ORIGINAL RESEARCH: EMPIRICAL RESEARCH –
QUANTITATIVE
Patient experiences of caring and person-centredness are associated
with perceived nursing care quality
David Edvardsson, Elizabeth Watt & Frances Pearce
Accepted for publication 13 June 2016
Correspondence to D. Edvardsson:
e-mail: d.edvardsson@latrobe.edu.au
David Edvardsson PhD RN
Professor/Director
La Trobe University/Austin Health Clinical
School of Nursing, Melbourne, Victoria,
Australia and
Department of Nursing, Umea University,
Sweden
Elizabeth Watt MNS RN RM
Lecturer
La Trobe University/Austin Health Clinical
School of Nursing, Melbourne, Victoria,
Australia and
Frances Pearce BHSc MPET RN
Nurse Educator
Clinical Education Unit, Austin Health,
Melbourne, Victoria, Australia
© 2016 John Wiley & Sons Ltd
E D V A R D S S O N D . , W A T T E . & P E A R C E F . ( 2 0 1 6 ) Patient experiences of caring
and person-centredness are associated with perceived nursing care quality. Journal
of Advanced Nursing 00(0), 000–000. doi: 10.1111/jan.13105
Abstract
Aims. To explore the extent to which patient ratings of perceived caring and person-
centredness are associated with perceived nursing care quality in an acute hospital
sample of inpatients.
Background. Self-reported patient experiences have had limited attention in
conceptualizations of healthcare quality as described in policy and national standards,
as well as in health and nursing care practice. The impact of central nursing concepts
such as caring and person-centredness on patient ratings of nursing care quality is
largely unknown.
Design. A descriptive non-experimental correlational design was used to collect and
analyse data from a sample of Australian acute hospital inpatients (n = 210) in
December 2012.
Methods. The study collected self-report patient data through a study survey including
demographic data and the Caring Behaviours Inventory, the Person-centred Climate
Questionnaire, the SF-36 and the Distress thermometer. Descriptive statistics together
with Pearson correlation and hierarchical linear regression were used.
Findings. Perceived caring behaviours of staff and the person-centredness of wards were
significantly associated with nursing care quality as evidenced by Pearson correlations
being significant and exceeding the pre-set cut-off of r > 0
5. Staff caring behaviours and
ward person-centredness also accounted for more than half of the total variance in
perceived nursing care quality as evidenced by the final regression model. Knowledgeable
and communicable staff, timeliness of assistance and environmental support stood out as
most significantly related to patient perceived nursing care quality.
Conclusions. Patient experiences of caring and person-centredness seem to have an
influential role in the extent to which patients experience the quality of nursing care.
Knowledgeable and communicable staff, timeliness of assistance and environmental
support stand out as most significantly related to patient-perceived nursing care quality.
Keywords: assessment healthcare quality, behaviour, caring, health services, hos-
pital nursing staff, nurses, nursing, nursing care, person-centred therapies, quality
in health care
1
D. Edvardsson et al.
Why is this research needed?
 Patient experiences have had limited attention in assess-
ments of nursing care quality.
 Health and nursing care quality as conceptualized in policy
and national standards rarely include patient experiences.
 The impact of central nursing concepts such as caring and
person-centredness on patient ratings of quality is absent
in contemporary literature.
What are the key findings?
 Patient ratings of caring and person-centred care had a
large and significant association with nursing care quality
as experienced by patients.
 The findings add a patient experience perspective to the
body of literature on quality in nursing and health care.
How should the findings be used to influence policy/
practice/research/education?
 Patient experiences of care quality can increasingly be
included in policy conceptualizations of quality in health
care and nursing,
 Patient experiences can be used in evaluation of quality in
practice and research.
 The impact of the experiential and environmental domains
on nursing care quality can be highlighted further in nurs-
ing education and practice.
Introduction
There is significant discussion in the nursing and wider
healthcare literature focusing on defining quality nursing
and other health care and examining ways quality in care
can be delivered. Quality in hospital settings is affected not
only by the quality of technical care received but also by
the quality of the interpersonal relationships (both patient-
to-staff and staff-to-staff) and the quality of the practice
environment (Safran et al. 2006, Hussey & Seccombe
2009, McCormack et al. 2011, Doyle et al. 2013). Evi-
dence directly links positive patient experiences with
improved patient safety, clinical effectiveness and better
health outcomes (Sequist et al. 2008, Meterko et al. 2010,
Fenton et al. 2012). Charmel and Frampton (2008) also
describe links between positive patient experiences to
reduced healthcare costs and improved employee satisfac-
tion.
Patient experience is widely recognized as a core compo-
nent of a quality healthcare system (World Health Organi-
sation 2007, Doyle et al. 2013, Luxford & Sutton 2014).
Measurements of patient experience have become an
2 © 2016 John Wiley & Sons Ltd
explicit component of accreditation certification and com-
pensation throughout most developed countries (National
Institute for Clinical Excellence 2012, Anhang Price et al.
2014). However, the common quality indicators as used by
policy agents are often conceived of in terms of standards,
guidelines and in particular the incidence of adverse events.
Self-reported patient experiences have had limited attention
in conceptualizations of healthcare quality as described in
policy, national standards and in health and nursing prac-
tice. The impact of central nursing concepts such as caring
and person-centredness on patient ratings of nursing care
quality in the acute-care context is largely unknown.
This study explores the extent to which patient ratings of
perceived caring and person-centredness are associated with
perceived nursing care quality in an acute hospital sample
of inpatients. The results indicate that the caring behaviours
of staff and the extent to which the ward was perceived as
being person-centred were significantly associated with and
accounted for more than half of the total variance in nurs-
ing care quality as perceived by patients. These findings add
an insider patient experience perspective to existing dimen-
sions of care quality, by suggesting that quality from the
patients’ perspective is more than a reduction of adverse
events, or presence of standards and guidelines. This high-
lights a potential to include the concepts and measures of
caring and person-centredness in contemporary conceptual-
izations and studies of nursing and healthcare quality.
Background
The Institute of Medicine (IOM), as an independent, non-
profit organization, initially defined quality of health care
in terms of care standards expressed as quality indicators
related to safety, effectiveness, patient centredness, timeli-
ness, efficiency and equity (Lohr 1990). This framework
linked health outcomes to quality indicators, in a systems
approach focusing on failures of services namely death, dis-
ease, disability, discomfort and dissatisfaction (Lohr 1990).
Improvements in quality of care developed as a cyclical pro-
cess of defining standards, measuring performance against
these standards to make service improvements. In addition,
Donabedian’s classic system-based framework evaluates
care delivery through a systematic review of the structure,
process and outcomes of service delivery. These constructs
remain current today (Donabedian 1988, Smitz Naranjo &
Viswanatha Kaimal 2011, El Haj et al. 2013).
In Australia, quality of care is defined and legislated
through the Australian Commission for Safety and Quality
in Health Care (ACSQHC 2011). This commission has pre-
sented a framework that links quality and safety through
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
three core principles: consumer centred, driven by informa-
tion and organized for safety (ACSQHC 2010). Each core
principle has defined standards identified as The National
Safety and Quality Health Service Standards, and the 10
standards involve governance for safety and quality, part-
nering with consumers, managing infections, medication
safety, patient identification, clinical handovers, blood
products, managing pressure injuries, clinical deterioration
and preventing falls (Australian Commission on Safety and
Quality in Health Care 2011). These standards require
compliance as in other countries, through an accreditation
assessment of organizational and clinical performance
against predetermined standards through both self-apprai-
sals and external third party reviews.
However, the ability of accreditation as a mechanism to
improve hospital care has been debated both in Australia and
internationally (Miller et al. 2005, Thornlow & Merwin 2009,
Braithwaite et al. 2010). Despite the increasing role of patients
and families identified as consumers in healthcare systems,
accreditation is not linked to measurably better quality of care
as perceived by patients and reflected by their recommendation
rates of institutions (Auras & Geraedts 2010). However, since
