions
(Table 1). Statistical significance, where relevant,
was set at p 6 0.05 and the internal homogeneity
reliability of the scales was examined using Cron-
bachs alpha coefficients.
Results
Participants
The response rate was 74% (N = 243, n = 180) of
which 47% were registered nurses. The mean age
of the respondents was 43 years (SD = 11, range
140 A. Berg et al.

2066) and most were female (93%). The nurses
education levels were: vocational (48%), diploma
in nursing (37%), bachelors degree (11%) and mas-
ters degree or more (1%) and missing values 3%.
About half (52%) of the nurses worked full time
and most of them on day duty (63%). The average
length of relevant work experience was 17 years
(SD = 13, range 3 months to 44.5 years) and the
average length of experience in the current work-
place was 9 years (SD = 9, range 2 months to
37 years).
Nurses assessments of the support of
patient individuality (ICS-A-Nurse)
At the sub-scale level, no mean score exceeded the
4.5 threshold (Table 2). The highest score was gi-
ven in the clinical situation sub-scale and the
lowest in the personal life situation.
At the item level, one item in ClinA-Nurse and
DecA-Nurse, respectively, was scored above 4.5
(Table 3).
In the sub-scale ClinA-Nurse 148 nurses (82%)
strongly agreed with the item I identify changes
in how they felt (mean 4.83 0.38) and 49 nurses
(27%) strongly agreed with the item I talk with
the patients about what the illness/health condi-
tion meant to them (mean 4.15 0.63).
In the sub-scale PersA-Nurse only 13 nurses (7%)
strongly agreed with the item I ask patients
whether they want their family to take part in
their care (mean 2.95 1.14) and 42 of the nurses
(23%) strongly agreed with the statement I ask pa-
tients what kind of activities they do in everyday
life outside the hospital (mean 4.00 0.74).
In the sub-scale DecA-Nurse 102 nurses (57%)
strongly agreed with I give instructions to
patients using a language that is easy to under-
stand (mean 4.51 0.66) and 30 nurses (17%)
strongly agreed with I listened to patients per-
sonal wishes with regards to their care (mean
3.88 0.72).
Nurses assessments about the provision of
individualised care (ICS-B-Nurse)
Similar to ICS-Nurse-A, at the sub-scale level, the
nurses perceptions of individuality in the provision
of care, ICS-Nurse-B, showed that no mean score
exceeded the 4.5 threshold (Table 2). The highest
assessment was again in the clinical situation
sub-scale and the lowest the personal life situa-
tion. At the item level, two items in ClinB-Nurse
and one item DecA-Nurse scored above 4.5
(Table 4).
In the sub-scale ClinB-Nurse, 125 nurses (69%)
strongly agreed with the item I took into account
the changes in how they felt (mean 4.70 0.47)
and 117 nurses (65%) strongly agreed with the item
I took into account their fears and anxieties
(mean 4.65 0.51).
In the sub-scale PersB-Nurse, 47 nurses (26%)
strongly agreed with the item I took into account
patients everyday habits during their stay in hos-
pital (mean 3.89 0.95) and 23 of the nurses
(13%) strongly agreed with the statement families
took part in their care if they wanted (mean
3.20 1.13).
In the sub-scale DecB-Nurse, 98 nurses (54%)
strongly agreed that I made sure that patients
understood the instructions they received (mean
4.52 0.57) and 73 nurses (41%) strongly agreed
with I took into account the opinions patients ex-
pressed about their care (mean 4.33 0.63).

Table 2 Nurses and patients assessments on individualised care at sub-scale and sum-scale levels.
Nurses Patients p-Value
Mean (SD) Mean (SD)a
ICS-A (total) 4.05 (0.45) 3.90 (0.82) 0.613
Clinical situation A 4.32 (0.40) 4.28 (0.73) 0.138
Personal life situation A 3.64 (0.69) 3.23 (1.10) 0.003
Decisional control A 3.97 (0.58) 3.86 (0.95) 0.721
ICs-B (total) 4.15 (0.47) 4.28 (0.61) 0.000
Clinical situation B 4.44 (0.43) 4.40 (0.61) 0.518
Personal life situation B 3.54 (0.80) 3.78 (0.92) 0.001
Decisional control B 4.20 (0.53) 4.46 (0.62) 0.000
ISC-A perceptions of the support of patient individuality through specific nursing activities.
