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Keywords:

  • general linear modelling;
  • nursing care;
  • nurses;
  • organisation;
  • person-related conditions;
  • quality of care QPP

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices

Aims and objectives.  To describe patients’ perceptions of quality of care and to explore combinations of person-related and external objective care conditions as potential predictors of these perceptions.

Background.  Several studies have examined various single factors of person-related and external objective care conditions in relation to quality of care. None of these has included the effect of over-occupancy on patients’ perception of quality of care. Furthermore, little is known about how combinations of different factors are related to each other and to the perception of quality of care using multivariate analysis.

Design.  A cross-sectional design.

Method.  A total of 528 patients (83·7%) from 12 medical, surgical or medical-surgical wards in five hospitals in Norway participated. Perceptions of quality of care and person-related conditions were measured with the ‘Quality from Patient’s Perspective’ instrument. Data on external objective care conditions was collected from ward statistics provided by head nurses. Multivariate general linear modelling was used (p < 0·05).

Results.  The combination of person-related and external objective care conditions revealed five factors that predict patients’ perception of quality of care. Three of these are person-related conditions: sex, age and self-reported psychological well-being and two of them are external objective care conditions: RNs (headcount) on the wards and frequency of over-occupancy. These five factors explained 55% of the model. Patients rated the quality of care high.

Conclusions.  Sex, age, psychological well-being, frequency of over-occupancy and the number of RNs are important factors that must be emphasised if patients are to perceive the quality of care as high.

Relevance to clinical practice.  Head nurses and healthcare authorities must continually prepare the wards for over-occupancy and they must consider the number of RNs working on the wards.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices

Patients’ experiences of the quality of care have become a topic that is discussed in the healthcare services (Thorne et al. 2002, Danielsen et al. 2007). Regulations and laws have strengthened patients’ rights in the healthcare systems in western countries (Gut et al. 2004, Turris 2005), including Norway (Ministry of Health and Care Services 1999, Danielsen et al. 2007). The healthcare authorities now require that healthcare institutions establish systems to obtain feedback from patients on hospital wards, so that the feedback can be used in quality work on the wards (Bjertnæs et al. 2005, The Norwegian Directorate of Health 2005, Turris 2005). Surveys of patient experiences with healthcare service quality are conducted regularly in several countries, to give healthcare authorities information from a patient perspective (Bjertnæs et al. 2005). Quality of care experiences can be seen as an endpoint in quality evaluation (Jenkinson et al. 2002, Danielsen et al. 2007) and they may affect health status, willingness to recommend and willingness to return to the same healthcare provider (Da Costa et al. 1999, Vedsted & Heje 2008, Wilde-Larsson & Larsson 2009, Otani et al. 2010).

‘Quality of care’ is a multidimensional concept and can be seen as a measure of patients’ experiences of the quality of the healthcare encounter: this is the perceived reality of the patients. The patients’ perceptions of what constitutes quality of care are formed by their system of norms, expectations and experiences and by their encounter with an existing care structure (Wilde et al. 1993). Factors that influence the perceived quality of care can be classified into two broad areas: person-related conditions and external objective care conditions.

Person-related conditions

Several studies have examined the effects of sex and obtained substantially different results. Some studies have found that women have poorer scores than men (Danielsen et al. 2007), while others found that sex is unrelated to patients’ perception of quality of care (Wilde Larsson et al. 1999). Elderly patients tend to rate the quality of care higher than younger patients (Jackson et al. 2001, Jenkinson et al. 2002, Vukmir 2006, Danielsen et al. 2007). Awarding high scores for quality of care is often associated with lower levels of education (Da Costa et al. 1999, Danielsen et al. 2007). However, one study has shown that the perception of quality of care improves with increased educational status (Vukmir 2006). Health status also affects the patients’ perception of quality of care: patients in better health tend to evaluate the quality higher than patients in poor health (Jenkinson et al. 2002, Danielsen et al. 2007). Patients with better physical health are more likely to rate the quality of care higher than patients with poorer physical condition (Da Costa et al. 1999, Jackson et al. 2001, Westaway et al. 2003, Henderson et al. 2004). Both Da Costa et al. (1999) and Westaway et al. (2003) found that patients with better psychological well-being give higher ratings to the quality of care. Emergency admissions and previous number of inpatient stays are negatively associated with the rating given to the quality of care (Danielsen et al. 2007).

