Physician-focused Care Program for Hospitals:

Enhancing Job Performance and Patient Satisfaction among Adolescents Diagnosed

with Anxiety

Kristine Bourne, RN, BSN

The State University of New York Polytechnic Institute

Abstract

Patients’ ages fifteen to twenty-four and those with a diagnosis of anxiety, are some of

the most dissatisfied patients in terms of their health care (Rahmqvist, 2001). Poor patient

satisfaction can lead to a negative patient-physician relationship, poor patient outcomes,

poor hospital reviews, as well as a lack of financial reimbursement for patient treatments.

The use of caring during health care encounters has been shown to have a positive impact

on patient satisfaction. The purpose of this research is to evaluate the implementation of a

nine-week Caring Program for physicians and it's impact/effect on patient satisfaction

among/in adolescents with a diagnosis of anxiety and job performance among physician

participants. The expectation is that adolescent patients with a diagnosis of anxiety who

are under the care of physicians participating in the Caring Program will report increased

levels of patient satisfaction and physician’s participating in a nine-week Caring Program

will report an increased level of job satisfaction. A true experimental design using simple

random sampling of twenty adolescents with a diagnosis of anxiety and ten physicians,

will provide evidence regarding the impact of caring on patient satisfaction. The study

will compare patient satisfaction between the control and test group, the test group

consisting of those adolescents seen by physician participants of the Care Program.

Results will analyzed and provide better understanding not only for physicians, but also

for the nursing profession as well in regards to how the health care worker’s demeanor

can positively or negatively effect a patient’s satisfaction and health care outcome.

Keywords: patient satisfaction, caring, adolescent, anxiety, physician, and job satisfaction

Background of the Problem

Patient Dissatisfaction

    Among all of the streamlined nations, the United States spends the most money on

health care expenses, yet their patients are most dissatisfied with their care (Lee,

Moriarty, Borgstrom, & Horwitz, 2010). Patients hold their medical care in high regard.

Unfortunately, not all patients are satisfied with the quality of care that they receive

(Afzal, Rizvi, Azad, Rajput, Khan, & Tariq, 2014). In fact, many hospital patients report

dissatisfaction with their care (Pear, 2008). Patient dissatisfaction can range from a

feeling; such as the hospital or staff’s need for improvement to having a negative

experience occur during their stay (Lee, Moriarty, Borgstrom, & Horwitz, 2010). One of

the most frequently reported complaints by patients is a feeling of lack of respect during

their course of treatment (Pear, 2008). Patient dissatisfaction may indeed be a result of

the quality of care they have received, however, it can also be influenced by the way

today’s health care system is structured. Patient dissatisfaction can also arise in response

to a particular medical provider’s technique, demeanor, and overall care (Ukah, Hetemi,

Duri, Fidahić, Pirani, Haskuka, & Karameta, 2008).

Patient demographics. The healthcare provider and environment are not the only

factors to influence patient satisfaction. Research has also discovered that patient

satisfaction is partially perceived and effected by the individual patient. A variety of

issues have been shown to effect patient satisfaction and care quality including those that

involve patient socio-demographics (Afzal et al., 2014). Patient age is a variation in

patient satisfaction with care and based upon previous research, is one of the most

significant variances. The age group of 75-84 years of age is shown to have the highest

rate of satisfaction while the age group of 15-24 years of age shows to have the lowest

(Rahmqvist, 2001). This in part, making the adolescent population a key component to

patient satisfaction research. Gender, marital status, educational level (Afzal et. al, 2014),

and previous medical care have also been shown to influence patient satisfaction (Naidu,

2014). One’s current mental health status is a contributing factor to their satisfaction.

More specifically, those with anxiety have been shown to have a lower satisfaction score

(Rahmqvist, 2001).

Provider Care

Three common components of patient dissatisfaction include perceived provider

incompetence, inadequate communication, and a lack of respect as perceived by the

patient. Patients who perceived their provider as incompetent felt that either the health

care provider lacked essential knowledge, the provider did not display the proper hygiene

during care, or the patient experienced a negative outcome as a result of the provider.

Inadequate communication and a lack of respect are also two dissatisfying provider

qualities identified by patients. Patients who found their provider not respectful felt that

their provider displayed harshness, lacked concern for their patient rights, and lacked

compassion (Lee et al., 2010).

Caring. The patient feels a sense of empowerment when they receive professional

caring while also experiencing a sense of control. If the physician does not demonstrate

true concern for the patient and their well-being, the patient is likely to view this as an

uncaring encounter (Halldorsdottir, 1996). An uncaring encounter may include: poor

patient/physician communication, a perceived lack of respect, a lack of patient positive

comments, roughness with physical exam, a lack of compassion for the patient’s current

situation, a lack of time spent with the patient, and the physician appears not interested

during interaction (Halldorsdottir, 1996). In this case a sense of trust is not formed, the

patient may feel discouraged, and there is an increased chance for an overall health

decline (Halldorsdottir, 1996).

Empathy. Research shows that patients who felt their provider was concerned with

their well-being are more compliant with their care (Luthra, 2015). “Clinical empathy

involves an ability to: (a) understand the patient’s situation, perspective, and feelings (and

their attached meanings); (b) to communicate that understanding and check its accuracy;

and (c) to act on that understanding with the patient in a helpful (therapeutic) way

(Mercer & Reynolds, 2002, p. S9). Today, insurance requirements and incentives are

beckoning a change to be made in terms of the care healthcare professionals provide

(Luthra, 2015). Research has found empathy within medical training to be underutilized.

An exemplary nine-week empathy-training program showed providers had not only a

notable improvement in their empathy skills, but also that this improvement was still

found three to six months later (Mercer & Reynolds, 2002).

Purpose

     The purpose of this research is to evaluate the implementation of a nine-week Caring

Program for physicians and it's impact/effect on patient satisfaction among/in adolescents

with a diagnosis of anxiety and job performance among physician participants.

Significance

Patient Satisfaction

Providing medicinal care in today’s health care system is challenging for the health

care provider. The health care provider not only is expected to provide positive patient

health care outcomes, but must also achieve this task in a way that coincides with the

satisfaction of the patient (Ferrand, Siemens, Weathers, Fredendall, Choi, Pirrallo, &

Bitner, 2016). What is patient satisfaction? "Pascoe has defined patient satisfaction as a

healthcare recipient’s reaction to salient aspects of his or her service experience" (Cleary

& McNeil, 1988, p. 2). Research has shown that patient satisfaction has a positive impact

on patient health care outcomes (Ferrand et al., 2016).