ISC-B Perceptions of individuality in the care provided.
a
Berg et al. (2007).
A comparison between orthopaedic nurses and patients perception of individualised care 141

Table 3 Descriptive data on the ICS-Nurse scale A, at the item level 17 statements (range 15).
Content of the item Strongly agree n (%) Mean (SD) Missing n (%)
Clinical situation
A01 Feelings about illness/health condition 57 (31.7) 4.24 (0.6) 0
A02 Needs that require care and attention 59 (32.8) 4.19 (0.71) 3 (1.7)
A03 Chance to take responsibility as far as possible 55 (30.6) 4.15 (0.75) 1 (0.6)
A04 Identify changes in how they have felt 148 (82.2) 4.83 (0.38) 1 (0.6)
A05 Talk with patients about fears and anxieties 80 (44.4) 4.40 (0.58) 1 (0.6)
A06 Find out how their health conditions affect them 70 (38.9) 4.33 (0.61) 2(1.1)
A07 What the illness/health conditions means to them 49 (27.2) 4.15 (0.63) 5 (2.8)
Personal life situation
A08 What kinds of things they do in their everyday life 42 (23.3) 4.00 (0.74) 4 (2.2)
A09 Previous experience of hospitalisation 35 (19.4) 3.68 (0.95) 2 (1.1)
A10 Everyday habits 41 (22.8) 3.89 (0.87) 1 (0.6)
A11 Family take part in their in their care 13 (7.2) 2.95 (1.14) 5 (2.8)
Decisional control over care
A12 Instructions to patients 102 (56.7) 4.51 (0.66) 1 (0.6)
A13 What they want to know about illness/health condition 31 (17.2) 3.62 (0.98) 3 (1.7)
A14 Patients personal wishes with regards to their care 30 (16.7) 3.88 (0.72) 3 (1.7)
A15 Help patients take part in decisions 43 (23.9) 3.99 (0.79) 2 (1.1)
A16 Encourage patients to express their opinions 71 (39.4) 4.21 (0.81) 1 (0.6)
A17 Ask patients at what time they would prefer to wash 33 (18.3) 3.56 (1.04) 2 (1.1)

Comparison of nurses and patients delivered compared to the nurses perceptions

perspectives of individualised care (DecB, p-value <0.001).

In the study used for comparison a majority of the

patients (86%, n = 236) strongly agreed with the
statement It is important that the nurses care
for me as an individual (Berg et al., 2007). This
compares with 59% (n = 107) of the nurses, in this
current study, who agreed with the statement It
is very important that the care provided is indi-
vidual (p < 0.001). This result corresponds well
with the patients experience where 59% (n = 162)
strongly agreed with the statement that during
hospitalisation the nurses cared for me as an
individual (Berg et al., 2007).
Comparing ICS-A for nurses and patients, over-
all, the nurses perceived that they supported pa-
tient individuality more than the patients thought
they were supported. This is seen most convinc-
ingly in sub-scale PersA (Table 2). Comparing ICS-
B nurses and patients, the patients perceived that
the care delivered (ICS-B) was more individualised
than the nurses perceptions (p-value <0.001). In
the personal life situation sub-scale (Pers-B),
though the perceptions that the patients personal
life situation was taken into account were fairly
low in both ICS-Nurse and ICS-Patient, the patients
assessments were higher than the nurses (PersB,
p-value = 0.001). The patients also perceived that
they had more decisional control over their care
Discussion
Methodological considerations
Some limitations have to be taken into consider-
ation when interpreting the results from this study.
The instrument indicates a high degree of homoge-
neity and constructs validity (cf. Jacobson, 1997)
and are comparable to earlier study (Suhonen
et al., 2010a). However, a single study with a newly
translated and adapted measure is insufficient to
be persuaded of the validity and reliability of the
scale. The descriptive and exploratory nature of
this study means that no firm explanations for the
phenomena reported can be provided. Even so,
threats to both the validity and the reliability in
the structure and the process of the study are of
concern and should be mitigated where possible.
Structurally, the comparative patients data (Berg
et al., 2007) were collected some years ago and
the time lag, between the studies, may have
caused some spurious results as modes of care
delivery may have changed in that time. However,
in mitigation of this, the questionnaires used to
collect the data from both nurses and patients
were equivalent and both the earlier and later
142 A. Berg et al.

Table 4 Descriptive data on the ICS-Nurse scale B, 17 statements (range 15).

