Hospital nursing, care quality, and patient satisfaction: Cross-sectional surveys of nurses and patients in hospitals in China and Europe

https://doi.org/10.1016/j.ijnurstu.2012.05.003Get rights and content

Abstract

Background

This study provides a comprehensive evaluation of nurse resources in Chinese hospitals and the link between nurse resources and nurse and patient outcomes.

Methods

Survey data were used from 9688 nurses and 5786 patients in 181 Chinese hospitals to estimate associations between nurse workforce characteristics and nurse and patient outcomes in China. Nurse and patient assessments in China were compared with a similar study in Europe.

Results

Thirty-eight percent of nurses in China had high burnout and 45% were dissatisfied with their jobs. Substantial percentages of nurses described their work environment and the quality of care on their unit as poor or fair (61% and 29%, respectively) and graded their hospital low on patient safety (36%). These outcomes tend to be somewhat poorer in China than in Europe, though fewer nurses in China gave their hospitals poor safety grades.

Nurses in Chinese hospitals with better work environments and higher nurse-assessed safety grades had lower odds of high burnout and job dissatisfaction (ORs ranged from 0.56 to 0.75) and of reporting poor or fair quality patient care (ORs ranged from 0.54 to 0.74), and patients in such hospitals were more likely to rate their hospital highly, to be satisfied with nursing communications, and to recommend their hospitals (significant ORs ranged from 1.24 to 1.40). Higher patient-to-nurse ratios were associated with poorer nurse outcomes (each additional patient per nurse increases both burnout and dissatisfaction by a factor of 1.04) and higher likelihoods of nurses reporting poor or fair quality of care (OR = 1.05), but were unrelated to patient outcomes. Higher percentages of baccalaureate nurses were strongly related to better patient outcomes, with each 10% increase in the percent of baccalaureate nurses increasing patient satisfaction, high ratings, and willingness to recommend their hospital by factors ranging from 1.11 to 1.13.

Interpretation

Nursing is important in quality and safety of hospital care and in patients’ perceptions of their care. Improving quality of hospital work environments and expanding the number of baccalaureate-prepared nurses hold promise for improving hospital outcomes in China.

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.

References (30)

  • Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services, 2011. CAHPS hospital...
  • L.A. Giordano et al.

    Development, implementation, and public reporting of the HCAHPS survey

    Medical Care Research and Review

    (2010)
  • Institute of Medicine

    Crossing the Quality Chasm: A New Health System for the 21st Century

    (2001)
  • A.K. Jha et al.

    Patients’ perception of hospital care in the United States

    New England Journal of Medicine

    (2008)
  • B.J. Kalisch et al.

    Comparison of nursing: China and the United States

    Nursing Economics

    (2009)
  • Cited by (235)

    View all citing articles on Scopus
    View full text