Medical reimbursement. Patient satisfaction surveys are utilized more frequently as

an attempt to evaluate quality of care from a patient’s perspective (Afzal et. al, 2014).

Quality measures provide the opportunity for improvement of care (Cleary & McNeil,

1988). Financial reimbursement is affected or can be affected by the patient’s level of

satisfaction, which in turn affects the health care provider and their organization. In 2012,

Medicare began adjusting a segment of the hospital’s reimbursement based upon the level

of their patient satisfaction, also known as hospital value-based purchasing (VBP). As

defined by the Affordable Care Act, value-based purchasing is the process of hospital

reimbursement that is based upon the quality of service, and not the quantity. The

combination of government incentives and guidelines with the probability of a better

patient outcome, makes it imperative that the health care provide be aware and proactive

in ensuring patient satisfaction (Ferrand et al., 2016).

Patient-focused care. Patient satisfaction is a specific feeling or a specific view

regarding an encounter. That being said, the importance of patient-centered care must be

stressed (Prakash, 2010). Patient satisfaction measures give the patient the opportunity to

take part in the care process of care by giving their perception of care and how it can

improve (Cleary & McNeil, 1988). Some general patient expectations of providers

include, proper behavior (courtesy), concern for their issues, communication, timeliness,

and the elimination of any language barrier (Prakash, 2010). Patient satisfaction material

can lead to improved communication between the patient and physician, also creating a

more productive relationship (Cleary & McNeil, 1988).

Patient/physician relationship. Interaction between patient and provider is at the

center of the patient’s medical care. Empathy is considered an essential building block for

a healthy doctor-patient relationship. A therapeutic patient-doctor relationship has been

shown to improve outcomes for the patient.  The goals of a therapeutic relationship

include providing support for the patient and learning about the patients’ views and

needs. This relationship also focuses on education and teaching the patient ways to cope

with their current situation. Lastly, the therapeutic relationship aims at improving or

resolving the patients’ ill elements (Mercer & Reynolds, 2002).

Stakeholders

     Patients. In today’s healthcare, the patient views him or herself as a consumer of

health care. (Prakash, 2010). Patient’s view of what they expect in good care is extremely

important. Research has shown that patients are more likely to comply with medical

treatments set forth if they are satisfied with their care, and when they are dissatisfied

they are less likely to comply with suggested care plan (Naidu, 2009).

     Healthcare industry. Across the country, a new wave to improve bedside manner has

begun. Medical facilities as well as private practices are making this effort. The health

law enforced in the year 2010 has played a large role in engaging facilities and providers

to change their methods. Patient satisfaction surveys under the health law could effect

payments under Medicare. Financial gain is certainly a driving force behind this recent

effort.

As a result of increased health care expenses, patients are more thoughtful when

choosing where to receive care and who to receive care from, focusing on quality

(Luthra, 2015). Positive patient evaluations have been connected with bonuses for

providers within the United States (Prakash, 2010). High patient satisfaction can mean

patient loyalty and increased patient retention. The majority of patients will tend to pay

more for a higher quality of care. One patient’s dissatisfaction does indeed matter. A

provider is estimated to lose approximately $200,000 per one dissatisfied patient over the

course of their life. Patient’s perception of care can create anywhere from a 17-24 percent

discrepancy in the hospitals’ financial profits. Negative talk can significantly be costly

the hospital. It is estimated that negative talk can cost the hospital anywhere from $6,000

up to $400,000 during a patient’s life span (Naidu, 2009).

Hypothesis

1. Adolescent patients with a diagnosis of anxiety who are under the care of

physicians participating in the Caring Program will report increased levels of

patient satisfaction.

2. Physician’s participating in a nine-week Caring Program will report an increased

level of job satisfaction.

Operational Definitions

Independent variable.

Nine-week Caring Program as measured by a statistical increase in patient

satisfaction measured by the Hospital Consumer Assessment of Healthcare

Providers and Systems (HCAHPS) survey among those adolescent patients seen

by physicians who had completed the Care Program.

Dependent variables.

Adolescent anxiety as measured by the Hospital Anxiety and Depression Scale

(HAD), please refers to Appendix A.

Patient satisfaction as measured by the Hospital Consumer Assessment of

Healthcare Providers and Systems (HCAHPS) survey, refer to Appendix C.

Physician job satisfaction as measured by the Employee Satisfaction Survey, refer

to Appendix B

Theoretical Framework

Jean Watson’s Theory of Human Caring

The Caring Program proposed would be modeled after Jean Watson’s Theory of

Human Caring. Jean Watson’s Theory of Human Caring was created between the years

of 1975-1979. Although designed specifically with the nursing practice in mind, its

theoretical framework can be crossed over for all those providing health care, including

physicians (Watson, n.d.). Watson’s theory is divided into ten carrative factors/clinical

caritas that aid in describing the essential aspects of the caring professional, including

(Watson, n.d.): remembering human dignity during care, being a source of hope for the

patient through the authenticity represented by the medical professional, being sensitive

to patient’s views, feelings, and beliefs; developing a relationship of trust with the patient

with a goal of improving the outcome, allowing the patient to feel safe when sharing not

only the positive, but the negative as well; utilizing different ways and measures in terms

of solving issues, providing an authentic teaching-learning experience, making efforts to

surround the patient with an environment conducive for healing, and holistically caring

for the patient’s needs, and remaining open to their spiritual beliefs (Watson, n.d.). This

theory involves the inclusion of holistic caring and patient focused relationships into our

ethical foundation of practice (Watson, 2006).