Content of item Strongly Mean (SD) Missing n (%)
agree n (%)
Clinical situation
B01 Feelings about illness/health condition 66 (36.7) 4.31 (0.61) 3 (1.7)
B02 Needs that require care and attention 86 (47.8) 4.48 (0.52) 4 (2.2)
B03 Chance to take responsibility as far as possible 48 (26.7) 4.02 (0.75) 4 (2.2)
B04 Identify changes in how they have felt 125 (69.4) 4.70 (0.47) 4 (2.2)
B05 Talk with patients about fears and anxieties 117 (65.0) 4.65 (0.51) 4 (2.2)
B06 Find out how their health conditions affect them 103 (57.2) 4.53 (0.63) 4 (2.2)
B07 What the illness/health conditions means to them 88 (48.9) 4.36 (0.77) 4 (2.2)
Personal life situation
B08 What kinds of things they do in their everyday life 19 (10.6) 3.45 (0.91) 7 (3.9)
B09 Previous experience of hospitalisation 30 (16.7) 3.58 (1.0) 7 (3.9)
B10 Everyday habits 47 (26.1) 3.89 (0.95) 4 (2.2)
B11 Family take part in their in their care 23 (12.8) 3.20 (1.13) 10 (5.6)
Decisional control over care
B12 Instructions to patients 98 (54.4) 4.52 (0.57) 2 (1.1)
B13 What they want to know about illness/health condition 69 (38.3) 4.25 (0.79) 8 (4.4)
B14 Patients personal wishes with regards to their care 63 (35.0) 4.25 (0.66) 5 (2.8)
B15 Help patients take part in decisions 45 (25.0) 3.97 (0.79) 8 (4.4)
B16 Encourage patients to express their Opinions 73 (40.6) 4.34 (0.63) 7 (3.9)
B17 Ask patients at what time they would prefer to wash 58 (32.2) 3.90 (1.0) 5 (2.8)

studies were completed in the same hospitals mak-
ing comparisons more valid.
The sample was taken from two major health
care areas in southern Sweden and the response
rate was good (74%). Nurses in Sweden are ex-
pected to provide individualised care under the
direction of The Health and Medical Service Act
(1982:763) which could have influenced the nurses
responses. However, since the comparator study
was completed in 2007, the responses of the nurses
would be similarly influenced by The Health and
Medical Service Act, of 1982. Additionally, re-
sponses could have been influenced by differences
in the care vision and standards of care delivery
found between wards and organisations (Suhonen
et al., 2010b) possibly affected by ideological is-
sues at a ward management level (Brown Wilson
and Davies, 2009; Suhonen et al., 2009). This can-
not be mitigated.
Process threats in the study were twofold: firstly
the translation and adaptation effects of the use of
a questionnaire developed in a different language
(Finnish) were reduced by using standard transla-
tion procedures. Secondly, the level of missing
data, which may indicate poor understanding of
the questions was low, overall, demonstrating that
the questions were understandable and that the
questionnaire was easy to complete. However
there were some missing data issues. There may
be three reasons for the missing data. The first is
concerned with the role the family plays in care
delivery. Missing data may indicate that the nurses
have not yet adopted a family-centric perspective
in their clinical practice. The second might be a
demonstration of culture differences which under-
play the significance of the family perspective. The
third is concerned with short hospital stays in
orthopaedic surgery. Berg et al. (2007) reported
an average stay of 7 days in Sweden for elective
surgery and, in these circumstances, nurses may
have found questions about the role of the family
less important. These reasons require further
study.
The threshold of >4.5 for each item in the ICS
(scale range 15) was chosen because this level
was used as the performance indicator for a high
level of individualised care in the comparator
study. This may seem to be high, however, the
items of the Individualised Care Scales have been
validated and represent important aspects of indi-
vidualised care. It is therefore reasonable to use
this high threshold. The results indicate that there
is still more to be done to achieve individualised
care in care provision.
The variation, given in the answers to the ques-
tions in the ICS-A-Nurse and ICS-B-Nurse and the
comparator sub-scales are similar. However,
although the conceptual content of the items in
A comparison between orthopaedic nurses and patients perception of individualised care
ICS-A-Nurse and ICS-B-Nurse are the same, as both
the scales include the same conceptual construct,
the lens the nurses used to answer the questions omitting to take account of their unique health
in the respective scales may have been different.