External objective care conditions

Studies have shown that different models of nursing care have an impact on patients’ ratings of quality of care. Specialist nursing care is significant for patients’ evaluation of quality of care on a neurosurgical ward (Thorne et al. 2002), while the model of organisation into primary nursing (characterised by extensive responsibilities for named nurses) or team nursing (characterised by extensive responsibilities for a group of patients) does not affect the quality of care (Sjetne et al. 2009). The competence of staff is important for the quality of care (Henderson et al. 2004), as is how well the staff are organised (Vukmir 2006). Staffing with higher qualified nurses (RNs) is a significant predictor of high quality of care (Otani & Kurz 2004, Cho et al. 2009, Tervo-Heikkinen et al. 2009, Otani et al. 2010) and is closely related to bed numbers (Aiken et al. 2002a). As early as 1957, Abdellah and Levine discovered a positive link between the availability of more hours of professional nursing service in hospitals and the patients’ perception of quality of care. Higher scores for the quality of care (Wilde et al. 1994) and for the quality of nursing care (Findik et al. 2010) have been given by inpatients who have experienced longer hospital stays.

Several studies have examined various factors of person-related and external objective care conditions and their relationships with the quality of care. Studies have investigated how hospital size affects patients’ perception of quality of care (Danielsen et al. 2007). However, no studies have investigated the effect of changing wards while hospitalised, or the impact of over-occupancy on patients’ perception of quality of care. Nurse staffing levels may be inadequate to provide safe and effective care during over-occupancy and the risk of burnout and job dissatisfaction among the RNs may increase, which in turn affect the patients’ perception of quality of care (Aiken et al. 2002b, Cho et al. 2009, Tervo-Heikkinen et al. 2009).

Most studies have used univariate analysis to explore the relationship between single factors and patients’ perception of quality of care. All of these factors, however, interact and co-vary with inpatients’ perception of quality of care. RNs must pay attention to all of the factors. Little is known about how combinations of factors are related to each other and to the perception of quality of care. Multivariate analysis of combinations of factors may give results that are closer to the actual situations in hospitals than univariate analysis gives. The aim of the study, therefore, was to describe the patients’ perceptions of quality of care and to explore combinations of person-related and external objective care conditions as potential predictors of these perceptions.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices

Design

A cross-sectional design was used. Patients completed one questionnaire which measured the patients’ perception of quality of care (perceived reality) and person-related conditions.

Participants

A consecutive sample of patients at eight medical, three surgical and one mixed medical/surgical ward in five hospitals in Norway took part in this study. The hospitals were chosen to be representative of the complete country. Hospital locations ranged from rural to city-university. Patients meeting the following inclusion criteria were invited to participate: (1) the person should be 18 years or older, (2) should understand Norwegian and (3) the person’s mental and physical health should be such that it was ethically justifiable to invite him or her to participate. The sample consisted of 631 patients discharged from the hospitals from May 2008–April 2009, which was 10% of all discharges from the studied wards. A total of 528 patients (83·7%) agreed to participate. Answers from 60 patients were excluded from the analyses because of incomplete questionnaires. The analyses are therefore based on 468 respondents with complete questionnaires.

Instruments

Patients’ perception of actual care was measured with the Quality from Patient’s Perspective (QPP) which is a patient-centred questionnaire derived from an empirically based theoretical model of patients’ perception of quality of care (Wilde et al. 1993, 1994). The model was developed using a grounded theory approach (Wilde et al. 1993) and operationalised into the QPP questionnaire using a conventional factor analytical approach (Wilde et al. 1994). To further validate and develop the instrument, a dimensional analysis of all items was performed using structural equation modelling (Larsson et al. 1998). A short version of the QPP was developed because patients found the original instrument too long (Wilde Larsson & Larsson 2002). The short version – in Norwegian – was used in the current study. The questionnaire consisted of 24 items divided into four dimensions/scales: (a) The medical-technical competence of caregivers (four items), which comprised personnel qualifications, knowledge and proficiency and their ability to make a correct diagnosis and give necessary treatment. (b) The identity-oriented approach of the caregivers (12 items), which included emphatic skills of caregivers when meeting the patient as a unique person and the ability to show interest in and commitment to the persons’ needs and wishes. This dimension is characterised by a symmetrical relationship between patient and caregiver. (c) The physical-technical conditions of the care organisation (three items), which considered such aspects as whether the environment was clean, comfortable and safe and the availability of medical-technical equipment. (d) The socio-cultural atmosphere of the care organisation (five items), which comprised how closely the surroundings resembled a home, rather than an institution, where patients’ needs and wishes had priority over fixed routines (Wilde et al. 1994). One item about the information concerning the effects and use of medicines was added to the identity-oriented approach dimension in the study. An index was calculated for each dimension by adding the item scores in that dimension and dividing by the number of items answered in it. See Appendix 1 for overview of items in each dimension/scale.