2001, the Institute of Medicine (IOM) has attempted to link
quality to the patients’ experience of care. Their seminal report,
‘Crossing the Quality Chasm’ recognized ‘patient centred care’
[sic] as directly linked to quality care (IOM 2001). The IOM
states that health care needs to be ‘respectful of and responsive
to individual patient preferences, needs and values and ensur-
ing that patient values guide all clinical decisions’ (p. 3). Pro-
viding healthcare driven by the preferences of patients has a
positive effect on financial and clinical outcomes (Charmel &
Frampton 2008, Meterko et al. 2010, Boulding et al. 2011),
yet the perceptions and ratings of the recipients of care remain
largely overlooked in contemporary measures of quality of
care.
Caring is considered as a fundamental concept in nursing
and considerable intellectual effort has been invested to
define caring in nursing and to describe caring behaviours
and processes (Leininger 1984, 1988, Benner & Wrubel
1989, Morse et al. 1990, Phillips 1993, Brilowski & Wendler
2005, Lui et al. 2006, Finfgeld-Connett 2008a,b, Khademian
& Vizeshfar 2008, Chan et al. 2009, Watson 2009, 2012,
Ranheim et al. 2012). While a deceptively simple term, car-
ing in nursing has been difficult to define. In an effort to clar-
ify the concept, Finfgeld-Connett (2008b) conducted a
qualitative meta-synthesis of 49 qualitative reports and six
concept analyses of caring. Her findings conceptualize caring
as a process that has antecedents, attributes and outcomes.
The antecedents of the process of caring include the nurse
and the recipient of care. For example, the care recipient
© 2016 John Wiley & Sons Ltd
Associations between caring, person-centredness and nursing care quality
needing care and being open to care, the nurse having the
professional maturity and moral foundations to care and
being in a work environment that is conducive to caring. The
attributes of caring were identified as expert nursing practice,
interpersonal sensitivity and intimate relationships (Finfgeld-
Connett 2008b). The outcomes of caring for the recipient of
care include improvements in physical and mental well-being,
and because of the reciprocal nature of nursing caring, the
outcome for the nurse includes a sense of mental well-being
and satisfaction (Finfgeld-Connett 2008b). These findings are
supported by previous studies of the concept of caring.
Caring has also been identified as a fundamental aspect
of quality of nursing care in the nursing literature. Caring
or the cost of not caring in nursing practice has been linked
to financial outcomes for the health system, as well physical
and emotional patient outcomes (Nelson 2011, Aiken et al.
2014, Buckley 2014). Despite the difficulty in defining the
concept of caring, there have been several published studies
that have attempted to measure caring in nursing and the
impact of caring on patient outcomes (Larrabee et al. 2004,
Green & Davis 2005) and the validity, reliability and com-
parability of many of the tools used to measure caring as
beginning to emerge (Papastavrou et al. 2011, Edvardsson
et al. 2015). However, some questions remain regarding the
congruence between perceptions of patients and nurses as
to which nursing attributes and behaviours are considered
caring (Papastavrou et al. 2011).
Person-centredness is a related contemporary concept
emerging of Rogerian psychotherapy, holistic dementia care
as firstly described by Kitwood (1997), as well as from the
consumer participation movement (Frampton et al. 2008,
Hill 2011) and lived experience perspectives on health and
care as surfacing through North American and Scandina-
vian life-world research. Person-centredness is commonly
conceptualized as denoting an ethical, humanistic and holis-
tic perspective on nursing care that builds on a fundamental
respect of subjectivity, agency, capability and personhood
(Edvardsson et al. 2008, McCormack & McCance 2010).
From a person-centred perspective, the focus of nursing
care explicitly includes the relational aspects of health and
illness inasmuch as biological aspects and strives towards
integrating the relational ‘being with’ together with the
task-based ‘doing for’ in nursing. Furthermore, person-
centred care has been described as bringing back the person
into care and by that reinforcing the ethical demand of
nursing to safeguarding patient dignity and autonomy, as
well as inviting and respecting shared decision-making,
choice and control (Edvardsson 2015).
Several intervention studies in the field of aged and
dementia care have recently showed various beneficial
3
D. Edvardsson et al.
effects of person-centred interventions on residents with
dementia and direct care staff. Studies have reported
increased well-being and reduced agitation for people with
dementia from person-centred interventions based on mean-
ingful activities and psychosocial interactions (Chenoweth
et al. 2009, Bone et al. 2010), improved well-being and less
symptoms of depression (Brooker 2007), and improved
bowel patterns for aged care residents from individualized
care management (Palese et al. 2010). In addition, studies
have also shown decreased job stress and strain and
increased personal and professional satisfaction from work-
ing in a more person-centred way (McCormack et al. 2010,
McKeown et al. 2010, Jeon et al. 2012), as well as experi-
encing fewer symptoms of burn-out (Passalacqua & Har-
wood 2012). A current trend in the nursing literature seems
to be on how person-centred care can be implemented and
sustained in nursing practice across specialties and contexts
(Edvardsson et al. 2014, Eaton et al. 2015, Ekman et al.
2015). However, person-centredness is yet to be empirically
related to perceived quality in nursing and health care in
acute-care patient populations for which there remains
being a shortness of evidence.
In summary, contemporary conceptualizations and assess-
ments of nursing and healthcare quality have been focussing
to a large extent on external standards, policies and issues
related to safety, management and prevention of adverse
events, efficiency and effectiveness and to a lesser extent on
the quality of nursing care as it is perceived and rated by
patients and/or family members. The nursing literature indi-
cates that the concepts of caring and person-centredness
may represent important dimensions of how quality is expe-
rienced in nursing care. However, one problem is that there
has been a limited focus on linking the concepts of caring
and person-centredness to nursing and healthcare quality,
and no studies have been located that provide empirical
data to indicate the extent to which caring and person-cent-
redness may associate with patient perceptions of nursing
care quality in acute-care patient populations. This study
addresses this problem and gap in the literature, with its
purpose to explore the extent to which patient ratings of
perceived caring and person-centredness are associated with
perceived nursing care quality in an acute hospital sample
of inpatients.
The study
Aim and research questions
This study aimed explore the extent to which patient rat-
ings of perceived caring and person-centredness are
4 © 2016 John Wiley & Sons Ltd
associated with perceived nursing care quality in an acute
hospital sample of inpatients.
The following research questions were explored:
1 To what extent are staff caring behaviours and person-
centredness associated with perceived nursing care
quality?
2 To what extent can caring and person-centredness
explain the variation in perceived nursing care quality as
reported by acute hospital inpatients?
Design
A descriptive non-experimental correlational design was
used to collect data from a sample of Australian acute hos-
pital inpatients.
Sample/participants
The study participants were recruited from 13 inpatient
wards at a metropolitan tertiary acute-care hospital in Vic-
toria, Australia. A consecutive sampling procedure was used
to recruit patients admitted to any of the participating 13
wards during 2 weeks in December 2012. To be eligible for
study inclusion, patients had to be admitted to the wards
during the time of data collection, be aged above 18 years,
literate in English and able to consent to and participate in
data collection. Eligible patients were informed about the
study in writing and/or orally by a member of the research
team on admittance to a ward and were asked to partici-
pate by completing a survey during their hospitalization.
Each participant was given a questionnaire and an
addressed envelope which could be deposited in a mail box
in each ward area. There was no identifying information on
the questionnaire or the envelope.
Data collection
The study survey included demographic data, such as age,
gender, marital status, education and employment, together
with 11 study-specific variables relating to preparation for
and experiences of care, as well as perceived quality of
nursing care which was assessed through a study-specific
visual analogue scale variable ranging between 0 (lowest
possible quality) and 100 mm (highest possible quality). In
addition, four established self-report measures were used to
explore the research questions, namely the Caring Beha-
viours Inventory (Wolf et al. 1994), the Person-centred
Climate Questionnaire (PCQ, Edvardsson et al. 2009), the
SF-36 (Ware & Sherbourne 1992) and the Distress
thermometer (NCCN 2003, Hoffman et al. 2004).
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Associations between caring, person-centredness and nursing care quality

