Elsevier

Social Science & Medicine

Volume 47, Issue 10, November 1998, Pages 1611-1617
Social Science & Medicine

The correspondence of patient satisfaction and nurse burnout

https://doi.org/10.1016/S0277-9536(98)00207-XGet rights and content

Abstract

This study examined the relationships of nurse burnout, intention to quit, and meaningfulness of work as assessed on a staff survey with patient satisfaction with nursing care, physician care, information provided and coordination of care, and outcomes of the hospital stay assessed post-discharge. Sixteen inpatient units from two hospital sites formed the data base and included 605 patients and 711 nurses. Patients' perceptions of the quality of each of the four care dimensions corresponded to the relationships nurses had with their work. Patients on units where nurses found their work meaningful were more satisfied with all aspects of their hospital stay. Patients who stayed on units where nursing staff felt more exhausted or more frequently expressed the intention to quit were less satisfied with the various components of their care. Although nurse cynicism was reflected in lower patient satisfaction with interactions with nursing staff, the correlations between cynicism and other aspects of care fell below statistical significance. No significant correlations were found between nurse professional efficacy and any of the patient satisfaction components measured. The implications of the relationship between patient satisfaction and nurses' perception of their work is discussed.

Introduction

Staying competitive in the health care field involves assuring consumer satisfaction (Bowers et al., 1994). Changes in the way we conceptualize and practice health care has resulted in changes in the way hospitals view patients. With the competition for medical dollars, patients are seen as paying customers rather than passive recipients of prescribed procedures. The expanding role that individuals are required to fulfill in maintaining their own health includes providing feedback to medical care givers on services rendered. Their involvement and satisfaction are crucial to good health care.

Assessing the satisfaction of these customers poses a number of problems. The process usually involves asking patients for their opinions on a range of care aspects including the technical skill of care providers. Answers given to questions of technical skill may be based on emotional response rather than expertise in the medical field. In spite of increased awareness of health and medical issues, few patients have the technical knowledge required to judge hospital staff on their diagnostic skills or technical abilities. This limitation is not grounds to dismiss the concept of patient satisfaction. Satisfaction with care goes beyond assessment of technical abilities to encompass both the cognitive and affective experience.

Pascoe (1983)defined patient satisfaction as “a health care recipient's reaction to salient aspects of the context, process, and result of their service experience” (p. 189). From this perspective, patient evaluation of health service involves two psychological processes: cognitive evaluation (or grading) of the structure, process, and outcome of services, and an affective response (or emotional reaction) to the structure, process, and outcome of services. The emotional response of patients is found to be as important as their cognitive judgment of the medical encounter. Rather than being related to technical competence, satisfaction with care was related to communication, responsiveness, and reliability (Bowers et al., 1994) as well as having expectations met (Linder-Pelz, 1982; Brody et al., 1989; Gustafson, 1991; Vuori, 1991; Greeneich et al., 1992).

If hospitals are to satisfy the wide range of patient needs, wants, and expectations, assessing patient satisfaction is crucial. A large number of surveys have been developed and used to measure various aspects of patient satisfaction (van Campen et al., 1995). Patient factors considered in previous work have included patient sociodemographic variables and patients' health-related behaviors (service utilization, switching services, compliance to treatment). Service characteristics measured have included service delivery; convenience, availability, and accessibility; structural and financial aspects; provider–patient interaction (technical competence, interpersonal skills, length of interaction, continuity of care, patient–provider fit); and clinical outcomes (Pascoe, 1983).

Assessing and understanding patient satisfaction is still at an early stage of development. As many questions have been produced as have been answered by the work done thus far. A few of these concerns are presented here. The emphasis of early studies has been on survey development and validation. While adequate development is important and necessary, few studies have gone beyond this stage to explore the underlying influences on patient satisfaction (Abramowitz et al., 1987; Hall and Dorman, 1988). Also the majority of early studies on patient satisfaction have explored the impact of physician care (55%) rather than nursing care (6%), or both types of care provision (39%) (Hall and Dorman, 1988). Physician studies may provide information of interest to private practitioners (both physician and non-physician), but they offer little for hospital-based care providers. Studies have also assessed relationships with sociodemographic variables. The sociodemographic factors explored have provided few clues to the patient satisfaction question (Hall and Dorman, 1990). Overall, little is known about the formation of patient attitudes regarding satisfaction with care received, especially in the hospital setting (Strasser et al., 1993).

