PATIENT SATISFACTION has always been

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1 Nurs Admin Q Vol. 37, No. 2, pp Copyright c 2013 Wolters Kluwer Health Lippincott Williams & Wilkins Can and Should Nurses Be Aware of Patients Expectations for Their Nursing Care? Donna L. Reck, PhD, RN, NE-BC Patients expectations for their care have long been identified as a critical factor in patient satisfaction that has become a decisive element in hospital reimbursement. But the standard definition of expectations as the level of care patients imagine they would receive in the ideal hospital setting may be off the mark. Most patients do not enter the ideal hospital, so we need to focus on patients expectations of their real nurses in the actual hospital they are entering. Nurses who are aware of patients expectations of them may have a distinct advantage in influencing patients expectations and thus positively affect patients level of satisfaction with their nursing care. The author discusses what changes may need to occur to shift our focus toward the advantages of nurses becoming aware of patients expectations and reports on her initial efforts to study nurses awareness of patients expectations of them. Key words: nurses awareness, patients expectations, patient satisfaction, satisfaction with nursing care PATIENT SATISFACTION has always been intrinsically important to health care providers, but its fiscal importance to providers and institutions has grown enormously in recent years. The steady rise in the measurement of patient satisfaction as an indicator of quality care has placed greater accountability on health care professionals to accurately gauge and monitor the efficiency and quality of services. In fact, measuring patient satisfaction has become essential to any institution s ability to survive in today s fiercely competitive environment. For several decades now, it has been suggested that health care organizations improve their competitive advantage in the marketplace by better understanding and appreci- Author Affiliation: BMC Associates, LLC, Arlington, Virginia. The author received no funding in support of this study. The author declares no conflict of interest. Correspondence: Donna L. Reck, PhD, RN, NE-BC, BMC Associates, the Penthouse, 3000 Spout Run Pkwy, Arlington, VA (dreck@bmcassociates.com). DOI: /NAQ.0b013e e03 ating the notion of consumer assessment of quality, thus increasing satisfaction, utilization of service, and revenues. 1,2 The evidence strongly suggests that patients with high satisfaction with care are more likely to return and continue to use the medical services. 3,4 In 2006, nursing researcher Naomi Ervin 5 noted that patient satisfaction has been measured, explored, examined, dissected, and thoroughly written about for several decades and was the subject of close to 2000 articles during the previous 30 years. Assessing patient care in hospitals is complex because of the large number of variables that affect care and the difficulty associated with measuring nursing care directly. 6 Over the past decades, researchers and clinicians have become increasingly focused on patients perspectives on illness and quality care. From a policy perspective, understanding patients concerns, expectations, and perceptions is important for the measurement of health care quality, the delivery of health services, and the costs of care delivery. 109

2 110 NURSING ADMINISTRATION QUARTERLY/APRIL JUNE 2013 PATIENT SATISFACTION WITH NURSING CARE The greater focus on patient satisfaction has meant a shift away from relying solely on clinical outcomes such as pressure ulcers, falls, mortality, and morbidity and resulted in more research on the other components of patient satisfaction. 7-9 Of the many studies examining a plethora of independent variables affecting patient satisfaction, only a small percentage has focused on the impact of nursing care. Nonetheless, some studies have found satisfaction with nursing care to be the most important predictor of overall satisfaction with hospital care Given this link between patient satisfaction and quality nursing care, it is not surprising to learn that patient satisfaction is generally found to be high in organizations where there are good relationships between nurses and patients. 14 Characteristics of a good relationship include mutual understanding, respect, trust, honesty, cooperation, and humor. 15 The initial contact with the patient is especially important for the development of a good relationship and the patient s level of confidence in the nursing care and the organization. 16 This demonstrated importance has made satisfaction with nursing care a critical issue in today s competitive health care environment, which places a premium on demonstrated effectiveness and public accountability To improve the quality of nursing care, the nurse needs to know what factors influence patient satisfaction. Laschinger and colleagues wrote that patient satisfaction has emerged as an important indicator of health care quality that has implications for the survival of health care organizations and the well-being of patients under their care. 20(p245) The research on patient satisfaction with nursing care was hampered for a long time by the lack of good instrumentation. Most measures of patient satisfaction had failed to capture key nursing activities and thus were poor indicators of nursing care. 21 The items found on instruments such as SERVQUAL and Press Ganey assess many aspects of the hospital environment, from equipment to the aesthetics of the hospital. The work done by Laschinger and colleagues is largely responsible for addressing this deficiency. With studies in 2003 and 2005, Laschinger and colleagues 4,20 developed a 19-item instrument that focuses exclusively on nursing behaviors from patients perspective. They were able to demonstrate that the Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ), which was developed from the Patient Judgments of Hospital Quality Questionnaire, showed excellent psychometric properties and a strong relationship with overall satisfaction with the quality of care received during hospitalization. 4,20 The PSNCQQ added specificity to a range of nursing care activities across the entire patient care process, from admission to discharge, in order to produce results that would be actionable and therefore able to inform quality improvement initiatives. PATIENTS EXPECTATIONS AND PATIENT SATISFACTION Patients expectations have been shown to be an important factor in patients eventual satisfaction with their care, 22 but this factor has not been studied in depth. Some have referred to it as the blind spot in patient satisfaction. 23 The match between patients expectations of care and the actual care they receive has been used as one definition of patient satisfaction. 10,24-26 More recently, an operational definition of patient satisfaction was offered by Mrayyan as the degree to which nursing care meets patients expectations in terms of art of care, technical quality, physical environment, availability, and continuity of care, and the efficacy/outcomes of care. 27(p226) Research findings have shown that if expectations exceed actual performance, dissatisfaction will result. 25,28,29 Therefore, having knowledge of patients expectations of the care they will receive should improve patient satisfaction.

