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Abstract
Objective To determine how patient experience with nursing care influence patient satisfaction with overall hospital services.
Design This was a cross-sectional study.
Setting Inpatients were consecutively recruited at the national hospital (with 2000 beds) in Shanghai, China.
Participants The inclusion criteria were as follows: (1) hospitalised for 2 days or more; (2) able to read and understand Chinese; and (3) aged 18 years old or above. Patients with mental health problems were excluded. 756 patient surveys distributed among 36 wards were analysed. The mean age of participants in the study was 57.7 (SD=14.5) and ranged from 18 to 80 years. Most participants were men (61.5%) and ever married (94.6%).
Primary and secondary outcome measures Patient experience with nursing care, meaning the sum of all interactions between patients and nurses, was measured using the self-designed questionnaire, which was developed by patient interviews, literature analysis and expert consultation. The overall patient satisfaction question was measured with a 10-point response option ranging from 1 to 10.
Results A linear relationship between the patient experience with nursing care and overall patient satisfaction was observed. The patient experience with nursing care was significantly associated with overall satisfaction in the crude model and in the adjusted models. Even after adjusting for six sociodemographic and three disease-related factors, the patient experience with nursing care explained 34.9% of the variation in overall patient satisfaction.
Conclusions This study showed that patient experience with nursing care was an important predictor for overall patient satisfaction.
- patient satisfaction
- patient experience
- nursing care
- health services research
Data availability statement
Data are available upon reasonable request. Data are available on the Dryad repository and the DOI number is https://doi.org/10.5061/dryad.qfttdz0jg.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
This study used a valid and specific questionnaire of patient experience with nursing care made by patient interviews, literature analysis and expert consultation to investigate patient experience with nursing care.
This study quantitatively analysed the impact of patient experience with nursing care on overall patient satisfaction.
This study first surveyed patient experience with nursing care systematically and comprehensively in China.
This was a single-centre study and our findings therefore may not be generalised.
This study did not survey hospital-unit-related characteristics, such as the organisation’s patient-centred culture and nurses’ practice environment. These variables were not available in our data sample but might be associated with patient experience with nursing care and also have an effect on overall patient satisfaction.
Introduction
In the age of patient-centred care, as value-based care expands, patient satisfaction has become a key indicator in assessing healthcare quality and hospital performance1 and is being used more frequently to determine hospital performance and hospital reimbursement.2 3 Patients who are satisfied with the healthcare system are more willing to comply with medical orders and treatments,4 are more likely to return to the healthcare organisation for future care and are more likely to recommend healthcare services to their family members and friends.5 As the healthcare quality improvement action plan proliferated internationally, the National Health Commission of the People’s Republic of China posted an announcement implementing the National Healthcare Improvement Initiative in January 2015, with the overall goal of improving the patient satisfaction on a national level.6
Recognising factors that influence overall patient satisfaction will help improve medical care. A large body of research has identified the factors that account for the variations in patient satisfaction.7 However, such studies have largely focused on patient characteristics, such as age,8 gender,9 race/ethnicity,10 financial status11 and organisational factors12 13; additionally, these studies have inconsistent findings and explained only a small fraction of the variance in patient satisfaction.
In recent years, patient experience has been increasingly used to evaluate the quality of healthcare.14 Patient experience is defined as ‘the sum of all interactions, shaped by an organisation’s culture, that influence patient perceptions across the continuum of care’.15 Patient experience measures the structures and processes of care, while patient satisfaction survey serves as a patient-reported outcome measure.15 The causal link between structure, process and outcome might be expected theoretically. However, patient satisfaction is subjective and obscure, and dependent on patients’ expectations, fulfilment of expectations, actual experiences, health outcome and other individual factors. Therefore, several studies have explored the relationship between patient experience and patient satisfaction with the healthcare system,16–18 with an attempt to determine to what extent that patient experience affects patient satisfaction, considered that patient experience can provide tangible feedbacks to current care delivery and these feedbacks are amendable and actionable by providers to improve quality of healthcare, whereas other factors such as patients’ expectations and individual characteristics are hard to change.
