Zhang Rong Fang BHSN, Nazeemah Bte Mohd Advanced Diploma, Chan Choong Ling BHSN
Department of Nursing Administration, SGH

* Presented at the SingHealth Scientific Meeting 2004 held on 15–17 October 2004.

Background. Patient satisfaction has become an important indicator measuring the quality of nursing care. To be able to meet patients’ expectations, nurses should know the patients and understand their needs. However, many nurses have expressed difficulty in doing so due to insufficient manpower in their work place.

Methods. A correlational study involving nurses (n=467) who were working in the general wards was carried out from February to March 2004. A proportional stratified sample was selected based on the total population studied by self-administered questionnaires (SSN & SN: SEN & EN: HCA=310:101:56). The questionnaires measured the nurses’ demographics, and their perspectives of patient satisfaction.

Results. Patient satisfaction with nursing care from nurses’ perspective measured by total satisfaction score was significantly related to nurse staffing level (p=0.059), designation (p<0.05), age (p<0.05), ward department (p=0.009), class status (p=0.023), qualification (p<0.05) and years of experience (p=0.015).

Conclusion. Patient satisfaction with nursing care from nurses’ perspective was proportionate to nurse staffing level, but there were other co-variables which were more significant, such as ward department and qualification. Controlling all the co-variables in order to find out the real significance between nurse staffing level and patient satisfaction with nursing care can be considered for future study.

Keywords: nurse staffing level, nurses’ perspectives, patient satisfaction, quality nursing care

INTRODUCTION

A major service provided to hospitalised patients is nursing care. The quality of nursing care is an important determinant of patients’ satisfaction. Quality is defined as "meeting the expectations" of customers, while quality nursing care is defined as "care carried out by nurses meeting the patients’/customers’ expectations".

Perceptions of quality nursing care differ between nurses and patients. Current measurements of quality nursing care tend to be based on the technical expertise of the hospital, especially nursing, staff. However, patients find satisfaction in aspects other than the technical expertise of the hospital staff. It is the human aspect, that is the "nurses’ affective activities", of hospital care that gives patients the satisfaction they are seeking in an environment of quality nursing care.

To be able to meet patients’ expectations, nurses must know the patients and understand their expectations. However, many nurses have expressed difficulties in doing so due to insufficient manpower in their workplace. Nurse staffing level is an important issue for nurses. It seems to be one of the major factors that influence patient outcomes with regard to nursing care provided.¹

How do our nurses perceive patient satisfaction in terms of nursing care provided to them? How does nurse staffing level affect nurses’ perception of that? It is essential to explore the relationship between these two variables, so as to further improve the quality of nursing care.

METHODS

In this study, nurse staffing level was defined as the number of nurses who were assigned, based on their qualifications and experience, to care for a certain number of patients in a general ward. To simplify, it refered to the nurse-to-patient ratio.

Design

A correlational study was carried out from February to March 2004. Self-administered questionnaires were distributed to nurses to survey their perspectives of nurse staffing level in relation to patient satisfaction with nursing care.

Setting and Sample

The study was conducted across the various general wards in the Singapore General Hospital. The study population comprised a proportional stratified sample of 500 nursing personnel ranging from senior staff nurses to healthcare assistants.

Instrumentation

The questionnaire used to measure nurses’ perspective of patients’ satisfaction was formulated based on the literature reviews. To test its validity, opinions of the research committee were sought. The committee was knowledgeable about the characteristics of the questionnaire. The test-retest reliability of the questionnaire was obtained from 20 nurses working in the general wards from one acute hospital after one week.

The questionnaire comprised 27 questions (Appendix 1). Nurses’ perspective of patients’ satisfaction with his/her nursing care was rated using a 4-point Likert Scale, ranging from excellent (4) to poor (1). A score of 3 and above was considered optimal whereas a score of 2 and below was considered minimal for each question. Total satisfaction score, ranging from 10 to 40, was measured by the last 10 questions.

Appendix 1. Questionnaire for nurses.

Procedures

Nurse managers of the study wards were consulted regarding the quota of their nurse staffing level respectively. A stratified sample was calculated based on the given quota. Approval was obtained from Singapore General Hospital Ethics Committee prior to the commencement of the study. The questionnaires were distributed by the nurse managers to the participants. Implied consent was obtained from the participants before the distribution of the questionnaires. Nurses were assured that there would be no penalties for non-participation in the study. They were also assured that their particulars would be kept confidential and that participation or information provided would not be used against them. The researchers’ contact numbers were given to the participants to enable them to contact the researchers at any point of time if they had any queries or clarifications.

Participants were encouraged to return the completed questionnaires to their respective ward managers within two weeks of receipt. The completed questionnaires, which were retrieved by the investigators, were placed in a sealed envelope. Questionnaires returned by participants after the given time frame were not included in the study.

Data Analysis

All quantitative data were analysed using SPSS Version 10. The proportional stratified sampling design allowed approximately equal precision in the estimation of the parameter of different grade nurses. The cross tabulation and chi-square test of independence were used to identify significant differences in the percentages across categories for the various populations of nurses. Correlation was analysed using One-way Anova and Univariate Analysis of all Variances to determine significance among all the variables (ratio, designation, qualification, department, age, years of experience, class status and total satisfaction score).

RESULTS

Four hundred and sixty-seven valid questionnaires were returned. Table 1 shows the demographic profile of the subjects. The majority of subjects were in the 20 to 29 age group (60.6%). The majority were also senior staff nurses and staff nurses (66.4%). All subjects had at least one year of working experience. Their professional qualifications ranged from Certificate to Master’s in nursing, however 0.1% did not answer this question. Of the 467 nurses, almost half (46.9%) were working in general medical wards. The majority (66.2%) was practicing in purely subsidised wards, 20.2% in purely paying wards, 13.5% in both subsidised and paying wards, while 0.1% did not answer this question.