3 Nurses Awareness of Patients Expectations of Nursing Care 111 PATIENTS EXPECTATIONS WITH THEIR NURSING CARE Early researchers of patients expectations used tools that tapped into patients views about the ideal care they could imagine at the ideal hospital instead of their views about the real care they thought they were about to receive at the actual hospital they were entering. This author hypothesized that patients base their satisfaction with nursing care not on an ideal experience but on their real hospital experience, so similarly, patients expectations will be based on their actual, expected hospitalization, not an ideal one. Given the importance of nursing care in patients satisfaction, it is critical to study patients expectations with respect to nursing care. A descriptive, correlational, mixedmethods research design was used to examine the relationships between 2 predictor variables (patients expectations before hospitalization of the nursing care they anticipated receiving, and nurses assessments of patients expectations of care) and the outcome variable (patient satisfaction with nursing care). The study used the PSNCQQ developed by Laschinger and colleagues, 4 along with 2 other instruments. Since no tool had been devised to assess patients expectations of their anticipated nursing care, the researcher made modifications to the existing PSNCQQ to create a questionnaire to measure patients expectations with nursing care (Patient Expectations for Nursing Care Quality Questionnaire, or PENCQQ) so that it inquired about care that was about to happen instead of care that had already been received. NURSES AWARENESS OF PATIENTS EXPECTATIONS As important as patients expectations of their care are, little is known about how aware nurses are of their patients expectations regarding the care they will receive. A greater understanding of patients expectations for care could help nurses better individualize the care they provide and thus promote more positive patient outcomes and satisfaction. Given this, the author/researcher wanted to learn whether nurses are aware of their patients expectations, that is, without having access to data from a tool such as the PENCQQ. Another questionnaire to measure nurses assessments of their patients expectations (Nurse Assessment of the Patient Expectations Questionnaire) was also created. This modification allowed the researcher to measure nurses assessment of patients expectations of the care they would receive. Dr Laschinger (oral communication, March 2008) stated that she was unaware of anyone either modifying the PSNCQQ to examine patients expectations with their nursing care or attempting to assess nurses awareness of patients expectations for their nursing care. RESULTS Nurses ability to influence patients satisfaction with their care goes beyond their ability to provide care. It includes nurses ability to influence and shape patients expectations regarding the care they will receive. This study was the first to ask nurses to rate their understanding of their patients expectations for nursing care. The relationships between these ratings and (1) their patients expectations for their care and (2) their patients satisfaction with their care were examined. The results showed a moderate relationship between patients expectations (measured by the PENCQQ) and patient satisfaction with their care (measured by the PSNCQQ). The researcher constructed a scatterplot diagram of the correlation between expectations and satisfaction, and divided it into 4 quadrants (Figure 1). If the concordance correlation coefficient was extremely significant then a clear and simple relationship would exist: The higher a patient s expectations for their care, the higher would be their satisfaction. And conversely, the lower a patient s expectations, the lower their eventual satisfaction. All of the data points, which represent individual patients scores on the two questionnaires, would fall on or close to the diagonal line