The six-item version of the Caring Behaviours Inven-

Data analysis
tory (Wolf et al. 1994) was included to measure the
extent to which patients’ perceived caring behaviours in Descriptive statistics were used to explore sampling charac-
nursing staff. This measure consists of six statements on teristics, and the Pearson product moment correlation coef-
how often staff exhibit dimensions of nurse caring beha- ficient was used to explore the strength of associations
viours (being hopeful, empathetic, sensitive etc.), and between perceived nursing care quality, caring and person-
responses are given on a six-point Likert-type scale rang- centredness. Hierarchical linear regression analysis was
ing from (0) ‘Never’ – (5) ‘Always’. A total sum score is conducted to explore the extent to which the total score
calculated with a potential range between 0–30, with continuous variables ‘caring’ and ‘person-centredness’ could
higher scores indicating a higher prevalence of caring explain the variation in the continuous dependent variable
behaviours. ‘nursing care quality’ after controlling for the influence of
The Person-centred Climate Questionnaire (PCQ-S) patients’ age, gender and place of care, and patients’ per-
(Edvardsson et al. 2009) was included to measure to ceived health and distress. Correlation coefficients of >0
5
what extent patients experienced care as being person- were considered high and P-values of 0
05 or less were con-
centred and focussing on their psychosocial needs. This sidered significant. All statistical analyses were performed
questionnaire consists of 17 statements on dimensions of using SPSS Statistics 21
0.
person-centredness and psychosocial dimensions of care
(safety, welcoming, hospitality, etc) and responses are
Ethical considerations
given on a six-point Likert-type scale ranging from (0)
‘No, I disagree completely’ – (5) ‘Yes, I agree completely’. Ethics approval was obtained from the hospital Human
A total sum score is calculated that can range between Research Ethics Committee (Project number 04779). The
0–85, with higher scores indicating higher levels of per- study complied with the Helsinki Declaration and achieved
son-centredness. implied consent through voluntary, anonymous return of
The SF-36 (Ware & Sherbourne 1992) was included surveys (World Medical Association 2013).
to evaluate participants’ self-reported health. The SF-36
consists of 36 items relating to perceived health, and its
Results
influence on daily life and participants are asked to rate
their health in different domains. The general health From a total of 528 patients admitted to the participating
item was included in this analysis, and this item asks wards during the time of data collection, 210 surveys were
participants to rate their general health on a five-point returned (40% response rate). As shown in Table 1, the
Likert-type scale between excellent and poor. participants consisted mostly of males (57%), with
The ‘distress thermometer’ (Roth et al. 1998) was
included to assess perceived distress among participating
patients. This is a visual analogue scale in the form of a Table 1 Participant characteristics (n* = 210).
vertical thermometer, on which respondents are asked to N (%) Mean (SD)
rate their global distress on a 10-point scale ranging
between (0) ‘No Distress,’ and (10) ‘Extreme Distress. Gender
Male 116 (57)
Female 88 (43)
Validity and reliability Age 61 (16
8)
Education
The four measurement tools included in the study all have Primary School 22 (11)
documented validity and reliability in previous publica- Secondary School 126 (62)
University 54 (27)
tions. The Caring Behaviours Inventory has satisfactory
Marital status
psychometric properties of the six-item version (Coulombe Married 101 (52)
et al. 2002, Edvardsson et al. 2015), as have the Person- Living with partner 19 (10)
centred Climate Questionnaire (Edvardsson et al. 2009) Living family 23 (12)
and the SF-36 (McCallum 1995). Previous studies have Living with friends 3 (2)
also indicated acceptable accuracy of the distress ther- Living alone 47 (24)
English as first language 167 (87)
mometer to assess psychological distress (Ransom et al.
2006). *n may not add up to 210 in all variables due to missing data.