Nurses are a vital and central part of the healthcare system,19 accounting for nearly half of the global health workforce and spending more time with patients than any other medical professionals.20 According to the data from the latest China Health Statistics Yearbook issued by the National Health Commission of the People’s Republic of China, as of the end of 2020, the number of nurses in China reached 4.7 million, accounting for 44.1% of the total number of healthcare professionals.21 In theory, patient experience with nursing care, as a process indicator, reflects interactions between patients and nurses and has an important impact on overall satisfaction with hospital care.22 23 In the study of Bjertnaes,18 13 variables were significantly associated with overall patient satisfaction with hospitals, and the results of the regression model showed that the most important predictor of patient satisfaction with hospitals was patient experiences with nursing care. Similarly, Schmidt found that the perception of nursing care received was the only significant predictor of overall satisfaction with the hospital experience.24
However, in terms of using these patient experience data to improve nursing care, existing studies have not offered enough feedback due to the low representation of nursing care in these patient experience surveys.17 18 Most patient experience scales include a limited number of items related to nursing and fail to provide thorough and detailed insight into nursing care from patients’ perspectives. For instance, the study of Bjertnaes18 included only four items related to nursing care, and the study of Min et al12 included only two items related to nursing care. Therefore, to what extent patient experience with nursing care explains satisfaction with the healthcare system remains unclear.
We hypothesise that patient experience with nursing care accounts for a considerable portion of the unexplained variation in health system satisfaction after adjustments for the demographic profile, health and organisational factors with which patient satisfaction is usually associated. Understanding the association between patient experience with nursing care and patient satisfaction may help in using the results to improve nursing services, resulting in better patient satisfaction. Therefore, the purpose of this study was to determine how patient experience with nursing care influence satisfaction among patients.
Methods
Design
This study is a cross-sectional survey and is reported according to the ‘The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement for reporting observational studies’ obtained from the EQUATOR Network website.25
Setting
Inpatients were consecutively recruited from July 2020 to August 2020 in Zhongshan Hospital of Fudan University, which is the largest academic hospital (with 2000 beds) in Shanghai, China.
Sample and participants
We calculated the sample size according to the requirements for multivariate analysis, which demands the sample size be 5–10 times the number of variables.26 There were 33 items in the questionnaire and 22 patients and organisational characteristics. Therefore, the sample size was required to be 660 with an estimated 20% non-response rate. During the study period, a total of 767 inpatients were eligible to participate in the study, 7 patients refused to participate (0.9%), and 4 patients’ questionnaires were incomplete (0.5%). Finally, 756 patients (98.6%) were analysed. The inclusion criteria were as follows: (1) hospitalised for 2 days or more; (2) able to read and understand Chinese; and (3) aged 18 years old or above. Patients with mental health problems, such as dementia, schizophrenia and severe depression, were excluded. Eligible patients were invited to participate in the study. When a patient showed an interest in participating, a recruitment letter explaining the aim, process and ethical considerations of this study was sent to them. To gain a broad and representative understanding of the patient experience, we varied the recruitment sites. A total of 36 wards were included, including 16 internal medical wards and 20 surgical wards, followed by cardiology, hepatology, respiratory department, gastroenterology, haematology, oncology, nephrology, orthopaedics, urology, neurology, obstetrics and gynaecology, endocrinology, otorhinolaryngology and hepatobiliary surgery department, from each of which accounted for at least 3% of the patients in our sample.
Measures
Patient characteristics
The following characteristics were collected: age, gender, ethics, religion, educational level, household monthly income per capita, family residence, medical assurance, primary caregiver, primary disease diagnosis, number of admissions within 1 year and length of hospital stay. The section for disease diagnosis consisted of 10 categories: (1) cardiovascular diseases, (2) pulmonary diseases, (3) diseases of the digestive system, (4) diseases of the musculoskeletal system, (5) endocrine/metabolic diseases, (6) neurological diseases, (7) diseases of ophthalmology, (8) diseases of the urinary system, (9) diseases of the haematological system and (10) other diseases, including allergies.
Patient experience with nursing care
Patient experience with nursing care was measured by the inpatient experience of nursing care questionnaire, which was self-designed to evaluate patients’ perceptions of quality of nursing care in Chinese hospitals. After a scoping review of current research results concerning patient experience with nursing care, 15 semi-structured in-depth interviews with 8 men and 7 women were conducted to obtain insights into patient-perceived important elements of nursing care. Example questions are ‘What aspects of nursing care do you feel are important?’ and ‘What do you see as the nurses’ role when you receive health services?’. The draft items of the questionnaire were generated by interviews and literature analysis. Then, to select the most suitable items to be retained in the questionnaire, the content validity of the items was evaluated by 15 experts in the fields of patient management and quality of care, and items were deleted if the content validity index was less than 0.8. Finally, we conducted a pilot survey and found the Cronbach’s α of the questionnaire was 0.84, and the split-half reliability was 0.75.