Each item was evaluated by perceived reality (PR) and subjective importance (SI). Only perceived reality ratings were used in the present study. The perceived reality of each item described the patients’ perception of the actual care received. The items were related to the sentence: ‘This is what I experienced …’ (for example, ‘I had good opportunity to participate in decisions regarding my medical care’). A four-point response scale ranging from 1 (‘Do not agree at all’) – 4 (‘Completely agree’) was used for responses. Each item also had a ‘Not applicable’ response alternative. Cronbach alpha coefficients measuring internal consistency of the dimensions/scales in the current study were 0·62 for medical-technical competence, 0·87 for identity-oriented approach, 0·54 for physical-technical condition and 0·73 for socio-cultural atmosphere. These are similar to those found in a previous study: 0·67 for medical-technical competence, 0·91 for identity-oriented approach, 0·65 for physical-technical condition and 0·72 for socio-cultural atmosphere (Wilde Larsson & Larsson 2002).

Person-related conditions comprised eight items from the QPP (Wilde Larsson & Larsson 2002); sex, age, education (compulsory school, upper secondary school, or university), hospital admission (scheduled or emergency), former stay in hospital (yes or no), changing wards during the episode of care (yes or no) and the patients’ self-rated health condition in response to: ‘How would you describe your present physical health condition?’ and ‘How would you describe your present psychological well-being?’ using a five-point scale ranging from 1 (‘Very poor’) – 5 (‘Very good’).

External objective care conditions comprised five items based on a literature review: ‘How many registered nurses (RN) (headcount), are working on the ward?’; ‘How is nursing care organised (model) in the ward – primary nursing, team nursing, specialist nursing, or mixed team nursing/ specialist nursing?’; ‘How many beds are on the ward?’; ‘What is the average length of patient stay on the ward?’; and ‘Frequency of over-occupancy – Never, Seldom, Weekly, Always?’

Procedure

One RN on each ward working day-time was responsible for giving information and the questionnaire to the patients. On the day of the patient’s discharge or the day before, the RN gave patients who satisfied the inclusion criteria both oral and written information about the study. Patients who agreed to take part in the study received the questionnaire. Patients were instructed to return their completed questionnaire together with their written, informed consent in a sealed envelope to the responsible RN before discharge. Data were not collected during summer and Christmas holidays since wards were often merged during these periods.

Data on external objective care conditions were collected from ward statistics by head nurses who received the questions by e-mail. The first author received the data by ‘phone three to four days later or shortly after data collection ended. These data were related to each patient staying on the 12 wards. The head nurses in each ward also collected data from ward statistics about the inpatient’s age, sex and duration of stay during the data collection period, to be able to compare the sample with the general population.

Ethical considerations and approval

The study was approved by The Regional Committee for Medical Research Ethics in East Norway and by Norwegian Social Science Data Services. It was also approved by the head administration of the hospitals taking part in the project. The responsible RN on each ward assessed whether the patient’s physical and mental health was in a condition that made it ethically justifiable to invite the patient to participate. The patients received both oral and written information and they were required to give their written, informed consent to participate. The patients could withdraw from the project whenever they wanted without any consequences. Confidentiality was secured according to the ICN’s ethical guidelines for nursing research (International Council for Nurses 2003).

Statistical analysis

spss version 17.0 was used to analyse the data. The descriptive statistics mean and standard deviation were used to describe the study sample and patients’ perceptions of the quality of care. Chi-square tests and t-tests were run to compare the study sample with the total number of patients staying on the study wards during the data collection period and with the respondents whose answers had been excluded from the analyses because of incomplete questionnaires.