© 2016 John Wiley & Sons Ltd 5

D. Edvardsson et al.

secondary school education (62%), being married or living variables contributed to 4% of the variance in nursing care
with a partner (61%), having a mean age of 61 years (SD quality, and after including caring and person-centredness,
16
8) and having English as their first language (87%). The the model explained 57% of the total variance in nursing
majority of participants reported having an emergency care quality. The unique contribution of person-centredness
admission (66%), and the majority also had experience of (P < 0
01) and caring (P = 0
05) was significant and border-
being in this particular hospital previously (70%). line significant with person-centredness having a higher con-
As shown in Table 2, most of the perceived staff caring tribution to perceived nursing care quality (0
65) compared
behaviours were highly associated with nursing care quality, with caring (0
15). Thus, the perceived person-centredness
as evidenced by a majority of the bivariate correlations and caring contributed to explain 53% of the variance in
being significant and exceeding the pre-set cut-off of the extent to which patient perceived nursing care quality
r > 0
5. Furthermore, most variables relating to perceived when confounding factors such as patients’ age, gender, dis-
person-centredness was also highly associated with nursing tress, general health and place of care were accounted for.
care quality as perceived by patients, as evidenced by signif-
icant and high (r > 0
5) correlation coefficients.
Discussion
Hierarchical multiple regression was used to evaluate the
extent to which perceived caring and person-centredness This study aimed explore the extent to which patient rat-
could explain the variation in nursing care quality, after ings of perceived caring and person-centredness are associ-
controlling for the influence of confounding variables, such ated with perceived nursing care quality in an acute
as patients’ age, gender, distress, general health and place hospital sample of inpatients. The findings indicate that the
of care (ward). As shown in Table 3, the confounding perceived caring behaviours of staff and the extent to which
the ward environment was perceived as being person-
centred accounted for more than half of the total variance
Table 2 Associations between nursing care quality, caring and in nursing care quality as rated by patients, when con-
person-centredness. founding variables were controlled for. Thus, it seems that
Variables Pearson’s r the concepts of caring and person-centredness have a signif-
icant role to play in further studies of nursing care quality
Being hopeful for you 0
46
and inviting first-hand ratings from patients can contribute
Being empathetic or identifying with you 0
53
Being sensitive to you 0
53 to an increasingly consumer-oriented approach to conceptu-
Treating your information confidentially 0
33 alizing, evaluating and improving nursing and healthcare
Meeting your stated and unstated needs 0
61 quality.
Putting you first 0
60 The views and priorities of patients have had a limited
A place where staff are knowledgeable 0
73
inclusion in quality and safety measurements to date, and
A place where I receive the best possible care 0
78
A place where I feel safe 0
64
arguments have been mounted in favour of increasingly
A place where I feel welcome 0
68 developing and implementing measurements and methods
A place where it is easy to talk to staff 0
73 that relates patient experiences to ratings of quality and
A place where staff takes notice of what I say 0
73 safety in health care (Groene et al. 2009, Jorm et al. 2009,
A place where staff come quickly when I need them 0
68 Groene 2011). Previous studies have shown that patient sat-
A place where staff talk to me so that 0
68
isfaction with care can be used to discriminate the quality
I can understand
A place that is neat and clean 0
54 of care received (Glickman et al. 2010, Isaac et al. 2010,
A place where staff seem to have time for patients 0
69 Boulding et al. 2011), and that patient experiences correlate
A place that has something nice to look at 0
47 significantly with better health outcomes such as low mor-
(e.g. views, artworks) tality and readmission rates, adherence to prevention and
A place that feels homely 0
57
treatment, patient safety and healthcare use (Manary et al.
A place where it is possible to get unpleasant 0
44
thoughts out of your head
2013, Price et al. 2014). These findings suggest that
A place where people talk about everyday 0
39 although patient-centred information and patient experience
life and not just illness ratings may appear to be underused in the contemporary
A place where staff make extra efforts for my comfort 0
62 quality and safety literature, they have an important role in
A place where I can make choices 0
18 quality and safety assessment, management and improve-
(e.g. what to wear, eat)
ment for health services and nursing care. This study con-
A place where I can get that ‘little bit extra’ 0
59
firms these international findings by highlighting strong

6 © 2016 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Associations between caring, person-centredness and nursing care quality

Table 3 Hierarchical multiple regression analysis of variables associated with nursing care quality.
Model P Explanatory variables Unstandardized B Coefficients SE Standardized beta P value Adjusted R2

