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J Nurs Care Qual Vol. 23, No. 4, pp. 316–321 Copyright c© 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Effect of Patient-Centered Care on Patient Satisfaction and Quality of Care

Debra M. Wolf, PhD, RN; Lisa Lehman, BSN, RN; Robert Quinlin, MD; Thomas Zullo, PhD; Leslie Hoffman, PhD, RN, FAAN

A clinical randomized study (posttest design) was conducted to examine whether patient-centered care (PCC) impacts patient satisfaction, perception of nursing care, and quality of care. Differences were seen in 2 of 3 subscales within the Baker and Taylor Measurement Scale. The PCC group rated satisfaction (P = .04) and quality of services (P = .03) higher than controls. PCC may impact patients’ perception of the level of satisfaction and quality of care received. Key words: model of care, nursing outcomes, patient-centered care, patient satisfaction, quality of care

P ATIENT-CENTERED CARE (PCC), also known as individualized care or negoti-

ated care, focuses on the individuality of a pa- tient to determine interpersonal approaches and nursing interventions.1 Lyon2 believes PCC focuses on the patient’s right to have his or her values and beliefs respected as an indi- vidual. This respect is viewed as part of a com- mitment to build a deep understanding of the patient’s perspective of own health status and related care. As an individual, a person has a right to respect, dignity, and care that focuses on the person and the situation, but not the disease process.3

This adaptation to a patient’s personal needs requires the nurse to be flexible, re- spectful, and reciprocal when providing pa- tient care. If the patient’s expectations are not

Author Affiliations: University of Pittsburgh Medical Center – St. Margaret, Pittsburgh, Pennsylvania (Drs Wolf and Quinlin and Ms Lehman); Department of Acute/Tertiary Care, School of Nursing (Drs Zullo and Hoffman), University of Pittsburgh, Pittsburgh, Pennsylvania; and Center of Excellence for Bariatrics, University of Pittsburgh Medical Center St. Margaret (Dr Quinlin).

Corresponding Author: Debra M. Wolf, PhD, RN, 2370 Trimble Rd, Pittsburgh, PA 15237 (6wolfs@ comcast.net).

Accepted for publication: November 21, 2007

appropriate to the type of care needed to heal or if the patient refuses or denies a specific type of treatment that is known to influence the quality of care, the nurse should negotiate with the patient. Negotiation allows the nurse and the patient to define a level of treatment that is specific to the patient’s needs but still seen as a quality indicator.2 A person-centered model of care requires a nurse to work with an individual’s beliefs, values, wants, needs, and desires.4 The goal is a plan of individualized care that develops as a consequence of nurse- patient interaction.1

The Institute of Medicine (IOM) has listed PCC as 1 of 6 national quality aims for improvement.5,6 The IOM’s vision is that all healthcare professionals will be educated to provide and deliver PCC as part of an in- terdisciplinary team.5 In its 2001 report, the IOM recommends a variety of approaches to achieve this vision, such as appropri- ate training, research, public reporting, and leadership.5,6

The aims of this study were to examine (a) the effect of PCC on patients’ satisfac- tion; (b) the effect of PCC on patients’ qual- ity of care; and (c) the relationship of pa- tients’ perception of nursing care on patient satisfaction. We hypothesize that PCC admin- istered by nurses will improve a patient’s level

316

Effect of Patient-Centered Care on Patient Satisfaction and Quality 317

of satisfaction and quality of care received at discharge more than patients receiving only usual care.

Several studies7–9 have been conducted that examine the impact of PCC as a result of physician-patient engagement. Little et al7

investigated patients’ preferences for a patient-focused approach in primary care consultation. Using a pre- and postsurvey of 824 patients, they found that 88% to 99% of the patients agreed good communication was needed, 77% to 87% agreed partnership was needed, and 85% to 89% believed health promotion was important for good physician- patient relationship and positive outcomes. Overall, patients preferred a patient-focused approach with their physicians, as did pa- tients in other studies examining PCC in this context.8,9