The completion of ICS-A-Nurse scale may have pre-
pared the respondents for the answers to the ICS-B-
Nurse items, producing a better consistency in the
answers. In addition, in completing the ICS-A-Nurse
nurses assess their own activities concerned with
supporting patient individuality, generally through
nursing interventions. In the ICS-B-Nurse the same
nurses answered questions about the perceived
level of individualisation in the care they provided
to patients in their latest shifts. These, ICS-
B-Nurse, items are concerned with direct individu-
alised care provision to which the respondents,
who understand the principles of individualisation
well, may aspire. Therefore, the answers given
may reflect the aspirations of the nurses rather
than the care they delivered.
Orthopaedic surgical patients may also be con-
sidered to be a fairly homogeneous group of pa-
tients who have similar interventions requiring
similar care. Nurses may have thought that there
was no need to know the patients as an individual
person but as a patient, similar to many, having a
surgical procedure without specific expectations
of being cared for as an individual (see Lynn and
MacMillen, 1999).
Interpreting the results
Perceptions about the importance of individualised
nursing care differ significantly between nurses and
patients in this comparative study. From the pa-
tients perspective, it was very important for almost
all of them to be cared for as in individual (Berg
et al., 2007) while barely 60% of the nurses thought
individuality in provision was important. This result
confirmed the work of Berg et al. (2007) who found
that 59% of the patients perceived that they were
cared for as an individual or unique person. This
finding is not unique to Swedish orthopaedic nurs-
ing care; studies from other western countries
(McCance et al., 2009; Weiss et al., 2010) have re-
ported similar results. The reason for the lack of
individualised care provision, it has been argued,
is the over-use of general guidelines as gold stan-
dards when striving for good quality care (Woolf
et al., 1999). These guidelines, formed into moni-
tored patient pathways, may restrict nurses flexi-
bility and decrease their opportunities for
innovative thought. (e.g. Ilott et al., 2006).
When general guidelines, surgical procedures
and patient pathways which support the provision
143
of nursing care, are followed rigidly there is a risk
that nurses neglect the patient, as an individual,
determinants and preferences (Radwin and Alster,
2002). Conversely, there is also a need for the
safety and efficiency provided when these same
guidelines are followed. Overall, there is a need
to balance the requirements of individualised care
with the requirements of the general process of
health care when striving for high quality in ortho-
paedic nursing. Extra demands are made of nurses,
who have to come to know their patients as individ-
uals creating unique interventions within hospital
policies and procedures for patients whose average
hospital stay is short, at around seven days.
Comparison of the results from the ICS-Nurse,
this prospective study, and the ICS-Patient (Berg
et al., 2007) at the ICS-A total and sub-scale levels
show that the nurses perceived the provision of
individuality in nursing care more positively than
perceptions reported by patients. This is in line
with results reported from several international
studies (e.g. Schopp et al., 2003; Scott et al.,
2003; McCance et al., 2009; Tucket et al., 2009;
Weiss et al., 2010). Worth noting is that in the com-
parison between the nurses total score (ICS-B-
Nurse) and the patients perception of individuality
in care provided (ICS-B-Patient) the patients per-
ceived the nursing care provision as more individ-
ual. This was also the case at the sub-scale level
for The ICS-B-Patient-Personal life situation and
ICS-Patient-Decisional control over care, and might
indicate a small change in the trend, which needs
to be verified in further studies.
Nurses consider individualised care to be a key
principle and concept in nursing (ICN, 2006) and
strive for it within many organisations. In one
way, this may explain the higher perceptions of
individuality in care delivery measured using the
ICS-B-Nurse where nurses assess individuality as a
result of the care they deliver. However, nurses
might have lower perceptions of individualised
care in their own activities and interventions (ICS-
A-Nurse) if they are not completely satisfied with
the care they provide. Whichever is the case, it
underlines the need for organisational and manage-
rial support of nurses efforts to provide care that
meets the individual needs of patients. The result
also emphasises the need for a closer evaluation
of nurses activities and their assessments of the
care quality, for example, in the form of regular,
clinical, group supervision (Berg and Hallberg,
1999).
The ICS-Nurse and ICS-Patient should also be fur-
ther evaluated. Individualised care was conceptua-
lised as a phenomenon that recognises that
144
patients experience and perceive the same care, in
a variety of ways, according to their different val-
ues (Suhonen et al., 2005). The ICS-Nurse, devised
after the ICS-Patient, is based on this conceptuali-
sation. However, nurses may not accept this ap-
proach to the measurement of individualised care
as it relies on perceptions at the endpoint of care
delivery and does not take account of related nurs-
ing activities which are not seen by patients. This
may mean that there are important issues about
the delivery of individualised care that are not rep-
resented in any of the Individualised Care Scales,
currently.