The argument can be made that to understand patient satisfaction with care would require focusing on nursing staff who comprise the vast majority of hospital staff and who have the greatest contact with patients. Abramowitz et al. (1987)noted that nurses act as goodwill ambassadors and frontline representatives for hospitals. Nurses, rather than physicians, are seen as responsible for the day-to-day activities on a unit. Nurses provide the main connection with patients, act as patient advocate with other care providers, give physical care to patients, and offer emotional support to both patients and families. In their teaching capacity, they also play a key role in post-hospital adjustment. The importance of the nursing role is evidenced in a number of studies.

In a large-scale survey study of over 17,000 inpatients, Carey and Siebert (1993)found that nursing care accounted for 45% of variance in overall quality of care ratings, while physician care accounted for 2% of variance beyond that explained by nursing care. In a telephone survey of 841 discharged patients, Abramowitz et al. (1987)found that of the ten sets of services examined (including physicians, nursing, housekeeping, food services), only satisfaction with nursing services related significantly to overall patient satisfaction. Satisfaction with nursing services and patient care expectations explained 24% of the variance in overall satisfaction. Satisfaction with nursing services, patient care expectations, and overall satisfaction accounted for 34% of the variance in intent to recommend the hospital to others.

The technical vs affective aspects of nursing care have also been examined in relation to patient satisfaction. Objectives that nursing managers develop to assure consistent, quality care tend to focus on physical needs, procedures, and the effective running of the unit. While meeting these objectives may be important to patient physical well-being, the objectives were generally not correlated with patient satisfaction with nursing care in a study by Eriksen (1987). In a study by Taylor et al. (1991), the importance of non-technical aspects of nursing such as caring, compassion, and communication were emphasized by patients responding to an open-ended question asking what quality nursing care is. Likewise, Bader (1988)reported that of the 15 predictor variables contributing to variance in overall satisfaction (comprising satisfaction with nursing care, intention to return if needed, and recommendation of hospital to others), three were technical instrumental activities while the rest were affective measures such as communication, kindness, and information provision.

Nurses have a unique role in the hospital setting, both from the perspective of their responsibilities and the perceptions of their patients. The variance explained in patient satisfaction by the nursing role warrants further exploration. As well, the relative importance of the affective aspects over the technical aspects of care in meeting patient expectations of quality service deserves further study. If, as suggested by the research cited, nurses influence patient satisfaction to a large extent by the affective nature of their interactions, then measuring the affective state of nursing staff may be as useful as assessing their technical ability. Thus, the issue of burnout among nursing staff becomes relevant to patient satisfaction.

Cherniss (1980)described burnout as “a process in which the professional's attitudes and behavior change in negative ways in response to job strain” (p. 5). Burnout consists of exhaustion, cynicism, and a lack of professional efficacy. Exhaustion is a measure of overextension and depletion of one's physical and emotional resources. Cynicism is characterized by an indifferent attitude towards one's work. Professional efficacy refers to a sense of professional competence and accomplishment; during burnout this sense of efficacy diminishes. Individuals experiencing burnout are less able to provide service in a consistent, caring manner. While they may still feel concern, they can no longer give of themselves as they had formerly (Maslach et al., 1996).

