Patient satisfaction has been evaluated as a component of healthcare quality for over 30 years since the widespread use of patient satisfaction surveys and promotion by the Centers for Medicare and Medicaid Services.1 One emerging topic in this field of research is understanding the patient as a consumer and the connection between patient expectations and satisfaction.2-7 Although studies provide important insights into this relationship, ambiguity remains regarding how satisfaction is associated with better outcomes in different healthcare settings.8,9 Additionally, patient satisfaction continues to be an important contributor to the success of the healthcare organization in terms of reimbursement and reputation, and is incorporated into health policy recommendations.10,11 In 2001, the Institute of Medicine described the role of satisfaction in patient-centered care, which was then reaffirmed in 2019 by the World Health Organization bulletin emphasizing the intersectionality between patient satisfaction, expectations, and health outcomes.12,13
Considering the majority of patients' physical and emotional care is completed by nurses, evidence suggests that satisfaction with nursing care may be the most important predictor of overall satisfaction.3,14 Patient-centered care is also a core nursing value, and nurses should be striving to surpass patient expectations as an integral part of the nursing care plan.15 Over the past decade, researchers have been investigating nurse perceptions of patient satisfaction, often uncovering a discordance between nurse and patient expectations. One study surveyed a group of ED nurses and patients on their perceptions of care, finding that patients consistently rated the care they received higher than the nurses' self-rating in each of the assessed nursing care attributes.7
Reasons for a gap in agreement may be that clinicians aren't fully aware of how significantly nursing care influences patient satisfaction or that expectations and perceptions of quality of care differ between patients and nurses. One survey study reported that only 18.3% of nurses in the US routinely asked about their patients' level of satisfaction.5 This is reaffirmed by other studies showing that only a minority of clinicians ask patients about satisfaction, representing an opportunity for leaders to promote awareness and training to address managing patient expectations.16,17 We postulate that better understanding of patient satisfaction may lead to greater nurse-patient agreement in whether patient expectations were met, which can be indicative of a deeper and more meaningful nurse-patient relationship.
Although these studies provide important feedback to nurses, there's a need to assess nurse and patient expectations in other acute care settings and increase generalizability and reliability of study findings on how perceptions of nursing care are associated with patient satisfaction.6,11,13,18 The aim of this study was to add to this knowledge base by measuring nurse and patient perceptions of three nursing care attributes: friendliness, courtesy, and respectfulness; comfort measures; and degree of information sharing.
Methods
This study was conducted on two surgical units at a Midwestern, urban, Level I trauma center: a 32-bed inpatient medical-surgical unit specializing in the care of trauma, orthopedic, neurosurgery, and general surgery patients and a postsurgical recovery unit comprising a 23-bay postanesthesia care unit/same-day surgery, which provides immediate postoperative care for all surgical specialties. Participants included in this study were discharging nurses and their corresponding patient from the ambulatory surgical setting and the inpatient medical-surgical unit. Adult patients older than age 18 from these units were included if their primary language was English, Spanish, or Polish, which are the most frequently spoken languages based on patient registration data. Patients were excluded from the study if they were in police custody or unable to consent.
The survey was based on a questionnaire created by Blank and colleagues, and permission to use this survey was obtained.7 The 13-item survey contained three questions on a Likert scale from 1 (way below expectation) to 5 (way above expectation), seven free-text questions, two yes/no questions, and one question regarding the patient's primary language. In addition, the nursing survey included questions regarding years on the unit and total years of nursing experience. To prevent participant identification, the survey administrator recorded the surgical unit and a unique identifier to pair the patient and nurse surveys.
The study was approved as exempt research by the Advocate Health Care Institutional Review Board. A convenience sample was used to collect data over a 2-week period and surveys were administered by two investigators on the day shift at the time of discharge. Interested patients and corresponding discharge nurses were given a paper copy of the informational sheet and survey. Trained research volunteers provided written documents in the patient's primary language of English, Spanish, or Polish and professional medical interpreters were used over the phone to explain the survey as needed.
A mixed-methods approach was utilized, with nurse and patient comments categorized into recurring themes using thematic content analysis.19 Descriptive statistics were summarized as frequencies and percentages for categorical variables and means and standard deviations for continuous variables, or as medians and interquartile range when the data distribution was abnormal based on the Shapiro-Wilk test. Descriptive statistics for agreement were represented in three methods: percentage of pairings in which the responses were a complete match on the Likert scale, percentage of mismatched pairings where the patient rating was lower than the nurse rating, and percentage of mismatched pairings where the patient rating was higher than the nurse rating. Wilcoxon rank-sum tests were subsequently conducted to assess differences between nurse and patient perceptions and weighted kappa statistics were calculated to test interrater reliability for each patient-nurse pair rating. The Kruskal-Wallis test was conducted in an exploratory analysis to assess any differences by patient primary language. Analysis was performed using statistical software and statistical significance was determined using a two-tailed test and P <.05.
