Hospital nursing, care quality, and patient satisfaction: Cross-sectional surveys of nurses and patients in hospitals in China and Europe
Introduction
China is in the midst of reforming and modernizing its health care system. Much has been written about market-driven imbalances in financial incentives to doctors and hospitals that may be at odds with achieving high quality, affordable, and accessible care (Blumenthal and Hsiao, 2005, Hu et al., 2008, Yip and Hsiao, 2008). Ma (2011), Vice Minister of Health, reported that new health reform priorities include increasing patient satisfaction with health care and improving quality and safety of care.
The Joint Learning Initiative concluded that effective workforce strategies enhance health system performance (Chen et al., 2004), but there is little published empirical research to inform China's nursing workforce and nursing education policies. China has set as a goal of a hospital bed to nurse ratio of 1:0.4 (Ministry of Health China, 2005) in comparison to a median of 1:1 in OECD countries (Anderson et al., 2005). China has more doctors than nurses, contrary to global evidence that higher ratios of nurses to doctors allow for efficiency gains (World Health Organization, 2006). China also lags international norms with the majority of nurses having completed their nursing education in secondary schools (Kalisch and Liu, 2009, Xu and Zhang, 2000).
Government-sponsored reforms are underway to increase the number of nurses and improve their education. In 2007, 71% of nursing students were enrolled in secondary schools (Zhongzhuan), 22% in associate degree programs (Dazhuan), and 7% in baccalaureate programs (You et al., 2010). China's current goal is 50% enrollment in secondary schools, 30% in associate degree programs, and 20% in baccalaureate programs, demonstrating that nursing education is on the national reform agenda (Ministry of Health China, 2005). This is an improvement but still lags industrialized countries where nursing education takes place largely in post-secondary institutions.
This study provides one of the first comprehensive evaluations of nurse resources in Chinese hospitals. We examine the associations between hospital variation in nurse staffing, educational qualifications, and work environments and patients’ assessments of their hospital care experiences as well as nurse workforce outcomes.
Section snippets
Data and methods
Data reported here are from a multi-center collaborative study by the China Medical Board China Nursing Network, with comparisons drawn from RN4CAST, a similar study of hospitals in Europe (Aiken et al., 2012, Sermeus et al., 2011). The study comprises 181 Chinese hospitals distributed nationally with surveys of 9688 nurses and 6494 patients. The purpose of the study was to determine the extent to which variation in features of the nurse workforce and the organizational context of nursing
Results
As shown in Table 1, the average age of nurses was 29 years and, on average, they had been working as nurses for 8 years. The average (mean) workload was 6.8 patients per nurse per shift overall, though it was decidedly (and quite expectedly) higher for medical and surgical nurses (7.9) than for ICU nurses (2.5). Nearly all (99%) of the nurses were female. Initially, 6% received a baccalaureate degree in nursing and 32% an associate degree; at the time of the survey 21% had obtained
Discussion
Our results suggest that in China the quality of the hospital work environment is associated with nurse satisfaction and more positive patient experiences. Substantial proportions of nurses experience high job-related burnout (38%) and dissatisfaction (45%). While perceptions of low salaries (76%) are part of the picture, over 60% of nurses rate the overall quality of their work environments as only fair or poor and a third give their hospital an inadequate grade on patient safety. Our measure
Conclusions and policy recommendations
In this first comprehensive assessment of nursing and patient outcomes in hospitals in China, we conclude that nursing contributes importantly to better quality of care and more positive patient reports. Three policy recommendations emerge from the study that can inform discussions in China about how to maximize nurses’ contributions to improved hospital care. Improving patient to nurse ratios, and moving to more patient-centered organization of nursing care, may hold promise for reducing the
Acknowledgments
The authors acknowledge the contributions of Timothy Cheney, Jing Zheng, Xiao-wen Zhu, Li-feng Zhang.
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