Multivariate general linear models (GLM) were used (Altman 1999, Field 2005, Tabachnick & Fidell 2007). The aim was to explore how much of the variance in the dependent variable (which consisted of the four perceived reality dimensions/scales) could be explained by the combination of the independent variables: person-related and external objective care conditions. GLM was chosen for analysis because the dependent variable was multivariate and consisted of four strongly correlated dimensions/scales (r between 0·52–0·73) (Cohen 1988): the caregivers’ medical-technical competence, the identity-oriented approach, the care organisations’ physical-technical conditions and the socio-cultural atmosphere. Rao’s F-approximation of Wilks’ lambda (Rao 1952, Field 2005) was used to test how much the independent variables in the model predicted the dependent variable, in the light of the level of inaccuracy of the model. Statistically significance is found when F-approximations are large and at least greater than 1. A good model, thus, has large F-approximations. The value of Wilks’ lambda ranges between 0–1 and small values correspond to greater statistical significance.

GLM analyses were conducted in three steps. The first GLM analysis was run on the combination of factors in the person-related conditions (sex, age, education, hospital admission, former stay in hospital, changing wards, physical health condition, psychological well-being) to identify factors with a statistically significant impact on the four dimensions/scales of the dependent variable. The second GLM analysis was run on the combination of factors in the external objective care conditions (RNs (headcount), model of nursing care, bed numbers, average of patient stay, frequency of over-occupancy), again to identify factors with a statistically significant impact on the dependent variable. The third GLM analysis was run on the statistically significant factors from the first and second GLM analyses (sex, age, education, physical health condition, psychological well-being, RNs (headcount), model of nursing care, frequency of over-occupancy) to identify potential predictors of the dependent variable. Statistical significance was set at p < 0·05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices

Characteristics of the patients

The results are based on 468 patients. Among the respondents, 48% were admitted to hospital after scheduled admission and 52% after emergency admission and 21% had been hospitalised during the last month, while 79% had not been to hospital. Regarding the distribution of patients on clinics, 65·6% stayed on medical wards, 29·3% on surgical wards and 5·1% on the medical-surgical ward. The RN/bed ratio ranged between 0·68–1·64. The average length of stay on the ward was 5·4 days (SD 7·3 days). Person-related and external objective care conditions in relation to patients involved in the study are presented in Table 1.

Table 1.   Description of respondents’ person-related and external objective care conditions
Variablen (%)M (SD)
  1. *Scale ranges from 1 (Very poor) – 5 (Very good).

Person-related conditions
Sex
 Men216 (46) 
 Women252 (54) 
Age 57·1 (16·3)
 Education level  
 Compulsory school145 (31) 
 Upper secondary school190 (40·6) 
 University133 (28·4) 
Health condition
 Self-reported physical health condition* 3·54 (0·87)
 Self-reported psychological well-being* 4·01 (0·82)
 Frequency of changing wards 2·55 (1·0)
External objective care conditions
 Model of nursing care  
 Primary nursing126 (26·9) 
 Team nursing164 (35·0) 
 Specialist nursing 108 (23·1) 
 Mixed team nursing/ specialist nursing 70 (15·0) 
RNs (headcount) 26·4 (9·8)
Ward beds 23·6 (5·7)
RN/Ward beds 1·1 (0·28)
Inpatient stay 5·4 (7·3)
Over-occupancy
 Never68 (14·5) 
 Seldom161 (34·4) 
 Weekly180 (38·5) 
 Always59 (12·6) 

Only patients who completed questionnaires were included in the analysis. There were no statistically significant differences regarding sex, ward type and length of stay between the sample and excluded patients, nor between the sample and all inpatients. The sample was, however, younger than the excluded patients (t = 3 ·801, p < 0·001) and also younger than all inpatients (t = 15·316, p = 0·042) during the study period.

Patients’ perception of quality of care: perceived reality

The mean score of the medical-technical competence was 3·53 (SD 0·56), of the identity-oriented approach 3·49 (SD 0·53), of the physical-technical conditions 3·52 (SD 0·60) and of the socio-cultural atmosphere 3·52 (SD 0·56).

Impact of person-related and external objective care conditions on patients’ perception of quality of care analysed by GLM

The first GLM analysis (Table 2) showed that the factors sex, age, education level, self-reported physical health condition and self-reported psychological well-being (five out of eight factors) in the person-related conditions had statistically significant impacts on the dependent variable (consisting of the four perceived reality dimensions/scales). The second GLM analysis (Table 3) showed that the factors number of RNs, models of nursing care and over-occupancy (three out of five factors) in the external objective care conditions had statistically significant impacts on the dependent variable.