Human Caring

Effect of caring. A randomized control trial was performed looking at the effect of

utilizing nursing care founded on Jean Watson’s Theory of Human Caring on patients

who were experiencing suffering caused by infertility. Infertility can cause not only

patient specific issues, but also familial and financial issues. Beginning in May 2010 until

February 2011, the study was conducted. The study consisted of one hundred and five

Turkish women who were experiencing infertility. The group was split approximately in

half, fifty-two women in the intervention group who received nursing care that was based

upon the Theory of Human Caring and fifty-three women who were the control. Three

tools were utilized to collect the data including the Infertility Distress Scale, the Turkish-

Fertility Adjustment Scale, as well as the Turkish-Infertility Self Efficacy Scale Short

Form. The results demonstrated that the intervention group experienced an increase in

self-efficacy score, a lower adjustment score (a positive change), as well as a drastic

decrease is their distress score. Overall, the study concluded that the implementation of

the Theory of Human Caring into nursing care decreased the negative effects of infertility

in women who were currently participating in fertility treatments (Arslan‐Özkan,

Okumuş, & Buldukoğlu, 2014).

Erik Erikson’s theory of Psychosocial Development

The proposal population is adolescents ages twelve to eighteen with a diagnosis of

anxiety. Erik Erikson’s theory of psychosocial development, will provide a greater

understanding of the adolescents individual stages of development. Erik Erikson’s theory

initially surfaced in 1959. According to Erikson, there are eight stages of psychosocial

development, each involving a crisis. The successful completion of all stages is said to

result in a personality that is considered to be healthy. If an individual cannot complete

the stages, they are at increased risk of developing an unhealthy sense of self as well as

personality challenges.

Developmental stages. For the purpose of this proposal involving adolescence, stages

one through five will be reviewed of Erikson’s theory. Stages six, seven, and eight are for

individuals over the age of 18 (McLeod, 2008).

Trust vs. mistrust. Trust vs. mistrust is the developmental stage that occurs during

infancy, ages of birth to 1-½ years old and helps to develop hope. Consequently, if the

child does not develop hope through consistency, predictability, and trust, the child will

instead develop fear. Later in life, this may display itself as anxiety and self-insecurities.

Autonomy vs. shame. Autonomy vs. shame is the developmental stage that occurs

during early childhood 1 ½ to 3 years old and helps to develop will. Consequently, if the

child is not shown supportiveness and understanding while learning independence, they

will have a lower self-esteem and will be more often to rely on others (McLeod, 2008).

Initiative vs. guilt. Initiative vs. guilt is the developmental stage that occurs during the

play ages of 3 and 5 and helps to develop purpose. Consequently, if the child receives too

much criticism while developing their initiative, they will develop a sense of guilt instead

of purpose and that will lower their self-esteem and they will have less initiative in the

future.

Industry vs. inferiority. Industry vs. inferiority is the developmental stage that occurs

in school age children ages 5 to 12 and helps to develop competency. Consequently, if

competency is not developed through encouragement and belief of goal attainment, self-

doubt can arise instead. This can lead the child to feel inferior (McLeod, 2008).

Ego identification vs. role confusion. Ego identification vs. role confusion is the

developmental stage that occurs in adolescence from ages 12 to 18 and helps to develop

fidelity. Fidelity involves understanding commitment to one self as well as commitment

to others. Also in this stage, self-identity forms. If the adolescent is not able to establish

their identity, they may then experience role confusion, and not understand their place in

the world. This confusion can later lead to a negative identity and unhappiness (McLeod,

2008).

Psychosocial Development

Personality changes. A 22-year sequential study was performed by Whitbourne,

Zuschlag, Elliot, and Waterman (1992), concerning psychosocial development within

adulthood. The study was based upon Erikson’s stages of psychosocial development.

This particular study was performed in result of earlier studies’ findings suggesting that

personality changes are a rarity in adulthood, specifically after the age of thirty. The

reality of this would contrast Erikson’s theory where personality is a continual process of

change throughout the life of an individual until death. The authors of this study reviewed

the personality invariability among three groups of college students over the course of 22

years, from age 20 to age 42. The findings of the study were in support of Erikson’s

theory of psychosocial development. Psychosocial development is continual throughout

the life span and can be influenced by the inner psyche, as well as external cultural and

psychosocial factors (Whitbourne, Zuschlag, Elliot, & Waterman, 1992).

Literature Review

Patient Satisfaction

  It is necessary that we take measures to improve the quality of care within America.

Reports by patients are being made, implicating that they are being provided less

individualized care and physician time spent. Patients believe their healthcare physician

is spending too much time with the technical components of their care, while lacking in

attention to their desired needs (Powell, 2001). In 2010, a qualitative telephone survey

was performed among 439 patients asking 5 questions aimed at retrieving the patient’s

perception of ways that care provided in the hospital could improve. The results of these

telephone interviews displayed that patients may be dissatisfied with care for the

following reasons including: incompetence of the provider, a lack of respect, improper

communication, long waits, a lack of environmental control, and receiving basic health

care service. Upon further analysis, quality of care as specified by the patient group

included: receiving high quality service, excellent communication, timely and effective

care, feeling safe and secure, humane treatment, and allowing the patient to feel a sense

of autonomy within their surrounding environment (Lee et al., 2010).

Provider care. The manner in which physicians communicate with their patients

impacts the patient’s views and actions (Mast, Hall, & Roter, 2008). Empathy is the most

frequently utilized term when discussing physician/patient relationships during the years

1950 to 2005. Physician empathy involves the utilization of emotions during interaction

that is considered a benefit to the care of the patient. The act of empathy involves

possessing similar feelings or emotions as someone else in a way that appreciates the

other. Certain researchers propose replacing the process of empathy with caring to

identify the ultimate approach to patient care (Auster & Weiner, 2007). “The expression

of caring in the clinical context is close observation, precise listening, and responsive

questioning, in concert with committed engagement and actions directly addressing the

patient’s problem, stripped of any assumptions about what the other might or might not

be experiencing” (Auster & Weiner, 2007, pg. 123). A sense of nurturing is derived from

caring for patients. This satisfaction brings a sense of reward for the health care provider

(Auster & Weiner, 2007).

When caring for a patient, we may at the same time also express empathy. There are

many aspects to caring within the clinical setting. The health care provider must use great

efforts to respect and value the patient’s current position. The health care provider can do

this by asking questions and by listening explicitly, in an unpretentious manner. Caring

mannerisms will move beyond the professional physician/patient relationship and

towards a more personal and human level. The significance of this personal relationship

between the patient and physician is strongly significant to the patient’s diagnosis,

treatment, and care (Auster & Weiner, 2007). As Peabody once stated, “The secret of the

care of the patient is in caring for the patient” (Auster & Weiner, 2007, pg. 129).