At present, there is little evidence to sup- port the critical role nurses play in providing PCC and satisfying patients’ needs.3 In 1985, Swan et al10 conducted marketing research to determine whether one’s intent to revisit the same hospital was affected by patient percep- tions of the quality of nursing care or overall level of satisfaction at discharge.10 More re- cently, Wolf et al11 surveyed cardiac patients to determine whether perceptions of nurs- ing care directly affected patients’ level of sat- isfaction. Both studies10,11 showed a moder- ately strong relationship between perceptions of nursing care and patient satisfaction. Find- ings from these studies10,11 provide prelimi- nary support for the assertion that a patient’s perception of hospital performance positively impacts expectations and intent to return to the same hospital in the future. Schmidt12 ex- amined, from the patient’s perspective, the relationship between nurse staffing and pa- tient outcomes. Schmidt found that a relation- ship existed between a patient’s perception of nursing care and the patient’s overall level of satisfaction during the hospital experience. This study provides preliminary evidence that a relationship exists between perception of nursing care and patient satisfaction.

Potentially, PCC may result in improved patient satisfaction through changes in the

way nursing care is delivered. Nurses need evidence-based research to support the vital role they play in providing quality care to pa- tients. Without this evidence, nurses lack sup- port for the centrality of their role in patient care. Although these studies13,14 suggest that nursing care influences patient satisfaction, the strength of this conclusion is limited by the correlational designs used in the research. No studies were identified that used a random- ized design to evaluate the impact of PCC on patient satisfaction or quality of care, with the exception of one study that was conducted in a skilled care facility.15

METHODS

This study used a randomized posttest de- sign. Potential participants scheduled to un- dergo gastric bypass surgery from June 2006 to September 2006 were introduced to the study at a routine office visit and asked to pro- vide informed consent. A convenience sample of 36 participants was obtained; of these, 18 were randomized to the PCC group (interven- tion) and 18 to the usual care group (control). Eligibility criteria included the following: (a) age greater than 18 years, (b) scheduled for bariatric bypass surgery, and (c) expected hos- pital length of stay of 2 days or more. Study participants were masked to treatment assign- ment for the duration of the study. Only the nurses administering the intervention and in- vestigators were aware of group assignment. The study was approved by the university’s in- stitutional review board, and all patients gave informed consent.

Participants randomized to PCC group were called 24 to 48 hours before the scheduled admission by nurses trained in providing PCC and interviewed to determine their expectations during their hospital stay, identify any concerns, and answer questions. The same nurses provided care during the hospital admission. The usual care group re- ceived traditional care routinely administered within the hospital setting. Usual care in- cluded standard hospital policy/protocols for

318 JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2008

admission and discharge with no contact before hospital admission. Both groups com- pleted questionnaires designed to measure patient satisfaction and perceptions of nurs- ing care at hospital discharge and contacted via phone 24 to 48 hours postdischarge to complete a structured interview.

PCC intervention

Nurses who provided PCC received 10 hours of education that focused on enhanc- ing communication, negotiation, and patient education to improve the interaction between nurses and patients. The training included role-playing to further develop skills and con- fidence. During the preadmission call, the PCC nurses obtained information from the pa- tient that identified his or her perceptions, goals, concerns, and fears regarding hospital- ization. This information was used to initiate the patient’s plan of care before hospital ar- rival. During their hospital stay, participants in the PCC group were actively involved in planning their daily activities/plan of care, es- tablishing daily goals, and planning for their transition to home. To ensure integrity of the intervention and minimize possible contami- nation, participants in the PCC and usual care groups were placed in rooms in 2 geograph- ically separated hallways. Nurses educated to provide PCC cared for participants in the PCC group only, and these nurses had no interac- tion with participants in the usual care group. Likewise, the usual care nurses cared for pa- tients in the usual care group only. Every ef- fort was made to limit contact between PCC and usual care nurses. This activity was moni- tored by the unit director who was part of the investigational team.

Age and years of experience did not differ significantly between PCC nurses (n = 6) and usual care nurses (n = 20). Nurses who pro- vided PCC had an average age of 38.7 years (SD = 9.2) in comparison with 40.1 years (SD = 11.8) for those providing usual care (P = .80). Those providing PCC had 12.0 years of experience (SD = 8.5) in comparison with 7.6 years of experience (SD = 9.0) for those pro- viding usual care (P = .30).