4 112 NURSING ADMINISTRATION QUARTERLY/APRIL JUNE 2013 Figure 1. Scatterplot of patient expectations (Patient Expectations for Nursing Care Quality Questionnaire) and patient satisfaction (Patient Satisfaction with Nursing Care Quality Questionnaire) showing the 4 quadrants. that represents a perfect correlation. In this perfect case all of the subjects data points would fall in the lower left quadrant (where 1 equals high expectations and high satisfaction) or the upper right quadrant (where 5 equals low expectations and low satisfaction). The reality of patient expectations and satisfaction with nursing care is not that simple, of course. The vast majority of the patients fall into the lower-left quadrant because they entered the hospital with fairly high expectations and left feeling fairly highly satisfied. The study found a moderate correlation between patient expectations and satisfaction so we know many of these subjects fell reasonably close to the diagonal line in the scatterplot. Nonetheless, many lie a distance from the line and diminish the correlation. Interestingly though, some of these are still desirable in terms of outcomes. For example, those in the upper left corner of this quadrant who came in with lowto-moderate expectations left with relatively high satisfaction. It should be noted that the concordance correlation coefficients for the questionnaires are based on the average of each subject s responses to the 19 questionnaire items, not the scores on the individual items themselves. Is a nurse s assessment of a patient s expectations for nursing care a predictor of that patient s satisfaction with nursing care after discharge? This study s findings did not demonstrate agreement, or a significant correlation, between (1) the patients satisfaction for their nursing care (PSNCQQ) and (2) nurse assessments of patient expectations (NAPEQ; Figure 2). Nurse-patient agreement regarding patient s expectations may be a mediating variable in the study of patient satisfaction. It would be important to better understand exactly how it influences patient satisfaction. With a greater understanding of the importance of nurse-patient agreement, nurses could more positively influence patient satisfaction. DISCUSSION This research addresses a gap in the literature that had not been investigated before. Prior to this study, researchers had relied on a definition of patient expectations that was not really about patient s expectations for the

5 Nurses Awareness of Patients Expectations of Nursing Care 113 Figure 2. Scatterplot of patient expectations (Patient Expectations for Nursing Care Quality Questionnaire) and nurse assessment of patient expectations (Nurse Assessment of the Patient Expectations Questionnaire). care they were about to receive. A significant development reported here is the development of two measures, one allowing patients to rate their expectations for nursing care and another allowing nurses to provide their assessment of patient s expectations. This study takes a step toward a new, more complex understanding of the role patients expectations may play in determining patient satisfaction. While more research is clearly needed on both of these new measures, the PENCQQ holds promise for being a conceptual improvement over previous methods of assessing patients expectations. While patient satisfaction has been defined in terms of patient expectations for a long time, 14,27,30 now researchers can look at patients expectations, nurses assessments of patients expectations, and patientnurse congruency in a new light. Looking closely at the four quadrants relating patients expectations and satisfaction helps to demonstrate that old formulations tying high satisfaction with high expectations were an oversimplification. It may be productive for certain expectations to be high, (eg, nurses will provide an atmosphere of peace and quiet) providing nurses can meet those expectations. If not however, nurses would do well to help a patient adjust her expectations downward. Low expectations are easier to exceed than high expectations, but that does not mean patients should be encouraged to harbor low expectations. In some situations, low expectations could harm eventual satisfaction. For example, if a patient has a low expectation for how well nurses will keep her informed about her condition, it may help her to learn sooner rather than later that this is not the case. Knowing this sooner could lower the patient s anxiety and improve her experience. In the study reported here, nurses were asked for the first time to rate their assessment of patients expectations. They were asked to do this blind, ie, without any access to the patients ratings of their expectations. The question arises, What if nurses could routinely have access to patients expectations with a simple tool like the PENCQQ? What if they could review each patient s scores and decide which expectations would be good to reinforce and most importantly, which would be good to try to adjust either upward or downward? Just providing nurses with patients completed PENCQQs would likely sensitize nurses to the importance of patients expectations, but it is hard to imagine the education or the benefit would stop there. It is important to identify what patients expect of hospital nursing care, ideally before they begin their hospitalization, and long before measuring their satisfaction. This study may help demonstrate that nurses, health care providers and administrators might be able to better understand what patients are thinking of their nursing care and services even before their hospitalization gets underway. Imagine patients reactions to being asked about what they expect in their pending hospitalization. With this information, nursing administrators and managers can educate patient care staff to the importance and advantage of seeing care through the patient s eyes 31 and heighten caregivers sensitivity to patient expectations and satisfaction issues. Hospitals today feel great pressure not only to measure patient satisfaction but also to