Measurement. Hospital Consumer Assessment of Healthcare Providers and Systems

(HCAHPS) survey will be utilized as measurement of the physician Caring Program’s

effect on adolescent patient satisfaction. The HCAHPS survey was created by the Agency

for Healthcare Research and Quality. This particular hospital survey consists of 27

patient questions related to their hospital experience as well as demographic data, please

refer to Appendix C (Jha et al., 2008). The HCAHPS survey looks at patient experience

by measurement and the results directly effect Medicare reimbursement (HCAHPS

Regulatory Survey, 2016). In the year, 2008, the first set of HCAHPS data was released

(Jha et al., 2008).

Anxiety

Temporary anxiety can be a normal aspect of life. An anxiety disorder however,

includes more than occasional fears and worry. In terms of anxiety disorders, the feelings

are constant and over time may worsen, and these feelings can affect the person’s

everyday life. There are several different types of anxiety disorders including generalized

anxiety disorder, panic disorder, and social anxiety disorder, each with varying

symptoms. Some of the most common symptoms of generalized anxiety include feeling

restless or irritable, tense, trouble with concentration, easily tires, difficulties stopping the

worry or fear, and issues with sleep. Research has found that there are certain

characteristics within the individual and their environment that can place them at a higher

risk for developing an anxiety disorder. Some of these factors include being of female

sex, poor socioeconomic status, shy during childhood years, familial anxiety disorders,

and trauma during childhood (The National Institute of Mental Health, 2016).

Childhood anxiety. Every child goes through phases of anxiety throughout their

childhood, this is considered a normal phase and is not permanent. Typically this form of

anxiety will not cause distress (Anxiety and Depression Association of America, n.d.). As

seen in Erik Erikson’s Theory of Psychosocial Development, there are developmental

stages of life that shape our minds for the future. Looking at the first stage of Erikson’s

theory, Trust vs. mistrust, if the stage is not completed successfully, fear in the infant

may develop. The infant was unable to develop trust or a sense of predictability.

Potentially, this child may present later in life with anxiety (McLeod, 2008). Of

psychiatric diagnoses, anxiety is one of the most prevalent. Anxiety composes

approximately 5-18 percent of all psychiatric diagnoses. Children who suffer from an

anxiety disorder can display symptoms such as excess worry, fright, and shy around

others. These symptoms can cause the child to not want to participate in certain activities

or to go places. Anxiety affects approximately 1 out of every 8 children (Anxiety and

Depression Association of America, n.d.).

Adolescent anxiety. Adolescents within the proposed population are those defined

within the age range of 12-18 years old. Patient age is a variation in patient satisfaction

with care and based upon previous research, is one of the most significant variances. The

age group of 75-84 years is shown to have the highest rate of satisfaction while the age

group of 15-24 years shows to have the lowest (Rahmqvist, 2001). Statistical evidence

shows that approximately 25.1 percent of those ages 13 to 18 have classified anxiety and

approximately 5.9 percent have profound anxiety. Statistical difference is presented

between genders among this age group, showing that 30.1 percent of females are effected

and 20.3 percent of males (Anxiety and Depression Association of America, n.d.). This

illness effects the quality of life of the individual and there are several negative impacts

of having an anxiety disorder.

Patient anxiety. Anxieties can effect ones communication, their self-esteem, social

life, and their ability to enjoy various aspects of life (Fisak Jr, Richard, & Mann, 2011).

Patients with anxiety have been shown to have a lower satisfaction score (Rahmqvist,

2001). There are potentially several reasons for this result. Psychological issues can

require more time with the patient and can be complex and increasingly difficult to

resolve the patient’s ill elements. There is the possibility that these patients in reality

receive subpar care compared to those who are not experiencing psychological

symptoms. The patient may also have impractical expectations for their care (Hjortdahl,

& Laerum, 1992).

Measurement. There is a necessity in evaluating the connection between mood

disorders and the patients’ experience. Most often times, patients are the best informants

of their current health status (Snaith, 2003).The Hospital Anxiety and Depression Scale

(HAD) is a self-screening tool used to screen for those at risk for anxiety and/or

depression, please refer to Appendix A. This tool consists of 14 components, of them, 7

relate to anxiety and the other 7 to depression. Each has a score that ranges from 0-21

(Spinhoven, Ormel, Sloekers, Kempen, Speckens, & Van Hemert, 1997). A score of an

11 or higher indicating a higher probability of the illness. The tool is widely accepted,

can be used in multiple health care settings, and only takes the patient approximately 2-5

minutes to complete (Snaith, 2003). The HAD screening tool would provide a

measurement of the adolescent’s level of anxiety while working with the physician.

Job Satisfaction

Physician job satisfaction has not previously been a topic of interest until more

recently. It has been presumed that while physicians hold a largely challenging position,

they are viewed with great regard among the public. Job security has not been an issue in

the past. However, with today’s current health care system and financial reimbursement

regulations, physician self-governing nature has been reduced. Research is now gathering

data on the ever rising disparities of the medical provider and their job dissatisfaction.

This is not only an issue for the physician, but the organization and patients as well.

Research correlates physician job satisfaction with patient satisfaction as well as

cooperation and efforts with their medical treatment (Konrad, Williams, Linzer,

McMurray, Pathman, Gerrity, & Douglas, 1999). Job satisfaction is a feeling of being

fulfilled and joyed from the work that the employee produces. If an employee is unhappy

with their job, it may be challenging for this not to come across to their patients and co-

workers. Improving job satisfaction can improve the quality of care given. Job

satisfaction also correlates with job retention (Powell, 2001).

Measurement. Benefits of evaluating job satisfaction include a reduction in turnover

rate, a reduction in the financial aspects of employee training, lowering absenteeism,

identifying issues in patient service, evaluation of what training is still needed, and it also

can be a communication tool (Powell, 2011). The Employee Satisfaction Survey is to be

utilized to evaluate the physician’s job satisfaction before and after the nine-week Caring

program, please refer to Appendix B.