Table 2.   The impact of person-related conditions on the four dimensions/scales of patients’ perceived reality (n = 468)
Multivariate tests
Independent variablesWilks’ LambdaRao’s FHypothesis dfError dfp
Person-related conditions
 Sex0·9554·9924·00425·000·001
 Age0·9278·3954·00425·000·000
 Education level0·9592·1488·00808·000·021
 Self-reported physical health condition 0·9585·2784·00425·000·000
 Self-reported psychological well-being 0·9495·6894·00425·000·000
 Admission type0·9970·3604·00425·000·837
 Former stay0·9901·1044·00425·000·354
 Changing wards0·9541·68912·001124·740064
Table 3.   The impact of external objective care conditions impact on the four dimensions/scales of patients’ perceived reality (n = 468)
Multivariate tests
Independent variablesWilks’ LambdaRao’s FHypothesis dfError dfp
External objective care conditions
 Model of nursing care 0·9522·03812·001304·650·018
 RNs (headcount) 0·9792·6424·00489·000·033
 Number of bed0·9940·6694·00471·000·614
 Average duration of stay0·9990·1244·00471·000·974
 Over-occupancy0·9332·85312·001294·100·001

The third GLM analysis (Table 4) showed that a combination of three person-related conditions (sex, age, self-reported psychological well-being) and two external objective care conditions (RNs (headcount) and over-occupancy] had a statistically significant impact on the dependent variable. This combination of independent variables in the final model explained 55% of the variation in the dependent variable (Wilks’ Lambda at Λ = 0·454). The combined impact of statistically significant factors in the person-related and external objective care conditions on the four perceived reality dimensions/scales is shown in Table 5.

Table 4.   The combined impact of person-related and external objective care conditions on the four dimensions/scales of patients’ perceived reality (n = 468)
Multivariate tests
Independent variablesWilks’ LambdaRao’s FHypothesis dfError dfp
  1. Final model Wilks’ Lambda: Λ = 0·454.

Person-related conditions
 Sex0·9496·1044·00451·000·000
 Age0·9318·2974·00451·000·000
 Education level0·9691·7738·00902·000·079
 Self-reported physical health condition 0·9970·3674·00451·000·832
 Self-reported psychological well-being 0·9515·7504·00451·000·000
External objective care conditions
 Model of nursing care 0·9641·40712·001193·5250·156
 RNs (headcount) 0·9752·9244·00451·000·021
 Over-occupancy0·9442·19012·001193·5250·010
Table 5.   The combined impact of statistically significant factors within person-related and external objective care conditions’ on the four dimensions/scales of perceived reality (n = 468)*
Dimensions/scales of the dependent variableIndependent variablesBFp
  1. *Factors with significance at p < 0·05 are listed in the table.

  2. Parameter set to zero because it is redundant.

Medical-technical competencePerson-related conditions
Sex 12·7520·000
 Man−0·182  
 Woman  0  
Age0·00616·9080·000
Self-reported psychological well-being0·13715·6870·000
Identity-oriented approachPerson-related conditions
Sex 10·5400·001
 Man−0·154  
 Woman  0  
Age0·00724·8300·000
Self-reported psychological well-being0·15222·0940·000
Physical-technical conditionsPerson-related conditions
 Age0·00716·0460·000
 Self-reported psychological well-being0·0225·2900·022
External objective care conditions
Over-occupancy 3·6910·012
 Never0·149  
 Seldom−0·200  
 Weekly−0·027  
 Always  0  
Socio-cultural atmospherePerson-related conditions
 Age0·0034·6450·032
 Self-reported psychological well-being 0·11911·4090·001
External objective care conditions
 RNs (headcount) −0·0105·6250·018
 Over-occupancy 2·7570·042
 Never0·275  
 Seldom0·030  
 Weekly0·024  
 Always  0  

Age and self-reported psychological well-being had statistically significant impacts on all four dimensions of patients’ perceived reality. Older patients rated the quality of care higher than younger patients. Patients who reported their psychological well-being to be low also rated the quality of care to be low on all four dimensions. Sex had a statistically significant effect on the dimensions medical-technical competence and identity-oriented approach of the caregivers. Women rated the quality of care higher than men.

