THE NURSE LEADERS at a medical center located in the Midwestern United States routinely perform nurse leader rounds to evaluate patients' satisfaction with their care, resolve problems, and observe for staff compliance with quality improvement initiatives. Typical questions asked during such interactions include "How has your care been?" "Did your nurses include you in bedside report?" "Have you been educated about the purpose and side effects of your new medications?" "Are there any staff members who have been exceptional?"
It is widely believed that when caregivers sit, rather than stand, during clinical encounters, the outcome is positive patient perceptions of the provider-patient interaction and its duration.1-7 The purpose of this study was to examine whether the nurse leader's posture (sit vs stand) influenced patients' perceptions of time at the bedside and quality of the interaction. Understanding patients' perceptions of the nurse leader's posture provides direction to improve communication between the nurse leader and patients.
LITERATURE REVIEW
A literature search was conducted to explore the evidence on patients' perceptions of time at the bedside and quality of the interactions when nurses sit versus stand for rounds. PubMed and CINAHL databases were searched with the following key words: position, sitting, patient satisfaction, physician, nurse, posture, health care worker, patient perceived time, nurse-patient relations, physician-patient relations, professional-patient relations, standing, body language, time perception, time factors, and communication. The search resulted in 7 peer-reviewed studies on this topic, revealing mixed results.
Various settings were represented: 5 discussed physicians and patients in inpatient settings such as oncology, emergency department, postsurgical unit, and postpartum; 1 study dealt with physicians and patients in an outpatient facility; and the remaining study was on patients viewing dramatized videos of physician and patient interactions. Several studies showed that sitting during clinical interactions resulted in patients' perceptions of greater length of time spent than actual time.1-3 Conversely, others reported that the seated posture had no impact on time perception.4-6 In addition, most researchers found patients' perceptions of the provider-patient interactions were positively influenced when the providers were seated.2-6 However, other studies found no correlation between patients' perceptions of quality and the provider posture.1,7
In summary, published studies have explored patients' perceptions of the time and quality of provider-patient interactions relative to the posture of medical staff. Absent from the literature is evidence of whether nurses' posture impacts patients' perceptions. The present study addressed this gap in the literature.
METHODS
This was a quasi-experimental study using a convenience sample in which the nurse leader's posture was randomized to sit or stand. Three medical-surgical patient care units providing care to adult patients (aged >18 years) served as the study units. The study received approval by the institutional review board. It was typical practice for the nurse leaders to make rounds to visit each patient before discharge. The discussions focused on questions about patient satisfaction with care and whether there were any other concerns. The only difference with the study was the randomization of the nurse leader's posture to either sit or stand. The study was conducted on the day shift (7 AM-7 PM) Monday through Friday, only when there were no visitors in the patients' room. The study focused exclusively on the patients' perceptions of the nurse leader interaction, not the overall hospital stay. To lessen interruptions, the nurse leaders did not carry phones or pagers but otherwise conducted the visit in their normal manner.
Instrument
The survey developed by the authors was based on an instrument used previously by other researchers to survey patients' perceptions of time spent with them by physicians.1 Permission to use the survey was granted by the original author. Items from that survey were modified slightly to adjust for the nurse leader role. The modified survey included 12 items. The first 2 items addressed time with a fill-in-the-blank estimation of the length of the interaction and a Likert-style evaluation ("way too little" to "way too much") of the appropriateness of that length. These were followed by 4 Likert-style items ("strongly disagree" to "strongly agree") assessing the nurse leader's bedside manner, caring, and understanding of patient problems and the patients' confidence in the nurse leader. Only patients who answered "yes" to having shared a problem with the nurse leader answered the question about whether the nurse leader understood their problem. The survey included an optional comment box and closed with 4 demographic questions. It was evaluated using the Flesch-Kincaid grade level measurement and was found to be at a 6-grade reading level. The modified instrument was tested for face validity by having 12 different experts review the survey. The instrument was adjusted on the basis of their feedback and rechecked for reading level.
A convenience sample of adult medical-surgical inpatients who met inclusion criteria was asked to complete the survey. In this study, there were 5 variables (time, bedside manner, caring, understanding problems, and confidence), which suggested a sample size of 75 based on the guidelines of Houser and Bokovoy.8 Inclusion criteria were age 18 years or older; fluent in spoken and written English; no diagnosis of dementia or confusion at the time of this admission; admitted to the medical-surgical unit for more than 24 hours; not in isolation precautions; no family, visitors, or hospital staff in the room at the time of the nurse leader's visit; and severity of illness does not present a known barrier for participation. In addition, exclusion criteria eliminated patients who had previously been asked to participate in the study, were unable to complete the survey due to a physical limitation (eg, blind, restricted position, upper extremity paralysis or fracture), employees of the medical center, or health care professionals.
Data collection
Immediately before entering the patient room, the research assistant (RA) performed a coin toss to randomize the posture that the nurse leader was to assume. The RA accompanied the nurse leader into the room and was introduced as a clinical person who was observing the nurse leader that day. The RA wore a lab coat with a concealed stopwatch in the pocket. A "Do Not Disturb" sign was posted on the door to limit interruptions. The RA started the stopwatch at the moment the nurse leader crossed the threshold into the patient room and stopped the clock when the nurse leader crossed the threshold on exit. If the nurse leader was able to complete the interaction without interruption, the RA immediately explained the survey process and requested that the patient complete the survey about the leader's interaction with him or her.