MethodologyDesign

     True experimental. The design for this study will be a true experimental design that

will compare patient satisfaction between the control and test group, among the study

specified population, adolescents with a diagnosis of anxiety. Experimental research is

objective and looks at the relationship between the independent and dependent variables

and the ability to manipulate an occurrence. The study sample will be random through the

utilization of probability sampling, specifically simple random sampling (Burns, Grove,

& Gray, 2013). The staff conductor will explain the aspects of the true experimental

study and obtain consent for participation, please see Appendix E. Patients who consent

to participate in the study will be randomly assigned to either the treatment group or the

control group. The control group will receive care by physicians who have not

participated in the newly implemented Care Program while the test group will receive

care by those physicians who have completed the program. Consent will also provide the

study conductor the ability to examine the adolescent participants’ demographic and

medical history. The HCAHPS survey will be utilized as measurement of the physician

Caring Program’s effect on adolescent patient satisfaction (HCAHPS Survey, 2012).

     The Anxiety and Depression Scale (HAD) screening tool will provide a measurement

of the adolescent’s level of anxiety while working with the physicians. This data will

provide for comparison with the patient satisfaction survey results to see if there was a

correlation with the patient’s anxiety level. The HADS is a self-screening tool used to

screen for those at risk for anxiety and/or depression (Spinhoven, Ormel, Sloekers,

Kempen, Speckens, & Van Hemert, 1997). The tool (HADS, n.d.) is widely accepted, can

be used in multiple health care settings, and only takes the patient approximately 2-5

minutes to complete (Snaith, 2003).

     Within this quantitative study, the physicians’ participation in the Caring Program is

also examined in terms of the effect it has on their job satisfaction. Each participating

physician will also provide written consent prior to his or her participation in the study,

please refer to Appendix F. The Employee Satisfaction Survey is to be utilized to

evaluate the physician’s job satisfaction before and after the nine-week Caring program,

please reference Appendix B.

Setting

     Rural. The study will take place on a medicine unit at a rural hospital within the

Northeast region. The hospital’s network consists of 47 Regional Health Centers, as well

as six hospitals. The setting is a teaching hospital with 180 inpatient beds. This facility

was chosen as they provide post residency training programs for their physicians in

Medicine and Surgery. It is proposed that the nine-week Caring Program be incorporated

and implemented into the post residency training. The medicine unit was chosen as it has

the most patient diversity (Network, n.d.)

     According to the 2014 census, approximately 2,133 individuals reside in this rural

community with approximately 57% of those individual being females. In terms of age

prevalence within the location, approximately 17% are younger than eighteen years old,

approximately 66% are between the ages of 18 and 64, and approximately 27% are ages

65 and older. It was estimated that 91% of the population were Caucasian with Black,

Native American, Islander, and Hispanic filling in the other 9% (Census, 2014).

Population 

Sample inclusion/exclusion criteria. The population included in this study are

adolescents ages 12 to 18 with a diagnosis of anxiety. The surveys are written in the

English language however an interpreter would be on site to assist with those whose

primary language is not English. 

     Sample size. The study sample will consist of 20 adolescents and 10 physicians while

maintaining validity of the study.

     Selection. Probability sampling utilizing simple random sampling will be used in the

selection. Each subject will have an equal chance of being selected.

Instruments

Hospital anxiety and depression scale. The Hospital Anxiety and Depression

Scale (HADS) is a self-screening tool used to screen for those at risk for anxiety and/or

depression (Spinhoven, Ormel, Sloekers, Kempen, Speckens, & Van Hemert, 1997). The

tool (HADS, n.d.) is widely accepted, can be used in multiple health care settings, and

only takes the patient approximately 2-5 minutes to complete (Snaith, 2003). Please see

Appendix A for reference.

Employee satisfaction survey. The Employee Satisfaction survey consists of 41

questions asking the employee to rate their satisfaction with various aspects of their

employer on a scale of 1-5. One would be considered very satisfied and five would be

considered very dissatisfied. The employee would circle the number reflecting their

response. Questions 42-50, with the exception of number 44 are questions that require the

employee to check their response. Number 44 does requires employee writing. The

questionnaire does consist of 50 questions and could take the employee anywhere from

10-30 minutes on average (Powell, 2011, slides 16-20). Please see Appendix B for

reference.

Hospital consumer assessment of healthcare providers and systems. Hospital

Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a

standardized, national, survey regarding the patient’s views on hospital care received.

The HCAHPS surveys consist of 27 questions regarding their recent hospitalization, and

are publicly reported. The survey is administered between 48 hours to six weeks post

discharge for evaluation (CMS, 2014). Please reference Appendix C for visual of

surveys.

Procedure

Physician requirements. Ten participating physicians are to complete their written

consent form prior to study participation. The participating physicians are to complete a

pre-participant Employee Satisfaction Survey, please refer to Appendix B. A minimum

of five physicians must successfully complete the nine-week Caring Program. Once the

nine-week program is completed, the physicians are to complete a post participant

Employee Satisfaction Survey to see if their participation in the Caring Program has

improved their job satisfaction.

Caring program. The nine-week Caring Program is to be incorporated and

implemented within the hospital’s post-residency education program.

Overview. Caring is an important aspect of patient care. Research has shown that even

with the right technical care provided, if the physician does not display a sense of caring

for the patient, the patient will be left dissatisfied. This program is designed for

physicians who must communicate caring as a part of their everyday healthcare

performance.

Program objectives. The physician will be able to display knowledge gained from the

following objectives by the completion of this program.

Explain what defines caring.

Explain how caring impacts patient satisfaction and why caring is important to

healthcare organization.

Describe and display behavioral measures that the physician can take that will

relay a caring demeanor to the patient, such as postural stance and tone of

voice.

Explain ways that the physician can still demonstrate compassion and methods

of caring even under difficult circumstances.

The program will conclude with a final written exam as well as a skills test.

Data collection. The study conductor will collect consents from the total 20

participants selected, please refer to appendix E. Once consents have been collected, the

study can begin. All patient participants will be coded for identity protection. Within the

first 48 hours of admission, the study conductor will ensure that a physician who

completed the Caring Program examines an adolescent within the test group as well as

ensuring that a physician who has not sees the control group. Within one hour after the

participant is seen, the study conductor will have the adolescent complete The Hospital

Anxiety and Depression Scale (HAD) in person, please refer to Appendix A. This

screening tool will later be used to evaluate the participant’s anxiety level close to the

time of physician visit, as well as if it may have impacted their satisfaction with care.