Overall the orthopaedic nurses in this study gave
the highest scores in the clinical situation, in porting the results of this current study. Further-
both ICS-A and ICS-B, implying that the nurses ob-
serve, identify and care for changes in their pa-
tients actual health conditions. This result is not
surprising if reliance on the use of general and
standardised care plans is common or are perceived
as more important than individualised nursing care
plans. In individualised care terms, although it is
important for nurses to be aware of the clinical sit-
uation, it is also important to consider the whole
person in care. Additionally, when caring for the
whole person, nurses incorporate comprehensive
psycho-social and spiritual care into their biological
care. This means that, within individualised nursing
care, the patients family and social network should
be considered important (Weiner, 2004). This
seems to be almost completely neglected in ortho-
paedic nursing care (cf. Berg et al., 2007). In this
current study, the nurses reported that they asked
the patients if they wanted the family to take part
in the care, infrequently. This was represented by
low mean scores (mean 2.95 1.14) which have
not been reported in previous studies. This suggests
that the orthopaedic nurses need to demonstrate,
or develop, the knowledge and skills required to ac-
tively collaborate with their patients and their fam-
ilies. This finding is important, because studies into
the nursing documentation system used in Swedish
hospitals (VIPS a Nordic acronym for well being,
integrity, prevention and safety) for many years
(Ehnfors et al., 1991, 2002), have shown that
nursing documentation about patient care, is not
individualised. Records studied with patient infor-
mation, such as name and clinical issues omitted
were very similar (Karkkainen et al., 2005) and
demonstrated a lack of documented, individualised
care (e.g. Bergh et al., 2007). However, models like
VIPS have been shown to be able to help nurses to
deliver individualised care patients (e.g. Bjorvell
et al., 2003; Darmer et al., 2004).
The nurses in this study stated that they support
patient individuality in their clinical situation and
A. Berg et al.
facilitated patients decisional control over their
own care. The high scores for individualised care
by nurses are important and perhaps demonstrate
the effect of education, process evaluation and re-
search used in some units, where nurses are
empowered to change care routines and adapt care
processes and ways of organising care (see Caspar
et al., 2009). The lowest assessments in both
groups, nurses and patients, were found in the
sub-scale personal life situation (Pers A and B).
Previously, Anderson et al. (2009) found that while
nursing staff generally knew their patients fairly
well, a significant percentage of nurses reported
knowing nothing at all of their patients lives, sup-
more, it has been found that both nurses and
patients have ranked the nursing content element
of know who they are as a person as one of those
items not so important (Lynn and MacMillen, 1999).
However, in our study both the nurses and patients
(Berg et al., 2007) considered individualised care as
highly important. One reason for this difference
may be that although patients desire individuality
in care, targeted for the individual alone, they do
not necessarily think that individualised care should
be based on patients individual characteristics and
their individual needs which recognise each per-
sons uniqueness (e.g. Radwin and Alster, 2002;
Thompson et al., 2007). Nurses need to assess the
characteristics and needs of their patients, coming
to know the individuals before being able to care for
them and a one size fits all (e.g. Alkema et al.,
2006) approach does not meet the varied character-
istics and needs of individuals. Alongside a change
in approach to nursing care delivery, a reduction
in the gap in understanding of individualised care
between nurses and their patients is required.
Conclusions
The results highlight the need for a continuous
development of the measurement of the quality
of care and individualised nursing care from differ-
ent perspectives. The discrepancy between the pa-
tients and nurses assessments warrants further
examination. However, perhaps the most impor-
tant requirement is the need to find ways to reduce
these differences by, for example, including pa-
tient perspectives in the development of nursing
care and, more generally, in healthcare services.
Changes in the management of the patients per-
sonal life situation, for example, might come to in-
clude changes in the role families play in care.
Development towards individualised care will re-
quire a concomitant development of management
A comparison between orthopaedic nurses and patients perception of individualised care
models that determine an individualised care envi-
ronment. However, the nature of individualised
care will also be determined by the environment
in terms of, for example, other needs of the con-
sumer, shorter patient stays and efficiency drives.