Burnout results from the gap between individuals' expectations to fulfill their professional roles and the structure of the organization (Leiter, 1991, Leiter, 1992b). Although organizations may agree in principal with the professional goals of their staff, the policies in place may not be supportive. Policy changes during restructuring or downsizing are designed to keep the organization viable; support for professional goals often takes a position of less importance. While this may seem necessary to administrators, there is a price to pay. When the workplace does not support professional goals, exhaustion and cynicism increase while professional efficacy decreases. Individuals become less effective in their work and less able to cope with the demands and changes in their environment (Leiter, 1992a). Staff may doubt their ability to maintain the quality of service that provided meaning in their work. Work that was once meaningful and satisfying can become the source of strain and disillusionment (Leiter, 1992b; Leiter and Harvie, 1997). When professionals experience burnout and feel unable to continue their work in a meaningful way, they are more likely to consider quitting (Jackson et al., 1986). This dissatisfaction with one's job may be reflected in the quality of care that patients receive and in patient ratings of satisfaction with care.

Burnout in nurses has been examined from the point of view of potential antecedents of nurse burnout (e.g., Maslach, 1982; Firth et al., 1987; Leiter and Maslach, 1988; Pick and Leiter, 1991; Robinson et al., 1991; Cordes and Dougherty, 1993; Kandolin, 1993; Eastburg et al., 1994). While this provides useful information regarding the possible prevention of burnout, relatively little research has been conducted on the outcomes of burnout. While it seems intuitively reasonable that burnout in nurses affects the performance of their duties and thus the satisfaction of patients in their care, the consequences of burnout in terms of patient care and satisfaction have not been explored.

The purpose of this study is to explore the correspondence of nursing staff burnout and patient satisfaction with care. In keeping with the literature reviewed on the importance of the nursing role in patient satisfaction, nurse interaction with patients is expected to influence patient satisfaction with most aspects of care. The following hypotheses are made:

(1) Nurses' scores on exhaustion will be negatively correlated with patient ratings of satisfaction with (a) nurses' care, (b) doctors' care, (c) information provided, and (d) outcomes of the hospital stay.

(2) Nurses' scores on cynicism will be negatively correlated with patient ratings of satisfaction with (a) nurses' care, (b) doctors' care, (c) information provided, and (d) outcomes of the hospital stay.

(3) Nurses' scores on professional efficacy will be positively correlated with patient ratings of satisfaction with (a) nurses' care, (b) doctors' care, (c) information provided, and (d) outcomes of the hospital stay.

(4) Nurses' scores on meaningfulness of work will be positively correlated with patient ratings of satisfaction with (a) nurses' care, (b) doctors' care, (c) information provided, and (d) outcomes of the hospital stay.

(5) Nurses' scores on intention to quit will be negatively correlated with patient ratings of satisfaction with (a) nurses' care, (b) doctors' care, (c) information provided, and (d) outcomes of the hospital stay.

Section snippets

Staff survey

Data were collected as part of an employee survey requested by hospital management to assess the impact of integration of two hospital sites. The entire range of professions and occupations participated on a voluntary basis with full encouragement from a survey team and time made available during working hours to complete the questionnaire. From 4000 potential participants (full-time staff, part-time staff, and volunteers of a 800 bed tertiary care hospital in central Canada), 3312 (83%)

Results

Cronbach's reliability alphas for all measures were quite high. To explore the integrity and distinctness of the measures, items in the scales were examined for face validity and confirmed by principal component factor analysis. Means and standard deviations for each unit for nurse measures and patient measures were calculated and used for further analysis. Table 1 displays the means, standard deviations, and Cronbach's alpha reliability values for the variables in the study. Table 2 displays

Discussion

The findings of this study add weight to previous research on the importance of nursing influence on patient satisfaction. This influence is not limited to patient satisfaction with nursing care; rather, it affects patient satisfaction with care provided by doctors, information provided and coordination of care, and outcomes of the hospital stay. These results are also in keeping with the contention that individuals completing patient satisfaction questionnaires are indicating their general

Acknowledgements

This research was supported by a grant from the Social Sciences and Humanities Research Council of Canada and from the Hamilton Civic Hospitals, Hamilton, Ontario. The researchers appreciate the contribution of Hospital staff to the staff survey. This study would not have been possible without the patient data provided by the Conference Board of Canada, Ottawa, Ontario.

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