1 Age 0
119 0
082 0
117 0
15

0
04 Gender 0
702 2
630 0
021 0
79
General health 0
204 1
354 0
013 0
88
Distress 1
248 0
488 0
224 0
01
Ward 0
683 0
392 0
137 0
08 0
04
2 Age 0
056 0
056 0
055 0
31
<0
01 Gender 1
504 1
767 0
045 0
40
General health 0
121 0
920 0
008 0
90
Distress 0
059 0
338 0
011 0
86
Ward 0
193 0
265 0
039 0
47
Caring 0
473 0
241 0
148 0
05
Person-centredness 0
738 0
086 0
646 <0
01 0
57*

*Adj. R2 change: 0
53.

associations between patient experiences of caring and per-
son-centredness with how they perceived the nursing care
quality.
From a national perspective, this study contributes with
data that relate to the second Australian National Safety
and Quality Health Service Standard on ‘partnering with
consumers’ both in terms of its methodology and findings.
Regarding methodology, the study employed two psycho-
metrically sound instruments for measuring patient experi-
ences. These can contribute to the emergence of valid and
reliable methods for collecting patient self-reports as a
means to complement more structural work to meet the
standard on partnering with consumers, for example,
through consumer representation in governance and com-
mittee levels (Price et al. 2014). This suggests that the scope
of ‘partnering with consumers’ has a potential to move
beyond committee representation by patient and consumer
representatives and this study towards making audits and
continuing data collection that uses patients’ experiences as
valid and important indicators of health and nursing care
quality. This article suggests valid and reliable tools to link
perceived caring behaviours of staff, the extent to which
the ward environment is perceived as being person centred
to nursing care quality as rated by patients. These tools can
offer a possible framework to strengthen and benchmark
the presence of nursing in the national safety and quality
standards and in clinical practice.
The data showed that the aspects most highly correlated
to perceived nursing care quality were perceptions of receiv-
ing the best possible care from knowledgeable staff, as well
as staff taking the time to make themselves available and
open for communication with patients. Such communica-
tion and interpersonal skills have previously been found to
be strongly related to patient satisfaction and ratings of
overall quality of care, for example, in emergency care set-
tings internationally (Boudreaux & O’Hea 2004, Toma
et al. 2009), as well as being highly predictive of high
patient experience scores and beneficial health outcomes
(Manary et al. 2013). The data also showed that the
aspects relating to the physical environment of the ward,
for example, the extent to which the ward was neat and
clean, offering something to look at, feeling homely and
providing opportunities for positive distractions, also were
highly correlated to perceived nursing care quality, even
though not quite as strongly as the ratings of standards of
care and knowledge of staff. These findings also confirm
previous data that has placed the environmental experience
of health services as being important to quality even if
ranked as comparably less important than communication
with nurses and doctors, pain management and timeliness
of assistance (Boulding et al. 2011, Manary et al. 2013).
From a nursing theory perspective, the study findings can
at least partly be located in the environmental meta-
paradigm of nursing. In this body of literature, creating and
maintaining caring environments to facilitate healing and
well-being has for long been conceptualized as central to
nursing due to the interconnectedness of people, health and
their environments described by nursing theorists, such as
Florence Nightingale, Martha Rogers and Jean Watson.
Previous studies have conceptualized that the extent to
which the psychosocial ward environment is perceived as
being person-centred originates from an interaction between
the physical environment, people’s ‘doing and being’ in the
environment and the organizational philosophy of care
(Werezak & Morgan 2003, Edvardsson et al. 2005, 2008).
It seems that in the pursuit of high-quality nursing care,
providing environmental dimensions such as cleanliness,
positive distractions and a general welcoming and homely