Frequency of over-occupancy had a statistically significant impact on the dimensions physical-technical conditions and socio-cultural atmosphere of the care organisation. The physical-technical conditions were rated poorer when over-occupancy seldom occurred compared with when over-occupancy never, weekly or always occurred. Furthermore, the socio-cultural atmosphere dimension was rated more positively when the wards never had over-occupancy than it was rated when the wards had over-occupancy seldom, weekly or always. The number of RNs on the ward also had a statistically significant impact on the socio-cultural atmosphere dimension. Patients rated the socio-cultural atmosphere significantly more negatively when number of RNs on the wards was higher.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices

Five factors (out of 13) from the combination of person-related and external objective care conditions had a statistically significant impact on patients’ perception of quality of care. The following three person-related conditions: sex, age and self-reported psychological well-being, together with the two external objective care conditions: number of RNs in the wards and frequency of over-occupancy, predicted accurately the patients’ perceptions of quality of care and explained more than half (55%) of the model.

It was necessary to use GLM because the dependent variable consisted of four strongly correlated dimensions/scales (Tabachnick & Fidell 2007). The results demonstrate the importance of using multivariate analysis to gain meaningful and specific information about what affects the patients’ perception of quality of care. Close examination of the five significant factors of patients’ perception of quality of care gave further new and specific information, which can be used to improve healthcare delivery at the ward level.

The person-related conditions age and self-reported psychological well-being had a significant impact on all four dimensions/scales of quality of care, a result which is consistent with previous results (Wilde et al. 1995, Da Costa et al. 1999, Westaway et al. 2003, Danielsen et al. 2007). It is possible that older patients rate the quality of care higher than younger patients do since they have more life experience, tend to have more realistic expectations than younger patients and appreciate the be cared for to a greater extent (Fitzpatrick 1997). It might also be that they receive higher quality healthcare. A low rating on psychological well-being was related to a low rating of the quality of care. A patient with a low psychological well-being may assess the whole situation more critically (Wilde et al. 1994). It is, on the other hand, possible that such patients receive lower quality healthcare. The relationship between psychological well-being and the rating of quality of care is not clear. It is a question of what comes first: perception of a higher quality of care or psychological well-being. It is therefore important for RNs to be aware of the patients’ psychological well-being, so that interventions can be planned and conducted carefully to optimise the quality of the patients’ experiences when hospitalised.

Women rated the quality of care higher then men on the dimensions/scales medical-technical competence and identity-oriented approach, which are the dimensions that refer to the qualities of the caregivers. Previous studies regarding sex have been inconclusive (Crow et al. 2002). This result is difficult to interpret. Women and men have different patterns of healthcare use (Crow et al. 2002) and this may play a role in their perception of quality. Future studies need to include sex and RNs need to be aware of the impact of sex on patients’ perceptions of quality of care.

Frequency of over-occupancy has not been explored in previous studies and we have shown that it had a significant impact on two of the four dimensions/scales of quality of care. The physical-technical condition (which includes such items as technical and medical equipment and meals) was rated more poorly by those who experienced over-occupancy seldom than by those who experienced it never or always. This suggests that wards that always have too many patients have developed routines that take care of the patients’ needs. The head nurses on such wards might, for instance, have regular RNs available who have knowledge both of the patients’ diagnosis and of the ward’s routines. This may not be the case for wards that occasionally have too many patients. It might also be the case that patients see the increase in activity and ‘forgive’ lapses in quality of care. Furthermore, wards that are always over-occupied have access to the necessary technical equipment even during over-occupancy.

The scores on the socio-cultural dimension/scale (including items that are related to patients’ needs versus ward routines, how relatives were treated and atmosphere) were higher in wards that never had over-occupancy compared with wards that always, weekly and seldom, had over-occupancy. It is possible that RNs have more time to create a good atmosphere, to encounter the patients’ relatives and to base the nursing care on the patients’ needs in wards that never have over-occupancy. Tervo-Heikkinen et al. (2008) found that nurses in emergency care wards who feel less job-related stress experience a better professional nursing environment and higher levels of job satisfaction and thus create a more favourable socio-cultural environment for the patients. It is important to note that the variation in the number of patients did not affect the patients’ perception of the two dimensions/scales associated with the quality of the caregivers, which indicates that the healthcare professionals treat patients with respect, show commitment and empathy and give the patients the best possible medical care. Considering the significant impact of frequency of over-occupancy on the quality of care, future studies should include this aspect and should explore the relationship between the quality of care and the degree of occupancy on the wards.