The final questionnaire consisted of 33 items assessing eight dimensions of patients’ perception of nursing care (online supplemental material 1): (1) Coordination of care (three items), for example, the process of admission. (2) Physical environment (three items), for example, the cleanliness of the ward. (3) Information and education (seven items), for example, the information about how to conduct scientific lifestyles. (4) Emotional support (four items), for example, nurses’ response to patients’ anxiety and fear. (5) Technical competencies (two items), for example, proficiency in performing nursing procedures. (6) Monitoring the progress of diseases (four items), for example, monitoring the vital signs. (7) Responding requests (three items), for example, the waiting time after pressing the call button. (8) Patient safety and privacy protection (seven items), for example, treating patients’ information confidentially. Most of the items were assessed by a 5-point Likert scale ranging from ‘never’ to ‘always’, where ‘never’=1, ‘occasionally’=2, ‘sometimes’=3, ‘usually’=4, and ‘always’=5. Response options ranged from ‘strongly disagree’ and ‘strongly agree’ for the admission process and discharge plan. For each item, the patients were offered the option of indicating whether it was not relevant. Each dimension score was determined by adding the scores of all items that corresponded to that dimension and dividing it by the number of items. The total inpatient experience score was the mean of all eight dimension scores.
Supplemental material
Patient satisfaction
The overall patient satisfaction question was ‘All in all, were you satisfied with the care and treatment you received at the hospital?’, with a 10-point response option ranging from 1 to 10 (with 1 labelled ‘not at all satisfied’ and 10 labelled ‘to a very large extent satisfied’).
Data collection
Eligible patients were invited to participate in the study. After informed consent was given, all data were obtained by trained investigators. Characteristics included in the hospital information system, such as gender, age and diagnosis, were collected by checking the information system, while characteristics related to family income, literacy level and number of hospital admissions were assessed by interviewing patients and their family members. The timing of collecting the patients’ feedback may affect their response to the questionnaires because some of them may worry that negative appraisals about their hospital experience and satisfaction would affect the treatment and care they received during hospitalisation, and thus they might be unwilling to provide negative feedback. To encourage the participants to respond frankly, the patient experience with nursing care survey and the overall patient satisfaction survey were taken on the patients’ discharge day, and the nursing staff did not administer the survey.
Data analysis
Statistical analyses were conducted using IBM-SPSS software V.22 (IBM Corp), Empower (R) (www.empowerstats.com, X&Y solutions) and R statistical software. Descriptive analysis was performed for participants’ characteristics and their responses to items about satisfaction and experience. Values were expressed as the mean and SD for continuous variables or percentages for categorical variables. Multiple regression models were used to analyse the effects of patient experience with nursing care and other variables on the overall patient satisfaction. Independent variables were selected based on evidence in previous studies6–8 showing a significant relation to overall patient satisfaction and we also included other variables based on our clinical experience. To ensure the stability of the model, and determine whether the relationship between patient experience with nursing care and patient overall satisfaction would be weakened after adjusting different variables, we chose different kinds of variables into the model successively. Model 1 was adjusted for age, sex, residence, literacy level, household monthly income per capita, type of medical assurance; model 2 was adjusted for age, sex, residence, literacy level, household monthly income per capita, type of medical assurance, diagnosis, number of admissions within 1 year, length of hospital stay. We also conducted the subgroup analyses test whether the relationship between patient experience with nursing care and overall patient satisfaction was valid among different populations. Non-ordinal categorical variables and ordinal categorical variables with non-equidistant data were transformed into dummy variables. The probability was considered significant when p<0.05. No missing data imputation methods were used.
Patient and public involvement statement
It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.
Results
Sociodemographic and clinical characteristics of the study participants
A total of 756 participants with a mean age of 57.7 years were recruited. Of these, 61.5% (465/756) were men, and 39.9% (302/756) were diagnosed with cancer. The detailed demographic and clinical characteristics of the participants are shown in table 1.