© 2016 John Wiley & Sons Ltd 7

D. Edvardsson et al.
feel, still remains relevant some 156 years ago since first
being described by Florence Nightingale (1969). Thus, using
the environment as a nursing intervention may have the
potential to maximize patient perceptions of quality in
nursing care. Also, the concept of caring surfaced as highly
correlated to perceived quality which empirically confirms
previous theoretical conceptualizations of caring as being
the interpersonal quality marker of nursing care through its
attributes of manifesting expert nursing practice, interper-
sonal sensitivity and the creation of intimate relationships
(Finfgeld-Connett 2008b).
Limitations
The sampling method used, the way the questionnaire was
administered and the single site for data collection are some
of the limitations of this study. As the data were derived
from a single-site cross-sectional sample, they need to be
cautiously interpreted. In addition, the study inclusion crite-
ria implied that an unknown number of patients may have
been excluded due to severe illness or inability to compre-
hend English. This means that illness severity and a
non-English-speaking background may have influenced the
sample characteristics. Therefore, the results of this study
are only valid for this population of English-speaking, Aus-
tralian acute hospital inpatients and other populations need
additional studies. In addition, participating patients’ per-
ceptions of nursing care quality may also be affected by the
reason for admission, length of stay and/or past experi-
ences. Hopefully, the findings are analytically and theoreti-
cally transferable to other contexts and participants, so
that further studies may be conducted and evidence be
accumulated.
Conclusions and implications
Patients’ self-report ratings of caring and person-centredness
were highly associated with patient ratings of nursing care
quality at an Australian tertiary acute hospital. Patient
experiences of the extent to which wards and staff manifest
caring and person-centredness seem to have an influential
role in the extent to which patients experience the quality
of nursing care. This implies that knowledgeable and com-
municable staff, timeliness of assistance and environmental
support stands out as most significantly related to patient
perceived nursing care quality and can have a significant
impact on practice. It seems reasonable to conclude that
assessment of health service and nursing care quality can
benefit from increasingly including self-report patient data
on their experiences of health and nursing care services and
8 © 2016 John Wiley & Sons Ltd
such data can also be used to assess and improve nursing
practice.
Acknowledgements
We are grateful to Anne-Marie Mahoney, Kathryn Salam-
one, Anne McLean, Tony McGillion, Juanita Hardy, Rod
Mann, Paul Coleman, Lee MacDonald, Elaine Yacoub,
Katina Aspridis and Rhea Martin for assistance with data
collection.
Funding
This study received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/recommendations/)]:
• substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content.
References
Aiken L., Rafferty A. & Sermeus W. (2014) Caring nurses hit by a
quality storm. Nursing Standard 28, 22–25. doi:10.7748/
ns2014.04.28.35.22.s26
Anhang Price R., Elliott M.N., Zaslavsky A.M., Hays R. D.,
Lehrman A. M., Rybowski L., Edgman-Levitan S. & Cleary P.D.
(2014) Examining the role of patient experience surveys in
measuring health care quality. Medical Care Research and
Review: MCRR 71, 522–554.
Auras S. & Geraedts M. (2010) Patient experience data in practice
accreditation – an international comparison. International
Journal for Quality in Health 22, 132–139. doi:10.1093/intqhc/
mzq006
Australian Commission on Safety and Quality in Health Care
(2010) Australian Safety and Quality Framework for Health
Care. Retrieved from http://www.safetyandquality.gov.
au/national-priorities/australian-safety-and-quality-framework-for
-health-care/ on 26 August 2016.
Australian Commission on Safety and Quality in Health Care
(2011) National Safety and Quality Health Service Standards.
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
ACSQHC, Sydney. Retrieved from www.safetyandquality.gov.au/
wp-content/uploads/2011/01/NSQHS-Standards-Sept2011.pdf on
26 August 2016.
Benner P. & Wrubel J. (1989) The Primacy of Caring. Addison-
Wesley, Menlo Park, CA.
Bone C., Cheung G. & Wade B. (2010) Evaluating person centred
care and dementia care mapping in a psychogeriatric hospital in
New Zealand: a pilot study. New Zealand Journal of
Occupational Therapy 57(1), 35–40.
Boudreaux E.D. & O’Hea E.L. (2004) Patient satisfaction in the
emergency department: a review of the literature and
implications for practice. Journal of Emergency Medicine 26,
13–26.
Boulding W., Glickman S.W., Manary M.P., Schulman K.A. &
Staelin R. (2011) Relationship between patient satisfaction with
inpatient care and hospital readmission within 30 days. The
American Journal of Managed Care 17, 41–48.
Braithwaite J., Greenfield D., Westbrook J., Pawsey M., Westbrook
M., Gibberd R., Naylor J., Nathan S., Robinson M., Runciman
B., Jackson M., Travaglia J., Johnston B., Yen D., McDonald H.,
Low L., Redman S., Johnson B., Corbett A., Hennessy D., Clark
J. & Lancaster J. (2010) Health service accreditation as a
predictor of clinical and organisational performance: a blinded,
random, stratified study. Quality and Safety in Health Care 19,
14–21. doi:10.1136/qshc 2009.033928.
Brilowski G. & Wendler M. (2005) An evolutionary concept
analysis of caring. Journal of Advanced Nursing 50, 641–650.
doi:10.1111/j.1365-2648.2005.03449.x
Brooker D. (2007) Person-centered Dementia Care: Making
Services Better. Jessica Kingsley, London.
Buckley J. (2014) The real cost of caring or not caring. Journal of
Emergency Nursing 40, 68–70. doi:10.1016/j.jen.2013.09.006
Chan E.A., Mok E., Ho P-yig A. & Hui Man-chun J. (2009) The
use of interdisciplinary seminars for the development of caring
dispositions in nursing and social work students. Journal of
Advanced Nursing 65, 2658–2667. doi:10.1111/j.1365-
648.2009.05121.x
Charmel P. & Frampton S. (2008) Building the business case for
patient-centred care. Healthcare Financial Management 62, 80–
85.
Chenoweth L., King M.T., Jeon Y.H., Brodaty H., Stein-Parbury J.,
Norman R., Haas M. & Luscombe G. (2009) Caring for Aged
Dementia Care Resident Study (CADRES) of person centred
care, dementia-care mapping and usual care in dementia: a
cluster randomised trial. Lancet Neurology 8, 317–325.
Coulombe K.H., Yeakel S., Maljanian R. & Bohannon R.W.
(2002) Caring behaviours inventory: analysis of responses by
hospitalised surgical patients. Outcomes Management 3, 138–
141. doi:10.1177/1054773812468447
Donabedian A. (1988) The quality of care. How can it be
assessed? Journal of the American Medical Association 260,
1743–1748.
Doyle C., Lennox L. & Bell D.A. (2013) Systematic review of
evidence on the links between patient experience and clinical
safety and effectiveness. BMJ Open 3, e001570.
Eaton S., Roberts S. & Turner B. (2015) Delivering person centred
care in long term conditions. BMJ 350, h181. doi:10.1136/
bmj.h181
© 2016 John Wiley & Sons Ltd
Associations between caring, person-centredness and nursing care quality
Edvardsson D. (2015) Notes on person-centred care: what it is and
what it is not. Nordic Journal of Nursing Research 35, 65–66.
doi:10.1177/0107408315582296
Edvardsson D., Sandman P.O. & Rasmussen B. (2005) Sensing an
atmosphere of ease – a tentative theory of supportive care
settings. Scandinavian Journal of Caring Sciences 19, 344–353.
Edvardsson D., Winblad B. & Sandman P.O. (2008) Person-
centred care for people with severe Alzheimer’s disease – current
status and ways forward. The Lancet Neurology 7, 362–367.
Edvardsson D., Koch S. & Nay R. (2009) Psychometric evaluation
of the English version Person-Centred Climate Questionnaire –
Patient version. Western Journal of Nursing Research 31, 235–
244. doi:10.1177/0193945908326064
Edvardsson D., Sandman P.O. & Borell L. (2014) Implementing
national guidelines for person-centered care of people with
dementia in residential aged care: effects on perceived person-
centeredness, staff strain, and stress of conscience. International
Psychogeriatrics 26, 1171–1179. doi:10.1017/S1041610214