Data analysis
Data analysis was conducted using SPSS (version 19) for Windows (IBM, Armonk, New York). Paired-samples t tests were used to determine the differences in patients' perceptions of time versus actual time spent. Level of significance was established at P <= .05. Regression analysis was used to determine whether there were any relationships between patient demographics and patient responses regarding time and perceptions of the interaction. One-way analysis of variance (ANOVA) was done to ascertain whether there was a provider effect on patients' perceptions of time.
RESULTS
Eighty of 84 subjects who enrolled into the study completed the surveys. One withdrew during data collection, and 3 were eliminated because they returned substantially incomplete surveys. More women (n = 46) than men (n = 30) participated. Most were aged 60 to 69 years (n = 22), Caucasian (n = 67), with some college but no degree (n = 28). This sample was representative of the hospital's patient demographics. Participants were randomly assigned to 2 groups: 39 (48.8%) in the standing group and the remaining 41 (51.2%) in the sitting group.
The mean time of the nurse leader standing rounds was 8 minutes 24 seconds. The participants in the standing group perceived the average time as 12 minutes 39 seconds. The mean overestimation of time by this group was 4 minutes 15 seconds. The mean time of the nursing leader sitting rounds was 8 minutes 36 seconds. The participants in the sitting group perceived the average time as 13 minutes 25 seconds. The mean overestimation of time by this group was 4 minutes 48 seconds. The sitting group's mean perception of time with the nurse leader was 2.4 seconds longer per minute than the standing group.
The results of total time versus patients' perceptions of time for the seated group were analyzed using a paired-samples t test. There was a statistically significant difference found between the total time spent (M = 8.2, SD = 3.5) versus the patients' perceptions of a time spent (M = 13.2, SD = 6.6) (t = -5.3, df = 37, P < .001). Findings were similar for the standing group. The results were statistically significant between the actual time spent (M = 8.4, SD = 5.8) and the patients' perceptions of time spent (M = 14.9, SD = 16.1) (t = -2.5, df = 37, P = .02). When comparing the patients' perception of time between the sitting and standing groups, no differences were found (P = .57). There also were no differences between the actual time spent sitting versus standing (P = .93).
The degree to which patients estimated time spent varied widely by the nurse leader. The mean rounding times by the 3 nurse leaders were 7 minutes 20 seconds, 8 minutes 43 seconds, and 10 minutes 55 seconds, respectively. The respective mean patients' perceptions were overestimated by 65%, overestimated by 62%, and underestimated by 5% of the actual time. To determine whether the individual nurse leader may have impacted the patient's perception of time, a one-way between-groups ANOVA was performed. There was no significant effect (F2,77 = 2.56, P = .08).
A regression analysis did not find significant relationships regarding gender, race, age, and education and the perceived adequacy of time the nurse leader spent (F4,74 = 0.73, P = .58). In addition, there were no significant findings regarding patients' perceptions of the quality of the interaction with the nurse leader based on their perception of the adequacy of time spent and the impact on bedside manner, whether the manager cared about the patient, confidence in manager, and manager understanding of patient problems (F4,74 = 0.41, P = .80).
DISCUSSION
This study revealed that the nurse leader's posture did not influence the patients' perceptions of the quality of the interaction. However, the preponderance of the published evidence suggests that patients prefer interacting with a seated provider.2-6 Also, this study did not reveal any disadvantages to the nurse leader sitting while making rounds. Sitting may be more comfortable for providers who are often on their feet for long periods of time.
The results showed that patients overestimated the time nurse leaders spent with them. This occurred regardless of the nurse leaders' posture. Patients who encountered the seated nurse leader overestimated slightly more than those who experienced the nurse leader standing, but there was no significant difference. This overestimation of time may actually be due to other effects not measured. The nurse leader role and nurse leader rounding are unique to the hospital setting. The encounters measured may have been the only time these patients interacted with the nurse leader. Patients typically have more exposure to health care staff in a variety of settings (eg, office, emergency department, hospital units) and are well aware of how busy they are. It is possible that because of the lack of history with the nurse leader role and limited interaction during this hospitalization, patients may not have understood the role and may not have appreciated their time constraints. This unfamiliarity with the role may have led to findings unlike previous studies using medical staff. The time leaders spent with patients varied widely, which may have been a result of the nurse leader's interpersonal communication styles. The patients' communication styles, needs, concerns, and questions also may have impacted the actual and perceived time.
The study had several limitations. Using a small, nonrandomized convenience sample from a single location may have created a risk of selection bias and limited generalizability. A possible threat to internal validity may have occurred because of the lack of a consistent script for the nurse leaders to use. In addition, a personnel change during data collection resulted in the replacement of a nurse leader; it is unknown whether this influenced the results. Another possible limitation is that posture may be one of many nonverbal cues that influence patients' perceptions of time or quality. Suggestions for future studies include repeating with a larger sample or using multiple caregiver roles, for example, physicians, midlevel practitioners, RNs, and patient care assistants.
CONCLUSION
While patients who experienced the nurse leader performing rounds in the sitting position overestimated the time spent with them to a greater degree than those who experienced rounds in the standing position, the difference was not statistically significant. However, leadership communication styles and interpersonal skills may influence the perception of time spent. Patients did not perceive differences in the quality of interaction based on posture. Assuming a seated position when interacting with patients is a simple approach, with no apparent disadvantages. The results also showed that sitting with the patients did not require much more of the nurse leader's time.
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