Conflict of Interest Statement
The authors stated that there is no conflict of
interest.
Funding Source
This study was funded by the Research Foundation
for Nursing Education, Forssa Health Care Districts
special grant-in-aid (EVO) and the Finnish Cultural
Federation, which are gratefully acknowledged.
Ethical Approval
The study complies with the principles laid down in
the Declaration of Helsinki; Recommendations
guiding physicians in biomedical research involving
human subjects. Adopted by the 18th World Medical
Assembly, Helsinki, Finland, June 1964, amended
by the 29th World Medical Assembly, Tokyo, Japan,
October 1975, the 35th World Medical Assembly,
Venice, Italy, October 1983, and the 41st World
Medical Assembly, Hong Kong, September 1989.
The study was conducted according to the Swed-
ish law for human research (SFS, 2004) and accord-
ing to ethical standard procedures outlined in
Beauchamp and Childress (2009). Permission for
the data collection was obtained from the Head
of the Department in the hospitals and nurses gave
informed consent to the work. Completed ques-
tionnaires sealed in a prepaid, addressed envelope
were returned by mail and signified the partici-
pants informed consent.
Acknowledgements
We want to thank the nurses who participated in
this study. We wish to thank Norman Rickard, B.Sc.
(Hons.) M.Sc. RN, for his help with the English
language.
References
Alkema, G.E., Reyes, J.Y., Wilber, K.H., 2006. Characteristics
associated with home- and community- based service util-
145
isation for medicare managed care consumers. Gerontologist
46 (2), 173182.
Anderson, R., Issel, L.M., McDaniel, R.R., 2003. Nursing homes
as complex adaptive systems. Relationships between man-
agement practice and resident outcomes. Nursing Research
52 (1), 1221.
Anderson, K.A., Taha, R.D., Hosier, A.F., 2009. Know thy
residents: an exploration of long-term care nursing staffs
knowledge. Research in Gerontolological Nursing 2 (1), 69
76.
Athlin, E., Furaker, C., Jansson, L., Norberg, A., 1993. Appli-
cation of primary nursing within a team setting in the hospice
care of cancer patients. Cancer Nursing 16 (5), 388397.
Badger, F., Werrett, J., 2005. Room for improvement? Reporting
response rates and recruitment in nursing research in the
past decade. Journal of Advanced Nursing 51 (5), 502510.
Barry, T., Brannon, D., Mor, V., 2005. Nurse aide empowerment
strategies and staff stability: effects on nursing home
resident outcomes. The Gerontologist 45 (3), 309317.
Beauchamp, T.L., Childress, J.F., 2009. Principles of Biomedical
Ethics, fifth ed. Oxford University Press, New York.
Berg, A., Hallberg, I.R., 1999. Effects of systematic clinical
supervision on psychiatric nurses sense of coherence,
creativity, work-related strain, job satisfaction and view of
the effects from clinical supervision: a pre-post test design.
Journal of Psychiatric and Mental Health Nursing 6 (5), 371
381.
Berg, A., Suhonen, R., Idvall, E., 2007. A survey of orthopaedic
patients assessment of care using the individualised care
scale. Journal of Orthopaedic Nursing 11 (34), 185193.
Bergh, A.L., Bergh, C.H., Friberg, F., 2007. How do nurses
record pedagogical activities? Nurses documentation in
patient records in a cardiac rehabilitation unit for patients
who have undergone coronary artery bypass surgery. Journal
of Clinical Nursing 16 (10), 18981907.
Bjorvell, C., Wredling, R., Thorell-Ekstrand, I., 2003. Prerequi-
sites and consequences of nursing documentation in patient
records as perceived by a group of registered nurses. Journal
of Clinical Nursing 12 (2), 206214.
Brown Wilson, C., Davies, S., 2009. Developing relationships in
long term care environments: the contribution of staff.
Journal of Clinical Nursing 18 (12), 17461755.
Burns, N., Grove, S.K., 2005. The Practice of Nursing Research.
Conduct, Critique and Utilisation, fifth ed. W.B. Saunders
Co., Philadelphia.
Caspar, S., ORourke, N., 2008. The influence of care provider
access to structural empowerment on individualized care in
long-term-care facilities. Journals of Gerontology Series B:
Psychological Sciences & Social Sciences 63 (4), 255265.
Caspar, S., ORourke, N., Gutman, G.M., 2009. The differential
influence of culture change models on long-term care staff
empowerment and provision of individualized care. Canadian
Journal of Aging 28 (2), 165175.