6 114 NURSING ADMINISTRATION QUARTERLY/APRIL JUNE 2013 positively influence it. With information about patients expectations for their care, hospital leaders should be better able to monitor patients needs and consider designing and implementing strategies for addressing specific areas of concern for improvement and enhancing nurses awareness of patient expectations. These findings reinforce the importance of understanding patients expectations, patient satisfaction, and the critical role that nursing care plays in achieving patient satisfaction. 22 A better understanding of patient satisfaction with nursing care could result in better patient experiences in hospitals, greater satisfaction, improved outcomes, and an improved financial bottom line. REFERENCES 1. Liu Y, Wang G. Inpatient satisfaction with nursing care and factors influencing satisfaction in a teaching hospital in China. J Nurs Care Qual. 2007;22(3): Otani K, Kurz RS. The impact of nursing care and other healthcare attributes on hospitalized patient satisfaction and behavioral intentions. JHealthc Manag. 2004;49(3): ; discussion Elder R, Neal C, Davis BA, Almes E, Whitledge L, Littlepage N. Patient satisfaction with triage nursing in a rural hospital emergency department. JNurs Care Qual. 2004;19(3): Laschinger HS, Hall LM, Pedersen C, Almost J. A psychometric analysis of the patient satisfaction with nursing care quality questionnaire: an actionable approach to measuring patient satisfaction. JNursCare Qual. 2005;20(3): Ervin NE. Does patient satisfaction contribute to nursing care quality? JNursAdm.2006;36(3): Yellen E. The influence of nurse-sensitive variables on patient satisfaction. AORN J.2003;78(5): Bond S, Thomas LH. Measuring patients satisfaction with nursing care. JAdvNurs. 1992;17(1): Lynn MR, McMillen BJ, Sidani S. Understanding and measuring patients assessment of the quality of nursing care. Nurs Res. 2007;56(3): Tomlinson JS, Ko CY. Patient satisfaction: an increasingly important measure of quality. Ann Surg Oncol. 2006;13(6): Abramowitz S, Cote AA, Berry E. Analyzing patient satisfaction: a multianalytic approach. QRB Qual Rev Bull. 1987;13(4): Cleary PD, Keroy L, Karapanos G, McMullen W. Patient assessments of hospital care. QRB Qual Rev Bull. 1989;15(6): Greeneich D. The link between new and return business and quality of care: patient satisfaction. ANS Adv Nurs Sci. 1993;16(1): Nelson EC, Larson C. Patients good and bad surprises: how do they relate to overall patient satisfaction? QRB Qual Rev Bull. 1993;19(3): Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry. 1988;25(1): Mitchell R, Leanna JC, Hyde R. Client satisfaction with nursing services. Evaluation in an occupational health setting. AAOHN J. 1999;47(2): Irurita VF. Factors affecting the quality of nursing care: the patient s perspective. Int J Nurs Pract. 1999;5(2): Dozier AM, Kitzman HJ, Ingersoll GL, Holmberg S, Schultz AW. Development of an instrument to measure patient perception of the quality of nursing care. Res Nurs Health. 2001;24(6): Shore MF. Empowering individuals as carers of their own health. World Hosp Health Serv. 2001;37(2):12-16, 33, Wagner D, Bear M. Patient satisfaction with nursing care: a concept analysis within a nursing framework. JAdvNurs. 2009;65(3): Laschinger HK, Almost J, Tuer-Hodes D. Workplace empowerment and magnet hospital characteristics: making the link. JNursAdm. 2003;33(7/8): Chang K. Dimensions and indicators of patients perceived nursing care quality in the hospital setting. J Nurs Care Qual. 1997;11(6): Bacon CT, Mark B. Organizational effects on patient satisfaction in hospital medical-surgical units. JNurs Adm. 2009;39(5): Rozenblum R, Lisby M, Hockey PM. Uncovering the blind spot of patient satisfaction: an international survey. BMJ Qual Saf. 2011;20(11): Linder-Pelz SU. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16(5): Ludwig-Beymer P, Ryan CJ, Johnson NJ, Hennessy KA, Gattuso MC, Epsom R, et al. Using patient perceptions to improve quality care. J Nurs Care Qual. 1993;7(2): Risser NL. Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nurs Res. 1975;24(1): Mrayyan MT. Jordanian nurses job satisfaction, patients satisfaction and quality of nursing care. Int Nurs Rev. 2006;53(3):

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