Socio-demographic and clinical characteristics of study participants
Patient experience with nursing care
The total patient experience score was 4.54 (0.37). The scores of each item are presented in table 2. The lowest scores were related to ‘information and communication’ (4.34±0.52), ‘coordination of care’ (4.42±0.53) and ‘emotional support’ (4.56±0.45). Patients had better experiences with ‘patient safety and privacy protection’ (4.65±0.39), ‘technical competencies’ (4.64±0.38) and ‘responding requests’ (4.63±0.41).
Percentage distribution of items for experience with nursing care in participants (n, %)
Patient satisfaction with hospital services
The overall patient satisfaction item was skewed toward a positive assessment: 9.2 on a scale of 1–10, where 10 represents the best score. Of those who responded, 52.0% were satisfied with the hospital services to a very large extent. Only 1.9% reported being satisfied to only a small extent, and 0.3% were not at all satisfied with the hospital services.
Relationships between patient experience with nursing care and overall patient satisfaction
A linear relationship between the patient experience of nursing care and overall patient satisfaction was observed after adjusting for age, sex, household monthly income per capita, literacy level, residence, medical insurance, length of hospital stay, number of admissions within 1 year and primary diagnosis (figure 1). Table 3 presents the results of multivariate regression for the effects of patient experience with nursing care on the patients’ overall satisfaction with hospital services. The patient experience with nursing care was significantly associated with overall satisfaction in the crude model and in the adjusted models. Even after adjusting for six sociodemographic and three disease-related factors in model 2, the patient experience with nursing care was still significantly associated with overall patient satisfaction (β=1.257, adjusted R2=34.9%, p<0.001).
The relationship between patient experience with nursing care and overall patient satisfaction.
Multivariate regression for effect of patient experience with nursing care on overall patient satisfaction
Subgroup analysis of the relationship between patient experience with nursing care and overall patient satisfaction
The subgroup analysis is presented in figure 2. No significant heterogeneity was found among analysed subgroups stratified according to age, sex, residence, literacy level, household monthly income per capita, type of medical assurance, primary diagnosis, number of admissions within 1 year and length of hospital stay.
Subgroup analysis for effect of patient experience with nursing care on overall satisfaction with hospital services.
Discussion
The aim of our study was to analyse the effects of patient experience with nursing care on overall patient satisfaction. The results showed a linear relationship between patient experience with nursing care and overall patient satisfaction after the adjustment for age, sex, family monthly income, educational level, residence, medical insurance, length of hospital stay, number of admissions, primary diagnosis (figure 1). The patient experience with nursing care explained 34.9% of the variance in overall patient satisfaction. This finding was consistent with previous studies,24 27 which showed that the most important predictor of patient satisfaction with hospitals was patient experience with nursing care. The variance in overall patient satisfaction that patient experience with nursing care explained in our study was larger than that in study of Bjertnaes.18 The possible reason may be the different tools we used. The study of Bjertnaes18 included only four items relating to nursing and had low representation of nursing care, failing to provide thorough and detailed insight into nursing care from the patients’ perspectives, while our study developed and used a questionnaire of patient experience with nursing care through patient interviews, literature analysis and expert consultation, which consisted of 33 items assessing eight dimensions of the patients’ perception of nursing care and had good validity and reliability. Therefore, the survey tool used in our study had a high representation of patient-perceived nursing care.
To our knowledge, this is the first study in China to survey patient experience with nursing care and to analyse its relationship with overall patient satisfaction. Recently, there has been a growing interest in using patient experience to assess and improve the performance of the healthcare system in China.11 However, nursing seems to be overlooked in this growing trend.28 Our study showed that patients had better experiences with ‘patient safety and privacy protection’, ‘technical competencies’ and ‘responding requests’. The year of 2021 is the 11th anniversary of the launch of Quality Care Demonstration Project by the Chinese government, aiming at improving satisfaction of patients, society and government through high-quality nursing care.29 Driven by the implementation of the ‘high-quality care project’, Chinese nursing services have continued to be improved regrading patients’ physical care.