Chappell, N.L., Reid, R.C., Gish J.A., 2007. Staff-based mea-
sures of individualized care for persons with dementia in
long-term care facilities. Dementia 6 (6), 527547.
Curry, L., Porter, M., Michalski, M., Gruman, C., 2000. Individ-
ualized care: perceptions of certified nurses aides. Journal
of Gerontological Nursing 26 (7), 4551.
Darmer, M.R., Ankersen, L., Nielsen, B.G., Landberger, G.,
Lippert, E., Egerod, I., 2004. The effect of a VIPS imple-
mentation programme on nurses knowledge and attitudes
towards documentation. Scandinavian Journal of Caring
Sciences 18 (3), 325332.
Dehn, B., 2007. Care of the menopausal patient: a nurse
practitioners view. Journal of the American Academy of
Nurse Practitioners 19 (8), 427437.
146
Ehnfors, M., Thorell-Ekstrand, I., Ehrenberg, A., 1991. Towards
basic nursing information in patients records. Vard I Norden
21, 1231.
Ehnfors, M., Ehrenberg, A., Thorell-Ekstrand, I., 2002. The
development and use of the VIPS-model in the Nordic
countries. In: Oud, N. (Ed.), ACENDIO 2002. Proceedings of
the Special Conference of the Association of Common
European Nursing Diagnosis, Intervention and Outcomes,
Vienna, Austria. Verlag Hans Huber, Bern, pp. 139168.
Florin, J., Ehrenberg, A., Ehnfors, M., 2005. Patients and
nurses perception of nursing problems in an acute setting.
Journal of Advanced Nursing 51 (2), 140149.
ICN, 2006. Nursing Care of the Older Person. International
Council of Nurses, Geneva. Available from: <http://www.icn.ch/
images/stories/documents/publications/position_statements/
A15_Nsg_Care_Older_Person.pdf> (cited 6 March 2011).
Ilott, I., Rick, J., Patterson, M., Turgoose, C., Lacey, A., 2006.
What is protocol-based care? A concept analysis. Journal of
Nursing Management 14 (7), 544552.
Jacobson, S.F., 1997. Evaluating instruments for use in clinical
nursing research. In: Frank-Stromberg, M., Olsen, S.J. (Eds.),
Instruments for Clinical Health Care Research, second ed.
Jones & Bartlett Publishers, Boston, MA, pp. 319.
Karkkainen, O., Bondas, T., Eriksson, K., 2005. Documentation
of individualized patient care: a qualitative metasynthesis.
Nursing Ethics 12 (2), 123132.
Lynn, M.R., MacMillen, B.J., 1999. Do nurses know what patients
think is important in nursing care?. Journal of Nursing Care
Quality 13 (5) 6574.
McCance, T., Slate, R.P., McCormack, B., 2009. Using the caring
dimensions inventory as an indicator of person-centred
nursing. Journal of Clinical Nursing 18 (3), 409417.
Muntlin, A., Gunningberg, L., Carlsson, M., 2006. Patients
perception of quality of care at an emergency department
and identification of areas for quality improvements. Journal
of Clinical Nursing 15 (8), 10451056.
Poochikian-Sarkissian, S., Wennberg, R.A., Sidani, S., 2008.
Examining the relationship between patient-centred care
and outcomes on a neuroscience unit: a pilot project.
Canadian Journal of Neuroscience Nursing 30 (2), 1419.
Radwin, L.E., Alster, K., 2002. Individualised nursing care: an
empirically generated definition. International Nursing
Review 49 (1), 5463.
Schopp, A., Valimaki, M., Leino-Kilpi, H., Dassen, T., Gasull, M.,
Lemonidou, C., Scott, P.A., Arndt, M., Kaljonen, A., 2003.
Perceptions of informed consent in the care of elderly people
in five European countries. Nursing Ethics 10 (1), 4857.
Scott, P.A., Valimaki, M., Leino-Kilpi, H., Dassen, T., Gasull, M.,
Lemonidou, C., Arndt, M., Schopp, A., Suhonen, R., Kaljonen,
A., 2003. Perceptions of autonomy in the care of elderly people
in five European countries. Nursing Ethics 10 (1), 2838.
Svensk Forfattnings Samling (SFS), 2004. Swedish law for human
research 2003:460. SWE. Available from: <http://www.riksd-
agen.se/webbnav/index.aspx?nid=3911&bet=2003:460>.