Instruments

Patient satisfaction was operationally de- fined as the degree to which patients expe- rience services in an acute care hospital set- ting and find the experiences acceptable to their preadmission expectations. The Baker and Taylor Measurement Scale (BTMS)16 was selected to measure patient satisfaction. This 7-item questionnaire included 7 possible op- tions for each question that ranged from 1 (strongly disagree or poor) to 7 (strongly agree or excellent). The tool includes 3 subscales: (a) purchase intentions (meaning one’s intent to return for additional services), measured by 2 questions with a possible to- tal range of response being 2 to 14 (Cronbach α = .91)16; (b) quality of services, measured by 2 questions with a possible range being 2 to 14 (Cronbach α = .72)16; and (c) sat- isfaction with services, measured by 3 ques- tions with a possible range of response be- ing 3 to 21 (Cronbach α = .71).16 Higher scores suggest greater satisfaction. The BTMS originally contained 99 items, which assessed the relationship between service quality, pur- chase intention, and customer satisfaction in a community-dwelling sample.16–18

Quality of care was operationally defined as a patient admission that lacked the oc- currence of infections (any positive culture obtained during hospital stay that was not present before admission), falls (any docu- mented fall that occurred during hospital stay), and a length of stay of more than 3 days (determined from medical records). Data collected from the medical record as a sec- ondary measure of quality included postoper- ative complications that occurred up to 7 days postdischarge.

Perception of nursing care was opera- tionally defined as the patient’s preestablished thoughts/ideas or beliefs regarding his or her care during the hospital stay. The Schmidt Perception of Nursing Care Survey (SPNCS)12

was selected to measure patient satisfaction. This 15-item questionnaire included 5 options for each question that ranged from 1 (strongly disagree) to 5 (strongly agree). The tool con- tains 4 subscales: (a) seeing the individual

Effect of Patient-Centered Care on Patient Satisfaction and Quality 319

patient, measured by 5 questions with a pos- sible range of scores from 5 to 25 (Cronbach α = .92)12; (b) explaining actions, measured by 3 questions with a possible range of scores from 3 to 15 (Cronbach α = .84)12; (c) re- sponding to needs, measured by 3 questions with a possible range of scores from 3 to 15 (Cronbach α = .92)12; and (d) watching over patients, measured by 4 questions with scores that could range from 4 to 20 (Cronbach α = .92).12 High scores suggest greater satisfaction.

Structured interview guides were used to guide preadmission and postdischarge inter- views. The guides ensured consistency dur- ing the interview process and wording of in- terview questions. Information obtained dur- ing interviews ranged from patients’ expecta- tions, concerns, or perceptions about the hos- pital experience before admission to feelings of satisfaction postdischarge.

Data analysis

Data were analyzed using SPSS (Version 14, SPSS, Inc., Chicago, Illinois). Descriptive statistics were used to describe sample demo- graphics, quality-of-care indicators, and com- plications for both control and PCC groups. Multivariate analysis of variance was used to compare scores on the BTMS and the SPNCS at postdischarge. A significance level of .05 was used when conducting 2-sided hypothe- sis testing.

RESULTS

Patients were predominately female, white, married, and on average 45.9 years of age (SD = 14.5; range = 22–70 years). No statis- tically significant differences were observed between the PCC and the usual care groups with respect to age, gender, race, marital status, or existing comorbidities. No statisti- cally significant differences were observed be- tween treatment groups for hospital length of stay, incidence of postoperative infection, falls, or complications such as renal failure, gastric bleeding, atrial fibulation, and post-

operative adhesions. This lack of difference between quality indicators could have been supported by the balance between nurses in age and years of experience when caring for both groups. Although a slight difference was present in years of experience, it was not statistically different. Participants in the PCC group tended to have a slightly higher inci- dence of preoperative diabetes (n = 6, 33.3%) than the usual care group (n = 4, 22.2%); however, the difference was not statistically significant.