Within 48 hours after the participant is discharged, the HCAHPS survey will be

completed via interactive voice recognition (CMS, 2014), please refer to Appendix C.

Plan for Analysis

Instruments

    Descriptive statistics. Multiple instruments will be utilized to assist with analysis of

this particular study. Demographic and medical data will be collected upon subject

consent. Descriptive statistics will be utilized to analyze and describe the study sample.

Means will be used to describe the average age. Percentages will be utilized for other

patient demographics such as marital status, physical health diagnostics, and mental

health diagnostics and formatted into a pie for visual evaluation.

T-test. The test study sample is less than 30, for this reason, the t-test will be used to

locate the differences between the control group and the test group. The t-test uses the

sample’s standard deviation in order to approximate the standard error(s) within the

sample dissemination (Burns et al., 2013), refer to Appendix D for formula. Independent

and dependent t-tests will both be utilized in this analysis.

. The participating physicians are to complete a pre-participant Employee Satisfaction

Survey, please refer to Appendix B. Once the nine-week course is completed, the

physicians are to complete a post participant Employee Satisfaction Survey to see if their

participation in the Caring Program has improved their job satisfaction. Dependent t-test

analysis technique will be utilized to examine the differences between the pretest and

posttest measurements of the Employee Satisfaction Survey (Burns et al., 2013). The

dependent t-test will also be used to evaluate the HCAHPS results at the conclusion of

the study to compare the effect, if any, the caring program had on the patient’s

satisfaction of the physician’s care provided.

During the hospitalization, data regarding patient participants’ anxiety level will be

gathered through the completion of the Hospital Anxiety and Depression Scale. This data

will be used for comparison the physician and the patient’s level of anxiety. An

independent t-test will be used to compare the anxiety levels between the experimental

group and the control group as the independent t-tests evaluates the differences between

two independent groups (Burns et al., 2013).

Dissemination

Approach

Once the analysis of data is complete, a multifaceted approach will be used to

disseminate the proposed findings.

Membership. Membership with the American College of Physicians (ACP) will

allow for potential in-person demonstrations at their regional meetings. The ACP is a

national organization in the United States and is considered to be the second biggest

group of physicians consisting of 148,000 members and is comprised of internists,

specialists, medical students, resident medical students, and others. The ACP hosts

regional meetings and courses with a mission to improve the quality and productivity of

care provided.

Publication. Publication within the Annals of Internal Medicine, a medical journal

that was published by the ACP will also have a positive dissemination effect as it is

considered to be one of the most utilized and influential journals around the world

(American College of Physicians, 2016). Publication within the American Journal of

Medicine, as well, will allow for this research to be available nationwide.

Hospitals. As stakeholders, patients, health care providers, and health care

organizations could be impacted by the proposed findings as they will shine a new light

on various factors effecting patient satisfaction. In response to the proposed findings, my

hope is that hospitals will adapt the Care Program in an effort to improve patient

satisfaction and overall quality of care. In regional effort, in person hospital meetings will

be organized to review the proposal information using a power point presentation format.

Academia. As word of this proposed study’s findings disseminate, other institutions

may become interested in instituting a program similar to the Caring Program defined

here. The Caring Program could be instituted not only by health care organizations but

within academia as well. Similar to the hospital presentations, in person presentations

will be advertised for any interested medical or nursing university as well. The Care

Program is suitable for medical and nursing academia and would instill these beneficial

techniques and qualities at the start of the professional’s educational journey.

Application to Nursing

Importance

Relevance of this topic cannot be stressed enough. Patient satisfaction effects patient

outcomes and potential reimbursement for healthcare organizations. Although there are

some contributing factors affecting patient satisfaction that cannot be changed, one that

can is the type of care that is given by the health care provider. This form of research

would provide the medical and nursing profession with evidence of the effect of

professional caring and its potential impact on patient satisfaction. This research also

provides the framework for an educational Caring program for future use.

Leadership. Within the past several decades, countries around the world are seeing a

rise in Advanced Practice Nurses (APN). Advanced Practice Nurses (APN) are

considered to be leaders and educators within healthcare such as nurse practitioners,

nurse educators, case managers, as well as nurse specialists within the clinical setting.

Advanced Practice Nurses have the ability to evaluate current practices; research, create,

and present new knowledge, as well as improve the deliverance of care among the

profession (Bryant‐Lukosius, DiCenso, Browne, & Pinelli, 2004).

Education. Numerous theorists, theories, and thousands of articles have arisen

throughout the years attempting to define and operationalize caring within the nursing

profession (Drahošová & Jarošová, 2016). Caring has been described as a professional

component of the nursing professional. One theoretical framework utilized for this

research proposal was Jean Watson’s Theory of Human Caring. In accordance with

Florence Nightingale’s original vision, nursing is to be comprised of caring (Watson &

Woodward, 2010). Although the proposed study focuses on physicians, the literature

within this quantitative study and the proposed Care Program are applicable for other

health care providers as well, including the nursing profession. Caring in nursing, similar

to the physician, involves the development of a relationship with the patient that

promotes trust and a healing environment. The same principles of caring and effective

communication apply, such as effective listening, and the demonstration of compassion

and empathy. This form of care and communication within the nursing profession has

been shown to decrease patient anxiety, as well as improved patient outcomes

(Drahošová & Jarošová, 2016). The proposed findings will reflect on how an extended

and specified caring training would impact the patient’s satisfaction, treatment

compliance, and health care outcome. The Care Program within this proposed study may

one day be instituted by nursing schools around the world providing a comprehensive

look into caring within healthcare, providing the knowledge necessary to promote a more

holistic and compassionate form of care.

Environment. Advanced Practice Nurses (APN) work within a multitude of

healthcare practice environments. Although this research applies mainly to the hospital

setting, the principles of professional care apply to all health care settings. Jean Watson’s

Theory of Human Caring is a theoretical component of this research, which involves the

inclusion of holistic caring, and patient focused relationships into the healthcare

professional’s ethical foundation of practice. The inclusion of these aspects of caring,

promotes a more promising healing environment (Watson, 2006).