Sidani, S., Guruge, S., Miranda, J., Ford-Gilboe, M., Varcoe, C., 2010.
Cultural adaptation and translation of measures: an integrated
Method. Research in Nursing & Health 33 (2), 133143.
Sousa, V.D., Rojjanasrirat, W., 2011. Translation, adaptation
and validation of instruments or scales for use in cross-
cultural health care research: a clear and user-friendly
A. Berg et al.
guideline. Journal of Evaluation in Clinical Practice 17 (2),
268274.
Suhonen, R., Leino-Kilpi, H., Valimaki, M., 2005. Development
and psychometric properties of the individualised Care Scale.
Journal of Evaluation in Clinical Practice 11 (1), 720.
Suhonen, R., Valimaki, M., Leino-Kilpi, H., 2008a. A review of
outcomes of individualised nursing interventions on adult
patients. Journal of Clinical Nursing 17 (7), 843860.
Suhonen, R., Berg, A., Idvall, E., Kalafati, M., Katajisto, J.,
Land, L., Lemonidou, C., Valimaki, M., Leino-Kilpi, H.,
2008b. Individualised care from the orthopaedic and
trauma patients perspective: an international comparative
survey. International Journal of Nursing Studies 45 (11),
15861597.
Suhonen, R., Valimaki, M., Leino-Kilpi, H., 2009. The driving and
restraining forces that promote and impede the implemen-
tation of individualised nursing care: a literature review.
International Journal of Nursing Studies 46 (12), 16371649.
Suhonen, R., Gustafsson, M.-L., Katajisto, J., Valimaki, M.,
Leino-Kilpi, H., 2010a. Individualised Care Scale nurse
version: a Finnish validation study. Journal of Evaluation in
Clinical Practice 16 (1), 145154.
Suhonen, R., Gustafsson, M.-L., Katajisto, J., Valimaki, M.,
Leino-Kilpi, H., 2010b. Nurses perceptions of individualised
care. Journal of Advanced Nursing 66 (5), 10351046.
Suhonen, R., Efstathiou, G., Tsangari, H., Jarosova, D., Leino-
Kilpi, H., Patiraki, E., Karlou, C., Balogh, Z., Papastavrou, E.,
2011a. Patients and nurses perceptions of individualised
care: an International comparative study. Journal of Clinical
Nursing. http://dx.doi.org/10.1111/j.1365-2702.2011.03833.x.
Suhonen, R., Papastavrou, E., Efstathiou, G., Lemonidou, C.,
Kalafati, M., Antunes da Luz, M.D., Idvall, E., Berg, A.,
Acaroglu, R., Sendir, M., Kanan, N., Sousa, V.D., Katajisto,
J., Valimaki, M., Leino-Kilpi, H., 2011b. Nurses perceptions
of individualised care: an international comparison. Journal
of Advanced Nursing 67 (9), 18951907.
The Health and Medical Service Act, 1982:763. Available from:
<http://www.ud.se/sb/d/108/a/23172>.
Teeri, S., Leino-Kilpi, H., Valimaki, M., 2006. Long-term nursing
care of elderly people: identifying ethically problematic
experiences among patients, relatives and nurses in Finland.
Nursing Ethics 13 (2), 116129.
Thompson, I.E., Melia, K.M., Boyd, K.M., Horsburgh, D., 2007.
Nursing Ethics, fifth ed. Elsevier-Churchill Livingstone, Edin-
burgh, UK.
Tucket, A., Hughes, K., Schluter, P., Turner, C., 2009. Valida-
tion of CARE-Q in residential aged-care: rating of importance
of caring behaviours from an e-cohort sub-study. Journal of
Clinical Nursing 18 (10), 15011509.
Weiner, S.J., 2004. Contextualizing medical decisions to indi-
vidualize care: lessons from the qualitative sciences. Journal
of General Internal Medicine 19 (3), 281285.
Weiss, M., Yakusheva, O., Bobay, K., 2010. Nurse and patient
perceptions of discharge readiness in relation to post-
discharge utilization. Medical Care 48 (5), 482486.
Woolf, S.H., Grol, R., Hutchinson, A., Eccles, M., Grimshaw, J.,
1999. Clinical guidelines: potential benefits, limitations, and
harms of clinical guidelines. British Medical Journal 318
(7182), 527530.