However, there should be recognition of the potential need for psychological and emotional support, as well as of the importance of meeting communication and information needs. The result of our study showed that patients had worse experience with ‘information and communication’, ‘coordination of care’ and ‘emotional support’, which was consistent with study of Senarat and Gunawardena.30 As patients’ healthcare demands increase, they are no longer satisfied with passively receiving care; instead, they are eager to become fully involved in the treatment and recovery process.31 Additionally, nurses spend the most time with them among all medical professionals. In addition to direct care providers, nurses are also expected to act as navigators coordinating all aspects of care and promoting patient-centred care. Therefore, coordination of care is a fundamental and core value of nursing care, a predictor of quality and a known predictor of patient satisfaction with healthcare.32 Humanistic care is an indispensable characteristic of nursing services. Numerous studies have demonstrated that patients’ health outcomes can be improved much more significantly when caring behaviours are performed with empathy and compassion.33 34 The study of Karam15 also showed that tactics alone, such as bedside shift reports, health education and follow-up phone calls after discharge, were insufficient, while meaningful strategies to create a positive organisational culture were vital drivers to promote a successful patient experience. However, most healthcare institutions in China are task-oriented, and the delivery of nursing care is streamlined with standardised processes, protocols and paths. These practices result in the fragmented nursing care, and patients receive less psychological care and more technical care from nurses, which negatively influences patient experience. Efforts should be made by hospital administrators and nursing managers to overcome the tendency to streamline the care delivery by standardised processes and determine how these patient-perceived attributes of nursing care can be developed and rooted in the daily practice through organisational changes, culture shaping and staff education.
Compared with the other determinants that influence overall patient satisfaction with hospital services, such as the reputation and the image of hospitals, education and socioeconomic status of the patients and length of stay,6 patient experience with nursing care is amendable and actionable. For instance, organising an afternoon ward round by nurses to address the communication needs of patients and hanging a poster to share patient feedback with the medical team have been proven to be efficient ways to facilitate good experiences with communication.35 Understanding the importance of patient experience with nursing care would enable nursing managers and nursing practitioners to have a better understanding of current problems with healthcare delivery, push for continuous improvement, redesign the delivery of services and help professionals reflect on their practice.
Limitations
This was a single-centre study and our findings therefore may not be generalised. However, our hospital is a national large general hospital and the nursing services model has a leading role around the country, therefore, for the Chinese region, our results can be regarded as representative to a considerable extent. Moreover, even though we had consider several variables which are likely related to patient outcomes, we might have omitted other hospital-unit-related characteristics, such as the organisation’s patient-centred culture and nurses’ practice environment. These variables were not available in our data sample but might be associated with patient experience with nursing care and also have an effect on overall patient satisfaction. Further researches are needed to analyse the external factors that could have influenced patient experience with nursing care.
Conclusion
This study provides the first evidence of the importance of nursing care in improving overall patient satisfaction, and demonstrates that nurses have the huge potential to contribute to the patient-centred healthcare system and nursing should be more involved in the healthcare quality improvement. Understanding the importance of patients’ perception of nursing services delivery would enable nursing managers and nursing practitioners to have better understanding of current problems with healthcare delivery, push for continuous improvement, redesign the delivery of services and help professionals reflect on practice modern.
Data availability statement
Data are available upon reasonable request. Data are available on the Dryad repository and the DOI number is https://doi.org/10.5061/dryad.qfttdz0jg.
Ethics statements
Patient consent for publication
Ethics approval
The study was approved by the Ethics Committee of Zhongshan Hospital of Fudan university (Approval number B2020-074) and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. Prior to data collection, all participants were informed of the purpose of this study and signed written consent forms were obtained to inform them of the rights, risks and advantages of participation. Participants gave informed consent to participate in the study before taking part.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors YZ is responsible for the overall content as the guarantor. XC and YZ contributed to the study conception and design. Material preparation, data collection and analysis were performed by XC, YZ, WQ, ZY, JY, YL, XL, ZZ and YW. The first draft of the manuscript was written by XC and YZ, WQ, ZY, JY, YL, XL, ZZ and YW commented on and revised previous versions of the manuscript. All authors read and approved the final manuscript, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.
Funding This work was supported by the Zhongshan Hospital of Fudan University under Award Number 20208ZSFZ02, and the funder had no role in the design of the study, the collection or analysis of data or the decision to publish.
Competing interests We had no associations with commercial entities that provided support for the work reported in the submitted manuscript. We had no associations with commercial entities that could be viewed as having an interest in the general area of the submitted manuscript. We had no similar financial associations involving their spouse or their children under 18 years of age. We had no non-financial associations that may be relevant to the submitted manuscript.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.