References

Afzal, M., Rizvi, F., Azad, A. H., Rajput, A. M., Khan, A., & Tariq, N. (2014).

Effect of demographic characteristics on patient’s satisfaction with health care

facility. Journal of Postgraduate Medical Institute (Peshawar-Pakistan), 28(2).

American College of Physicians. (2016). About ACP. Retrieved from

https://www.acponline.org

Anxiety and Depression Association of America. (n.d.). Children and Teens.

Retrieved from:

https://www.adaa.org/living-with-anxiety/children

Arslan‐Özkan, İ., Okumuş, H., & Buldukoğlu, K. (2014). A randomized controlled trial

of the effects of nursing care based on Watson's Theory of Human Caring on distress,

self‐efficacy and adjustment in infertile women. Journal of advanced nursing, 70(8),

1801-1812.

Auster, S., & Weiner, S. J. (2007). From Empathy to Caring: Defining the Ideal

Approach to a Healing Relationship. The Yale Journal of Biology and Medicine;

80(3): 123-130.

Bassett Healthcare Network. (n.d.). Bassett Medical Center. Retrieved from

http://www.bassett.org/medical/locations/hospitals/bassett-medical-center/

Bryant‐Lukosius, D., DiCenso, A., Browne, G., & Pinelli, J. (2004). Advanced practice

nursing roles: development, implementation and evaluation. Journal of Advanced

Nursing, 48(5), 519-529.

Burns, N., Grove, S., & Gray, J.  (2013). Practice of nursing research:

Appraisal, synthesis, and generation of evidence. (7th ed.).

Philadelphia: Saunders. ISBN: 978-1-4160-5468-9

Cleary, P. D., & McNeil, B. J. (1988). Patient satisfaction as an indicator of

quality care. Inquiry, 25-36.

CMS.gov. (2014, September 25). HCAHPS: Patient’s Perspectives of Care Survey.

Retrieved from

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/HospitalQualityInits/HospitalHCAHPS.html

Cooperstown, NY. (2014). Retrieved from

https://censusreporter.org/profiles/16000US3618047-cooperstown-ny/

Drahošová, L., & Jarošová, D. (2016). CONCEPT CARING IN NURSING. Central

European Journal Of Nursing & Midwifery, 7(2), 453-460.

doi:10.15452/CEJNM.2016.07.0014

Ferrand, Y. B., Siemens, J., Weathers, D., Fredendall, L. D., Choi, Y., Pirrallo, R. G., &

Bitner, M. (2016). Patient Satisfaction With Healthcare Services: A Critical Review.

Quality Management Journal, 23(4).

Fisak Jr, B. J., Richard, D., & Mann, A. (2011). The prevention of child and

adolescent anxiety: A meta-analytic review. Prevention Science, 12(3),

255-268.

Halldorsdottir, S. (1996). Caring and uncaring encounters in nursing and health care:

Developing a theory.

HCAHPS Regulatory Survey. (2016, September 26). Retrieved from

     http://www.pressganey.com/solutions/service-a-to-z/hcahps-regulatory-

survey

HCAHPS Survey. (2012). Retrieved from http://www.hcahpsonline.org/Files/1HCAHPS%20V7%200%20Appendix%20A%20- %20HCAHPS%20STANDARD%20Mail%20Survey%20Materials%20(English)%20 March%202012.pdf

Hjortdahl, P., & Laerum, E. (1992). Continuity of care in general practice: effect

on patient satisfaction. Bmj, 304(6837), 1287-1290.

Hospital Anxiety and Depression Scale (HADS). (n.d.). Retrieved from

http://www.svri.org/sites/default/files/attachments/2016-01-13/HADS.pdf

Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). Patients' perception of

hospital care in the United States. New England Journal of Medicine, 359(18), 1921-

1931.

Konrad, T. R., Williams, E. S., Linzer, M., McMurray, J., Pathman, D. E., Gerrity, M., ...

& Douglas, J. (1999). Measuring physician job satisfaction in a changing workplace

and a challenging environment. Medical care, 1174-1182.

Lee, A. V., Moriarty, J. P., Borgstrom, C., & Horwitz, L. I. (2010). What can we learn

from patient dissatisfaction? Analysis of dissatisfying events at an academic medical

center. Journal of Hospital Medicine : An Official Publication of the Society of

Hospital Medicine, 5(9), 514–520. http://doi.org/10.1002/jhm.861

Luthra, S. (2015, September 18). How to improve doctors’ bedside manner.

Retrieved from

http://www.cnn.com/2015/09/13/health/doctor-empathy-increase/

Mast, M. S., Hall, J. A. & Roter, D. L. (2008). Caring and dominance affect participants’

Perceptions and behaviors during a virtual medical visit. Journal of general internal

medicine, 23(5), 523-527.

Mercer, S. W., & Reynolds, W. J. (2002). Empathy and quality of care. Br J Gen

Pract, 52(Suppl), S9-12. 

McLeod, S. (2008). Erik Erikson. Retrieved from

http://www.simplypsychology.org/Erik-Erikson.html

Naidu, A. (2009). Factors affecting patient satisfaction and healthcare quality.

     International journal of health care quality assurance, 22(4), 366-381.

Pear, R. (2008, March 29). Study Finds Many Patients Dissatisfied With Hospitals. New

New York Times. Retrieved from:

http://www.nytimes.com/2008/03/29/washington/29hospital.html

Powell, L. (2001). Conducting Hospital Employee Satisfaction Surveys [PowerPoint

slides]. Retrieved from https://www.ruralcenter.org/sites/default/files/Assessing-Employee-Satisfaction.pdf

Prakash, B. (2010). Patient Satisfaction. Journal of Cutaneous and Aesthetic

Surgery, 3(3), 151–155. http://doi.org/10.4103/0974-2077.74491

Rahmqvist, M. (2001). Patient satisfaction in relation to age, health status and

other background factors: a model for comparisons of care units. International

Journal for Quality in Health Care, 13(5), 385-390.

Snaith, R. P. (2003). The hospital anxiety and depression scale. Health

and quality of life outcomes, 1(1), 1.