No statistically significant differences were found between groups when measuring “overall satisfaction” (BTMS score, P = .14). However, a significant difference was ob- served with patients in the PCC group, rat- ing their satisfaction of services (M = 11.44, SD = 3.07, P = .04) and quality of services (M = 17.11, SD = 4.56, P = .03) higher than participants in the usual care group.

No statistically significant differences were observed between groups when measuring both “overall level of satisfaction with nursing care” (SPNCS score, P = .21) and individual levels of satisfaction about how the nurse (a) responded to one’s needs, (b) explained pro- cedures, (c) watched over patients, and (d) saw patients as individuals.

DISCUSSION

The purpose of this randomized controlled study was to examine the effects of PCC on patients’ level of satisfaction and quality of care received and the relationship of patients’ perception of nursing care to satisfaction at discharge from an acute healthcare setting following gastric bypass surgery. Patient satisfaction and quality of services were rated more highly by participants in the PCC group. This difference likely resulted from the intervention, which involved specialized education the PCC nurses received.

An additional important consideration relates to perceptions of those involved in carrying out the intervention. PCC nurses verbalized their roles as being more satisfying. On average, a PCC nurse estimated spending

320 JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2008

10 to 20 minutes more with each patient, which did not affect ability to complete daily routines/assignments. Preadmission interviews allowed nurses to initiate the PCC intervention before patient arrival and develop the plan of care with an improved understanding of patients expectations, per- ceptions, and concerns about their hospital stay. Participants in the PCC group were able to verbalize any additional needs such as edu- cation and questions about various processes and where to report the day of surgery. The preadmission calls were an attempt to make the patients feel welcomed, comfortable, less anxious, and actively engaged in their care, making their overall hospital experience more positive. Key concerns identified during preadmission calls centered on pain manage- ment, successful surgery, and expectations of staff. Postdischarge interviews allowed the PCC nurses to assess the ease of transition to home, answer questions, explore perceptions about preparation for discharge, and assess the overall hospital experience. Unfortu- nately, because of miscoding of the postdis- charge interview form, responses could not be separated by randomized groups.

While significant differences were ob- served in subscale scores for satisfaction and quality of services, significant differences were not seen in overall total scores, a find- ing that could be contributed to the small sample size. Also, no differences were ob- served in scores reflecting patients’ percep- tions with nursing care. In retrospect, this out- come might have resulted from the choice of units. The institution in which the study was conducted is recognized as a Center of Excel- lence for Bariatric Surgery wherein nursing care had been tailored over the past 2 years to meet the unique needs of this population. Future studies comparing outcomes on units that do not have this focus may show greater differences between groups.

If patient perceptions of quality and satis- faction can be influenced by PCC on a unit that is noted as a Center of Excellence, one could question what the effects would be on a general medical-surgical unit. Of importance,

PCC can be incorporated into every health- care environment for little cost. It can be in- troduced using mini workshops to strengthen one’s communication skills, as done in this study, allowing nurses in surgical areas, medi- cal, clinical offices, and other settings to indi- vidualize their care to a greater extent.

Current research is limited on PCC used by nurses in an acute tertiary setting to compare findings of this study. A study15 conducted in 2004 examined whether training nursing as- sistants in a person-centered approach during showering and with towel bathing would im- prove caregiving behaviors for nursing home residents with cognitively impairment. The training reduced aggressive behavior of the el- derly individuals by 53% to 60% in the PCC group in comparison with 7% in the usual care group.15 The study used a person-centered ap- proach that addressed the individual likes and needs of each person (such as using favorite soaps and distracting residents with food).

Patient experiences and level of satisfaction may influence one’s decision to return to a particular hospital. Healthcare organizations have placed critical value on bottom-line prof- its; therefore, the concept of patient satisfac- tion has emerged as a measure of tremendous and multifaceted importance.19 Future stud- ies are needed to continue to explore how PCC affects patients’ outcomes when used by nurses in various settings.