000258
Edvardsson D., Mahoney A.-M., Hardy J., McGillion T., McLean
A., Pearce F. & Watt E. (2015) Psychometric performance of the
English language six-item Caring Behaviours Inventory in an
acute care context. Journal of Clinical Nursing 24, 2538–2544.
doi:10.1111/jocn.12849
Ekman I., Hedman H., Swedberg K. & Wallengren C. (2015)
Commentary: Swedish initiative on person centred care. BMJ
350, h160.
El Haj H.I., Bahr I.K., Rais N. & Lamrini M. (2013) Patient
satisfaction: the importance of its measurement in improving the
quality of care and services in a public paediatrics department.
Journal of Biology, Agriculture and Healthcare 3, 96–104.
Fenton J., Jerant A.F., Bertakis K.D., et al. (2012) National study
of patient satisfaction, health care utilization, expenditures and
mortality. Archives of Internal Medicine 172, 405–411.
Finfgeld-Connett D. (2008a) Qualitative convergence of three
nursing concepts: art of nursing, presence and caring. Journal of
Advanced Nursing 63, 527–534. doi:10.1111/j.1365-2648
Finfgeld-Connett D. (2008b) Meta-synthesis of caring in nursing.
Journal of Clinical Nursing 17, 196–204. doi:10.1111/j.1365-
2702.2006.01824.x
Frampton S., Guastello S., Brady C., Hale M., Horowitz S., Smith
S.B. & Stone S. (2008) Patient-centered Care Improvement
Guide. Retrieved from http://planetree.org/wp-content/uploads/
2015/03/Patient-Centered-Care-Improvement-Guide-10.10.08.pdf
on 26 August 2016.
Glickman S.W., Boulding W., Manary M., Staelin R., Roe M.T.,
Wolosin R.J., Ohman M., Peterson E.D. & Schulman K.A.
(2010) Patient satisfaction and its relationship with clinical
quality and inpatient mortality in acute myocardial infarction.
Circulation: Cardiovascular Quality and Outcomes 3, 188–
195.
Green A. & Davis S. (2005) Toward a predictive model of patient
satisfaction with nurse practitioner care. Journal of the American
Academy of Nurse Practitioners 17, 139–148. doi:10.1111/
j.1041-2972
Groene O. (2011) Patient centredness and quality improvement
efforts in hospitals: rationale, measurement, implementation.
International Journal for Quality in Health Care 23, 531–537.
9
D. Edvardsson et al.
Groene O., Lombarts M.J.M.H., Klazinga N., Alonso J.,
Thompson A. & Sunol R. (2009) Is patient-centredness in
European hospitals related to existing quality improvement
strategies? Analysis of a cross-sectional survey (MARQuIS
study). Quality and Safety in Health Care 18, 44–50.
Hill S. (ed) (2011) The Knowledgeable Patient: Communication
and Participation in Health – A Cochrane Handbook Blackwell
Publishing, London. doi:10.1002/9781444346855
Hoffman B.M., Zevon M.A., D’Arrigo M.C. & Cecchini T.B.
(2004) Screening for distress in cancer patients: the NCCN
rapid-screening measure. Psychooncology 13, 792–799.
Hussey D. & Seccombe I. (2009) Do associations between
staff and inpatient feedback have the potential for
improving patient experience? An analysis of surveys in NHS
acute trusts in England. Quality and Safety in Health Care 18,
347–354.
Institute of Medicine (2001) Crossing the Quality Chasm: A New
Health System for the 21st Century/Committee on Quality
Health Care in America. National Academy Press, Washington,
DC.
Isaac T., Zaslavsky A.M., Cleary P.D. & Landon B.E. (2010) The
relationship between patients’ perception of care and measures of
hospital quality and safety. Health Services Research 45, 1024–
1040.
Jeon Y.-H., Luscombe G., Chenoweth L., Stein-Parbury J., Brodaty
H., King M. & Haas M. (2012) Staff outcomes from the caring
for aged dementia care resident study (CADRES): a cluster
randomised trial. International Journal of Nursing Studies 49,
508–518.
Jorm C.M., Dunbar N., Sudano L. & Travaglia J.F. (2009) Should
patient safety be more patient centred? Australian Health Review
33, 390–399.
Khademian Z. & Vizeshfar F. (2008) Nursing students’ perceptions
of the importance of caring behaviors. Journal of Advanced
Nursing 61, 456–462. doi:10.1111/j.1365-2648
Kitwood T.M. (1997) Dementia reconsidered: the person comes
first, Open University Press, Buckingham.
Larrabee J.H., Ostrow C.L., Withrow M.L., Janney M.A., Hobbs
G.R. & Burant C. (2004) Predictors of patient satisfaction with
inpatient hospital nursing care. Research in Nursing & Health
27, 254–268. doi:10.1002/nur.20021
Leininger M. (1984) Care: The Essence of Nursing and Health.
Wayne State University Press, Detroit, MI.
Leininger M. (1988) Caring: An Essential Human Need. Wayne
State University Press, Detroit, MI.
Lohr K. (1990) Committee to Design a Strategy for Quality
Review and Assurance in Medicare. National Academy Press,
Washington, DC.
Lui J.E., Mok E. & Wong T. (2006) Caring in nursing:
investigating the meaning of caring from the perspective of
cancer patients in Beijing, China. Journal of Clinical Nursing 15,
188–196. doi:10.1111/j.1365-2702.2006.01291.x
Luxford K. & Sutton S. (2014) How does patient experience fit
into the overall healthcare picture? Patient Experience Journal 1,
20–27.
Manary M.P., Boulding W., Staelin R. & Glickman S.W. (2013)
The patient experience and health outcomes. New England
Journal of Medicine 368, 201–203.
10
McCallum J. (1995) The SF-36 in an Australian sample: validating
a new, generic health status measure. Australian Journal of
Public Health 19, 160–166. doi:10.1111/j.1753-6405
McCormack B. & McCance T. (2010) Person-centered Nursing:
Theory and Practice. Wiley-Blackwell, Chichester, UK.
McCormack B., Dewing J., Breslin L., Coyne-Nevin A., Kennedy
K., Manning M., Peelo-Kilroe L., Tobin C. & Slater P. (2010)
Developing person-centred practice: nursing outcomes arising
from changes to the care environment in residential settings for
older people. International Journal of Older People Nursing 5,
93–107.
McCormack B., Dewing J. & McCance T. (2011) Developing
person-centred care: addressing contextual challenges through
practice development. Online Journal of Issues in Nursing 16, 3.
McKeown J., Clarke A., Ingleton C., Ryan T. & Repper J. (2010)
The use of life story work with people with dementia to enhance
person-centred care. International Journal of Older People
Nursing 5, 148–158.
Meterko M., Wright S., Lin H., Lowy E. & Cleary P.D. (2010)
Mortality among patients with acute myocardial infarction: the
influences of patient centered care and evidence-based medicine.
Health Services Research 45, 1188–1204.
Miller M.R., Pronovost P., Donithan M., Zeger S., Zhan C.,
Morlock L. & Meyer G.S. (2005) Relationship between
performance measurement and accreditation: implications for
quality of care and patient safety. American Journal of Medical
Quality 20, 239–252.
Morse J., Soldberg S., Neander W., Bottorff J. & Johnson J. (1990)
Concepts of caring and caring as a concept. Advances in Nursing
Science 13, 1–14.
National Institute for Clinical Excellence (2012) Patient Experience
in Adult NHS Services: Improving the Experience of Care for
People Using Adult NHS Services. NICE clinical guideline 138.
NICE, London.
National Comprehensive Cancer Network (2003) Distress
management clinical practice guidelines. Journal of National
Comprehensive Cancer Network 1, 344–374.
Nelson J.W. (2011) Measuring caring-the next frontier in
understanding workforce performance and patient outcomes.
Nursing Economics 29, 215–219.
Nightingale F. (1969) Notes on Nursing: What it is and What it is
Not. Dover Publications, New York.
Palese A., Granzotto D., Broll M.G. & Carlesso N. (2010) From
health organization-centred standardization work process to a
personhood-centred care process in an Italian nursing home:
effectiveness on bowel elimination model. International Journal
of Older People Nursing 5, 179–187.
Papastavrou E., Efstathiou G. & Charalambous A. (2011) Nurses’
and patients’ perceptions of caring behaviours: quantitative
systematic review of comparative studies. Journal of Advanced
Nursing 67, 1191–1205. doi:10.1111/j.1365-2648x
Passalacqua S.A. & Harwood J. (2012) VIPS communication skills
training for paraprofessional dementia caregivers: an intervention
to increase person-centered dementia care. Clinical Gerontologist
35, 425–445.
Phillips P. (1993) A deconstruction of caring. Journal of Advanced
Nursing 18, 1554–1558. doi:10.1046/j.1365-2648.1993.
18101554.x
© 2016 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Associations between caring, person-centredness and nursing care quality