Spinhoven, P. H., Ormel, J., Sloekers, P. P. A., Kempen, G. I. J. M.,

Speckens, A. E. M., & Van Hemert, A. M. (1997). A validation study of

the Hospital Anxiety and Depression Scale (HADS) in different groups

of Dutch subjects. Psychological medicine, 27(02), 363-370.

The National Institute of Mental Health. (2016, March). Anxiety

Disorders. Retrieved from:

https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

Ukah, F., Hetemi, A., Duri, I., Fidahić, B., Pirani, Z., Haskuka, M., & Karameta, B.

(2008). Causes and consequences of patient dissatisfaction with healthcare services in

Ferizaj/Uroševac Municipality. Public Pulse Analysis. Retreived from: http://www.academia.edu/9551945/Causes_and_consequences

_of_patient_dissatisfaction_with_healthcare_services_in_

Ferizaj_Uroševac_Municipality

Watson, J. (n.d.). Theory of Human Caring. Retrieved from

http://www.watsoncaringscience.org/images/features/library/THEORY%20OF%

20HUMAN%20CARING_Website.pdf

Watson, J. (2006). Caring theory as an ethical guide to administrative and clinical

practices. Nursing Administration Quarterly, 30(1), 48-55.

Watson, J., & Woodward, T. (2010). Jean Watson’s theory of human caring. Nursing

theories & nursing practice, 351-369.

Whitbourne, S. K., Zuschlag, M. K., Elliot, L. B., & Waterman, A. S. (1992).

Psychosocial development in adulthood: A 22-year sequential study.

Journal of Personality and Social Psychology, 63(2), 260.

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Informed Consent on Care Program

Investigator: Kristine Bourne, RN, BSN

Dear ___(Patient’s Name)___,

Mrs. Bourne is a registered nurse studying the implementation of a nine week Caring

Program for physicians and its impact/effect on patient satisfaction among/in adolescents

with a diagnosis of anxiety and job performance among physician participants.

Purpose

The purpose of this research is to evaluate the implementation of a nine-week Caring

Program for physicians and it's impact/effect on patient satisfaction among/in adolescents

with a diagnosis of anxiety and job performance among physician participants.

Potential Risks and Benefits

Although the study may not benefit you directly, it will provide information that might

enable health care physician’s to engage in a more therapeutic relationship that is patient

centered in turn improving patient care outcomes and overall patient satisfaction. The

appropriate parties have approved the study and its procedures. The study procedures

pose no potential risk to you as the participant.

Procedure

The procedures include: (1) Your demographics and medical history will be obtained

by Mrs. Bourne for data purposes, (2) You will be examined by a physician, one hour

post, the study conductor will have you, the adolescent, complete The Hospital Anxiety

and Depression Scale (HAD) in person, and (3) within 48 hours after your discharge, you

will complete a Hospital Consumer Assessment of Healthcare Providers and Systems

(HCAHPS) survey via interactive voice recognition. Your time commitment of

participation within this study will vary on your length of hospital stay. However, your

participation will begin when you are seen by the study physician and will end 48 hours

after you are discharged. You are free to ask any questions about the study or about being

a subject and you may call Mrs. Bourne at (888) 982-0000 (work) if you have any further

questions.

Voluntary Consent

Your participation in this study is voluntary; you are under no obligation to

participate. You have the right to withdraw at any time and you care will not be effected

in any way.

Confidentiality

The study data will be coded so there will not be a connection to your name. Your

identity will not be revealed while the study is being conducted or when the study is

reported or published. All study data will be collected by Mrs. Bourne, stored in a secure

environment, and not shared with any other person without your permission.

I have read this consent form and voluntarily consent to participate in this study.

_________________________________ __________________________________Subject’s Signature Date Legal Representative Date

I have explained this study to the above subject and have sought his/her understanding for informed consent.

_______________________________________________Investigator’s Signature Date

Appendix F

Informed Consent on Care Program

Investigator: Kristine Bourne, RN, BSN

Dear __(Physician’s Name)____,

Mrs. Bourne is a registered nurse studying the implementation of a nine-week Caring

Program for physicians and it's impact/effect on patient satisfaction among/in adolescents

with a diagnosis of anxiety and job performance among physician participants.

Purpose

The purpose of this research is to evaluate the implementation of a nine-week Caring

Program for physicians and it's impact/effect on patient satisfaction among/in adolescents

with a diagnosis of anxiety and job performance among physician participants.

Potential Risks and Benefits

The appropriate parties have approved the study and its procedures. The study

procedures pose no potential risk to you as the participant. If you are chosen to participate

in the nine-week caring program, there are several benefits to this training that include

learning what defines caring, how caring impacts patient satisfaction and why caring is

important to healthcare organizations, techniques that will relay a caring demeanor to the

patient, such as postural stance and tone of voice, and methods in which the physician

can still demonstrate compassion and methods of caring even under difficult

circumstances. And if the study does not benefit you directly, it will provide information

that might enable health care physician’s to engage in a more therapeutic relationship that

is patient centered in turn improving patient care outcomes and overall patient

satisfaction.

Procedure

The procedures include: (1) You will complete a pre-participant employee satisfaction

survey, (2) Your participation and completion of a nine-week training program (5 of the

10 participants), (3) You will complete a post participation employee satisfaction survey

(5 of the 10 participants), and (4) You will examine an adolescent with a diagnosis of

anxiety during there hospital stay. Your time commitment of participation within this

study will vary in relation to training participation, as well as patient’s length of hospital

stay. Mrs. Bourse estimates a minimum of 12 weeks for program participants and 3

weeks non-program participants. You are free to ask any questions about the study or

about being a subject and you may call Mrs. Bourne at (888) 982-0000 (work) if you

have any further questions.

Voluntary Consent

Your participation in this study is voluntary; you are under no obligation to

participate. You have the right to withdraw at any time and you care will not be effected

in any way.

Confidentiality

The study data will be coded so there will not be a connection to your name. Your

identity will not be revealed while the study is being conducted or when the study is

reported or published. All study data will be collected by Mrs. Bourne, stored in a secure

environment, and not shared with any other person without your permission.

I have read this consent form and voluntarily consent to participate in this study.

__________________________________ _________________________________Subject’s Signature Date Legal Representative Date

I have explained this study to the above subject and have sought his/her understanding for informed consent.

_______________________________________________Investigator’s Signature Date