Table 1. Demographic profile of subjects.

There was no significant difference in the nurse-to-patient ratio for the various designations (r=0.249, p=0.164, N=462) and qualifications (r=0.686, p=0.658). There was a negative correlation between qualification and designation (p=0.016).

The results showed 66.7% of the respondents were satisfied with the working environment, out of whom 50.8% expressed insufficient manpower. The remaining 33.3% of respondents were dissatisfied, citing "insufficient manpower", "heavy workload" and "work stress" as the main reasons. In addition, 60% of subjects felt there was insufficient manpower to deliver quality nursing care, 87% felt that nurses’ qualification and working experience affected the quality of nursing care, 74.3% felt there was insufficient time to participate in patient education most of the time, 72.5% felt that non-subsidised patients had more demands on nursing care than subsidised patients, and 60% were able to attend to patients’ call bell promptly (Table 2). The most frequently selected optimal nurse-to-patient ratio was 1:3 to 1:4 across all the general wards (Table 3).

Table 2. Nurses’ perspectives on meeting requirements influencing patient satisfaction.

Table 3. Optimal nurse staffing level for 12 patients as rated by nurses.

When using one-way ANOVA, ratio is not significant as p=0.483, while when using univariate analysis, ratio (p=0.059) and designation (p=0.014) were significant predictors of total satisfaction score (Tables 4 and 5). There was a negative relationship between ratio and designation with total satisfaction score. Qualification was found to be a significant predictor of the total satisfaction score in this study (p<0.05). Age, ward department, ward class status and years of experience were significant predictors of the total satisfaction score at p<0.05, p=0.009, p=0.023 and p=0.015, respectively (Table 4).

Table 4. Relationship between total satisfaction score and all variables.

Table 5. Univariate analysis of variance.

DISCUSSION

Shortage of nursing staff has become a global issue.² Due to the shortage of nurses, unlicensed personnel are hired to reduce the workload of nurses.

Studies have shown that the inability of nurses to deliver quality nursing care due to insufficient staffing leads to frustration and anger in both nurses and patients.^3-5 Studies have also shown that insufficient staffing will result in a low level of patient satisfaction in nursing care.^1,6,7

McKenzie et al found that having qualified staff led to high levels of patient satisfaction.⁸ A study by Irurita found that patients defined quality nursing care in terms of the amount of attention they received and the level of genuine interest that nurses showed in them as a person.² From the patients’ perspectives, it was important that the nurses had enough time to talk to them. Patient education is also a very important factor in ensuring patient satisfaction.²

In this study, although 50.8% of respondents expressed that manpower was insufficient for delivering quality nursing care, they were nonetheless happy with the current working environment. This could have been influenced by factors such as good interpersonal relationship with colleagues, positive professional attitude, good teamwork, adequate facilities and good leadership.

This study showed a negative correlation between qualification and designation. The majority of the nurses of lower designation employed from overseas hold at least a Bachelor’s degree in Nursing in their own country. In contrast, the basic requirement to be a qualified registered nurse in Singapore is a Diploma in Nursing.

Staff of higher designation had a lower satisfaction score. This could be because these staff bear more duties and responsibilities, or have higher expectations of nursing care. They felt that they had insufficient time to attend to the patients’ call bell or participate in patient education. They also expressed unhappiness over the "lack of manpower", "heavy workload" and "pressure from their supervisors and patient’s relatives". Further study is needed to explain this more clearly and scientifically.

Years of experience was a significant predictor of total satisfaction score (p=0.015). A possible reason is that experienced nurses had higher expectations of nursing care than novice nurses. Further study is needed to explore this in depth.

In this study, nurse-to-patient ratio was found to be a significant predictor of total satisfaction score. The lower the ratio, the lower the total satisfaction score. Nurse-to-patient ratio is not equally implemented across the various departments. At present, the nurse-to-patient ratio is 1:6 in all general wards except oncology ward (including haematology ward), which is 1:4. Nurses working in surgical wards had lower total satisfaction scores than those in medical wards (p<0.005). That could have been due to low nurse-to-patient ratio, less contact time with the patients and high turnover.

Nurse-to-patient ratio was also not equally implemented across different ward classes. Nurses working in subsidised wards had a lower satisfaction score. Possible reasons may be low nurse-to-patient ratio, poor working conditions and heavy workload. It was interesting that nurses working in the medical oncology ward (including haematology ward) had a higher satisfaction score. Further study is needed to determine whether this was due to the higher nurse-to-patient ratio of 1:4.

LIMITATIONS OF THE RESEARCH

This research study was intended to find out the positive relationship between nurse staffing level and nurses’ perspective of patient satisfaction of quality nursing care in an acute hospital. Although response rates were high in this study, bias still existed as the respective ward nurse managers distributed the questionnaires. This could be improved by engaging a neutral party to distribute the questionnaires and provide an area for the respondents to complete them. The attitude of the respondents and non-respondents may differ markedly on certain issues, which was difficult to control. Gender was not considered as a co-variable in this study as male nurses were minorities and may not have made a great impact on differences between groups.

CONCLUSION

It is important to note that the conclusions drawn from this project are context specific. Patients’ satisfaction of quality nursing care from nurses’ perspective was proportionate to nurse staffing level. The recommended nurse patient ratio by the nurses is 1:3 or 1:4. There were other co-variables, which are more significant, such as, ward department and qualification.

Controlling all the co-variables in order to find out the accurate significance between nurse staffing level and patients’ satisfaction of quality nursing care needs further study.

REFERENCES