Price R.A., Elliott M.N., Zaslavsky A.M., Hays R.D., Lehrman
W.G., Rybowski L., Edgman-Levitan S. & Cleary P.D. (2014)
Examining the role of patient experience surveys in measuring
health care quality. Medical Care Research and Review 71, 522–
554.
Ranheim A., K€ arner A. & Berter€ o C. (2012) Caring theory and
practice-entering a simultaneous concept analysis. Nursing
Forum 47, 78–90. doi:10.1111/j.1744-6198.2012.00263.x
Ransom S., Jacobsen P.B. & Booth-Jones M. (2006) Validation of
the distress thermometer with bone marrow transplant patients.
Psycho-Oncology 15, 604–612. doi:0.1002/pon.993
Roth A.J., Kornblith A.B., Batel-Copel L., Peabody E., Scher H.I.
& Holland J.C. (1998) Rapid screening for psychologic distress
in men with prostate carcinoma: a pilot study. Cancer 82, 1904–
1908.
Safran D.G., Miller W. & Beckman H. (2006) Organizational
dimensions of relationship-centered care. Journal of General
Internal Medicine 21, 9–15.
Sequist T.D., Schneider E.C., Anastario M., Odigie E.G., Marshall
R., Rogers W.H. & Safran D.G. (2008) Quality monitoring of
physicians: linking patients’ experiences of care to clinical quality
and outcomes. Journal of General Internal Medicine 23, 1784–
1790.
Smitz Naranjo L. & Viswanatha Kaimal P. (2011) Applying
donabedian’s theory as a framework for bariatric surgery
accreditation. Bariatric Nursing and Surgical Patient Care 6, 33–
37. doi:10.1111/jocn.12703 235
Thornlow D.K. & Merwin E. (2009) Managing to improve quality:
the relationship between accreditation standards, safety practices
and patient outcomes. Health Care Management Review 34,
262–272. doi:10.1097/HMR. 0b013e3181a16bce
Toma G., Triner W. & McNutt L.A. (2009) Patient Satisfaction as
a function of emergency department previsit expectations. Annals
of Emergency Medicine 54, 360–367.
Ware J.E. & Sherbourne C.D. (1992) The MOS 36-item Short-
Form Health Survey (SF-36): conceptual framework and item
selection. Medical Care 30, 473–483.
Watson J. (2009) Assessing and Measuring Caring in Nursing and
Health Science. Springer, New York.
Watson J. (2012) Human Caring Science: A Theory of Nursing.
Jones & Bartlett Learning, Mississauga, Canada.
Werezak L.J. & Morgan D.G. (2003) Creating a therapeutic
psychosocial environment in dementia care: a preliminary
framework. Journal of Gerontological Nursing 29, 18–25.
Wolf Z.R., Giardino E.R., Osborne P.A. & Ambrose M.S. (1994)
Dimensions of nurse caring. Journal of Nursing Scholarship 26,
107–111.
World Health Organisation (2007) People-Centred Health Care. A
Policy Framework World Health Organisation Press, Geneva.
World Medical Association (2013) World Medical Association
Declaration of Helsinki. Ethical Principles for Medical Research
Involving Human Subjects. Retrieved from http://www.wma.net/
en/30publications/10policies/b3/ on 26 August 2016.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·917 – ranked 8/114 in the 2015 ISI Jour-
nal Citation Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 3,500 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

© 2016 John Wiley & Sons Ltd 11