The number of RNs (headcount) had a significant negative impact on the socio-cultural atmosphere on the wards. When the positions were filled with RNs who worked part-time, patients may had to cooperate with more individual RNs than would have been the case if the positions had been filled with RNs working full-time. It is possible that RNs who work part-time are more occupied with following the routines on the wards and are more uncertain about delivering individualised nursing care. It is also possible that the RNs do not feel quite comfortable and are uncertain of each other, because they do not know each other that well. This might influence the atmosphere on the wards. It is worth noting, however, that the dimensions/scales of medical-technical competence and identity-oriented approach (which are related to the quality of the caregivers) were not affected negatively by the fact that the RNs worked part-time. This suggests that the RNs on the wards in the present study had a high degree of competence. It also suggests that more nurses were available for the RNs to consult when they had questions concerning the patients’ care. Previous studies have shown that the team-based model of care delivery is associated with increased confidence and job satisfaction (Fairbrother et al. 2010). Previous studies that have explored the effects of various factors on the patients’ perception of quality of care have focussed on patients’ experiences with the nursing service and on the number of hours worked by RNs. These studies have not considered the number of RNs who work part-time (Abramowitz et al. 1987, Graveley & Littlefield 1992, Otani & Kurz 2004).

Education (Danielsen et al. 2007), physical health condition (Henderson et al. 2004), models of nursing care (Eriksen 1995), hospital admission (Danielsen et al. 2007) and previous inpatients stays (Danielsen et al. 2007) are all factors that other studies have found to have a significant impact on patients’ perception of quality of care. These factors did not predict patients’ perceptions of quality of care in the present study. This may be due to the issue of different measurement and analysis methods. We have used multivariate analyses and these give a deep and valid knowledge of the factors that predict patients’ perceptions of quality of care.

However, 45% of the model is unexplained. Other external objective care conditions and other person-related conditions such as patients’ expectations (Jackson et al. 2001), preferences (Wilde et al. 1993), personality and coping ability are examples of other aspects than those explored in the current study that need to be further investigated.

The patients in the current study rated the quality of care between 3·49–3·53 on the four dimensions/scales, showing that the overall view of quality of care in the Norwegian wards participating was good. Mean scores in this study are slightly more favourable than those obtained in previous studies among Swedish patients (Wilde Larsson 1999, Wilde Larsson & Larsson 1999, Wilde Larsson et al. 1999), but quite similar to the mean scores in a study that compared England, France, Sweden and Norway (Wilde Larsson et al. 2005). Patients’ general views of the quality of care in a hospital are an important starting point for quality improvement work. It has, however, been suggested (Jenkinson et al. 2002) that such general views present a limited and optimistic picture.

Limitations

It was impossible to obtain a strictly consecutive sample because the RNs were often too busy. The responsible RN had to give priority to other tasks in the ward and did not always have time to ask patients whether they were willing to participate in the study. In addition, the RN forgot to ask in some cases. The loss of respondents, however, was random and has not compromised the statistical reliability of the study. Patients were approached on different days of the week and at different times during the day; they were approached in spring, autumn and winter. The loss of 60 respondents from the GLM analysis is a further weakness of the study, but sex, length of stay and type of ward of the lost patients were comparable to those of the sample and only age differed. The 60 respondents and the average patient in hospital were slightly older than the study sample (n = 468). The difference in age between the groups suggests that the loss was not random and this may have affected the results. The oldest old were not represented to the same extent as younger patients. The RNs on the wards decided which patients to ask and only patients who were physically and mentally able to answer the questionnaire were asked. Therefore, the most ill patients did not take part in the study. Patients with mental disorders such as dementia and patients with very poor mental health were not invited to participate in the study. The results, therefore, cannot be generalised to these groups. Other studies have experienced similar problems with obtaining responses from the oldest old, the severely ill and those with language problems (Crow et al. 2002). The RNs may have had different views of a patient’s condition, so that patients included in one ward, may not have been included in another ward. The first author tried to make this effect as small as possible by giving oral information and written guidelines about the inclusion criteria to the responsible RNs.