Limitations

This study was subject to several limita- tions. First, because of the nature of the vari- ables being studied, only a posttest design was possible. Although less rigorous, there was no way to measure patient satisfaction or quality of care received before admission. Second, be- cause all patients were admitted to the same unit, there could have been diffusion of the intervention. A number of steps were taken to minimize this potential. The unit has 3 hall- ways that are geographically separated, which facilitated the ability to separate the groups. Patients in both the PCC and the usual care groups were assigned to a separate hallway and assignments were structured so that care

Effect of Patient-Centered Care on Patient Satisfaction and Quality 321

was received only from group-matched nurses on all shifts and days of the week. Although a limitation, the choice of one unit ensured that both groups received a similar level of care and were managed by the same surgeon. Fi- nally, the small sample size (total n = 36) lim- its the ability to generalize the findings.

SUMMARY

Historically, the investigation and use of PCC has been explored from a physician- patient experience rather than a nurse-patient

experience. This study reported on an inno- vative way of caring for patients. By focus- ing on each patient’s individual needs, nurses can work collaboratively with patients to de- velop a plan of care that best meets patients’ needs while improving their level of satisfac- tion and quality of care. Although the sample size was small, the results of this pilot study suggest that PCC affects patients’ perception of the level of satisfaction and quality of care. A larger sample size is needed to examine the impact nurses have on patient outcomes us- ing the PCC model.

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3262  |  wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2019;28:3262–3270.© 2019 John Wiley & Sons Ltd

Received: 9 November 2018  |  Revised: 18 April 2019  |  Accepted: 2 May 2019

DOI: 10.1111/jocn.14903

O R I G I N A L A R T I C L E

Improved patient satisfaction 2 years after introducing person‐ centred handover in an oncological inpatient care setting

Anna Kullberg RN, PhD, Nursing Development Manager1  | Lena Sharp RN, PhD, Head of Department2,3 | Hemming Johansson MSc, Statistician1 | Yvonne Brandberg PhD, Psychologist1 | Mia Bergenmar RN, PhD, Assistant Professor1,4

1Department of Oncology‐Pathology, Karolinska Institutet, Stockholm, Sweden 2Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden 3Regional Cancer Centre Stockholm‐ Gotland, Stockholm, Sweden 4Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden

Correspondence Anna Kullberg, Department of Oncology‐ Pathology, Karolinska Institutet, Stockholm 171 76, Sweden. Email: [email protected]

Abstract Aims and objectives: To investigate patients’ satisfaction with care, 2 years after the introduction of person‐centred handover (PCH) in an oncological inpatient setting, and to describe patients’ perceptions of individualised care. Background: To obtain higher levels of patient satisfaction, bedside nursing hando‐ vers have been evaluated with positive results. One such model is PCH, which blends aspects of person‐centred care with the bedside report and provides the opportunity for nursing staff and patients to perform the handover together. Design: A survey‐based design was used with one data collection period. Patient satisfaction scores were compared with baseline data from a previous study that has been conducted in the same wards. Method: Patient satisfaction was measured with the EORTC IN‐PATSAT32 question‐ naire, and individualised care was assessed with the Individualized Care Scale. A total of 120 adult patients with cancer were invited to participate from August 2017– March 2018. Of these, 90 chose to participate. The STROBE checklist for cross‐sec‐ tional studies was used when preparing the paper. Results: Compared to the previous study, statistically significant improvements in patient satisfaction were observed in the subscales “Exchange of information be‐ tween caregivers” and “Nurses’ information provision” postimplementation of PCH. Regarding patients’ perceptions of individualised care, the highest scores were in the ICS‐A subscale “Clinical situation” and ICS‐B “Decisional control,” while “Personal life situation” scored the lowest overall. Conclusions: Person‐centred handover seems to have sustainable positive effects on important outcomes regarding patient satisfaction. A novel finding is the positive impact on nurses’ information provision, indicating that PCH can facilitate effective information exchange between patients and nurses. Relevance to clinical practice: Person‐centred handover seems to improve patients’ satisfaction with nurses’ provision and exchange of information. Nurses and manag‐ ers should carefully consider the implementation process of PCH and evaluate its long‐term effects. PCH can be recommended in the oncology inpatient setting.

     |  3263KULLBERG Et aL.

1  | INTRODUC TION

The importance of transforming health care to further promote patients’ influence and participation has been widely described, both in terms of health

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