The patients completed the questionnaire while they were still in hospital, which might be seen as a weakness. Patients may have felt obliged to answer more positively than they would have answered after discharge. To avoid this, the patients were asked to complete the questionnaire in their room and return the questionnaire in a sealed envelope. Indeed, the completion of the questionnaire while still in hospital may be a strength, because the experiences are still fresh and not biased by the passing of time (French 1981). Results that have examined the effect of survey timing are contradictory and the effect may depend on the nature of the patients’ illness and the extent of recovery (Crow et al. 2002). Cronbach alpha for the perception of quality of care dimension scales in the questionnaire ranged between 0·54–0·87 and this range was generally comparable with that found in previous studies. One exception was the Cronbach alpha for the physical-technical dimension, 0·54, lower than that found in previous studies (Wilde Larsson 1999, Wilde Larsson & Larsson 2002). On the other hand, the Cronbach alpha is lower for dimension scales that comprise fewer items (Streiner & Norman 2008). The physical-technical dimension scale included only three items. We chose to retain the dimension despite its moderate Cronbach alpha, because the dimension is one of four dimensions/scales that the dependent variable (perceived reality) consists of. The physical-technical condition dimension/scale forms, together with the other three dimensions, the theoretical model of quality of care from patients’ perspective and cannot be excluded from the analysis. Physical-technical conditions are part of the inpatients’ stay and their impact on the perceived quality of care must be explored. The results obtained, should be interpreted with care. The instrument is, however, well known and often used (Wilde Larsson et al. 2005, Rahmqvist & Bara 2010, Fröjd et al. 2011).

Relevance to clinical practice

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices

It is of great importance that both person-related conditions (sex, age and psychological well-being) and external objective care conditions (frequency of over-occupancy and RNs – headcount) should be emphasised during the patients’ stay in hospital, for the patients to perceive the care they receive as of high quality. It is important that individualised care based on the patients’ sex, age and psychological well-being is given. Head nurses and healthcare authorities must continually prepare the wards for over-occupancy and consider the employment of full-time RNs rather than part-time RNs on the ward. Too many patients in the wards will probably have a negative impact on the working situation of the healthcare professionals. Overworked personnel may have an additional negative effect on patients’ perception of quality of care (Cho et al. 2009). Arentz and Arentz (1996) and Aiken et al. (2002a) have shown that that patients’ perception of quality of care is strongly correlated with the work situation of the healthcare workers. Unions for the healthcare workers continue to fight for full-time positions for their members. At the same time, politicians and healthcare authorities continue to reduce both the number of positions and the number of beds in hospitals – a fact that might be seen as a major challenge for quality improvement work in hospitals.

Contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices

Study design: VAG, IK, MLH-L, JA, BW-L; data collection and analysis: VAG, IK, MLH-L, JA, BW-L and manuscript preparation: VAG, IK, MLH-L, JA, BW-L.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices
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Appendices

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Relevance to clinical practice
  8. Contributions
  9. Conflicts of interest
  10. References
  11. Appendices
Table Appendix1.   Short form of the Quality from Patient’s Perspective (QPP) instrument
Dimensions/scalesItems
  1. *Item added in the current study.

Medical-technical competenceI received the best possible physical care: e.g. help to take care of my personal hygiene
I received the best possible medical care (as far as I can tell)
I received effective pain relief
I received examinations and treatments within an acceptable waiting time
Identity-oriented approachI received useful information on how examinations and treatments would take place
I received useful information on the results on examinations and treatments
I received useful information on self-care, ‘How I should take care of myself’
I received useful information on which doctors were responsible for my medical care
I received useful information on which nurses were responsible for my nursing care
I had good opportunity to participate in the decisions that applied to my care
The doctors showed commitment, ‘cared about me’
The nurses and assistant nurses showed commitment, ‘cared about me’
The doctors seemed to understand how I experienced my situation
The nurses and assistant nurses seemed to understand how I experienced my situation
The doctors were respectful towards me
The nurses and assistant nurses were respectful towards me
I received useful information on the effects and use of medicine*
Physical-technical conditionsI received food and drink that I like
I had access to the apparatus and equipment that was necessary for my medical care (as far as I can tell)
I had a comfortable bed
Socio-cultural atmosphereI talked to the doctors in private when I wanted to
I talked to the nurses in private when I wanted to
There was a pleasant atmosphere on the ward
My relatives and friends were treated well
My care was determined by my own requests and needs rather than the staff’s procedures

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