Results
A total of 61 patients were approached to complete the survey. Two patients declined to participate, four surveys were missing from nurses, and five surveys were missing from patients, resulting in 54 nurse-patient pairs analyzed in this study. Of the 54 nurse participants, 24 (44%) had more than 5 years of experience as a nurse and 29 (54%) had more than 1 year of experience on the unit. Among corresponding patient participants, 33 (61%) were discharged from one of two postsurgical recovery units and 45 (83%) spoke English as their primary language. (See Table 1.) All but one patient could describe their nurse and 44 (85%) could name their nurse.
Our primary analysis resulted in low agreement between nurse-patient pairs, and patients were more likely to report higher ratings compared with nurses for all three nursing care attributes. Across all three attributes, less than one-third of the nurse-patient pairs selected the same exact rating. Figure 1 shows that nurse ratings for each question were significantly lower than patient ratings (4 versus 5 for friendliness, P < .001; 4 versus 5 for comfort, P < .001; and 3.7 versus 4.5 for information, P < .001). Across all attributes, weighted kappa statistics resulted in consistently low agreement (.06 [-.05, .17] for friendliness; .01 [-.09, .10] for comfort; and .11 [.0, .22] for information sharing) when compared with a weighted kappa of .50 as a benchmark for moderate agreement. When comparing median rating by attribute in Table 2, nurses and patients reported information sharing as being the lowest for meeting expectations (3.7 and 4.5, respectively). This attribute had the highest percentage of exact agreement between nurses and patients at 16 (30%).
In exploratory analysis, the Kruskal-Wallis test didn't identify any statistically significant differences in responses by patient primary language (friendliness, P = .36; comfort, P = .17; and information, P = .64). Among nurse participants, no statistically significant differences were found in responses neither by years on the unit (friendliness, P = .09; comfort, P = .17; and information, P = .84) nor years of overall experience (friendliness, P = .07; comfort, P = .35; and information, P = .14).
Using thematic content analysis for open-ended questions, responses were categorized by theme and results were aggregated by nurse or patient participants. (See Figure 2.) Four themes were identified from the nurses' responses: gaining connection and rapport, focusing on pain control, advocating for the patient, and answering questions. Patient responses also revealed four recurring themes: friendliness, encompassing kindness, caring, and compassion; explaining, including concepts of being helpful and meeting needs; attentiveness and showing concern; and comfort and timeliness in responding to pain needs.
Discussion
This study examined nurse and patient perceptions and agreement in a unique postsurgical acute care setting. Adequate reliability was demonstrated for the survey tool when comparing results with previous findings in the emergency setting, with patients consistently rating nursing care higher than nurses rated their own care across all attributes.7 Furthermore, although the level of agreement between nurses and patients was low, overall ratings for all three attributes were positive, with information sharing being the only category that wasn't considered above or way above expectations. Both qualitative and quantitative results highlight the importance of communicating information to improve the nurse-patient connection, which includes explaining procedure details, answering patient questions, and providing clear and understandable instructions and medication information.
This study also addressed a gap in the literature related to understanding patient perceptions of care at the time of discharge versus days, weeks, or months later when the patient may be asked to complete a survey. By examining both nurse and patient expectations and perceptions of the same encounter, the current research provides an enhanced understanding of the importance of identifying patients' expectations early in the hospital stay to improve patient satisfaction beyond task-based tactics, such as rounding and scripting.4
Utilizing a mixed-methods research approach, open-ended responses provided greater insight into nursing care attributes, and both quantitative and qualitative findings were found to be positive. Nurses expressed that they had a good connection with their patients, appreciated being acknowledged, and were focused on pain control and advocating for their patients. Patients expressed feeling cared for, having their needs met, and feeling compassion from their nurses.
Implications for nursing management
Human connectedness is inextricably tied to how we present ourselves to others, address pain and comfort needs, and communicate information effectively. High levels of both nurse and patient satisfaction have the potential to provide better experiences and outcomes, and a strong connection can help nurses understand and meet patient expectations as patients heal and address challenging medical needs during the hospital stay.
This research also raises the question: How does this connectedness sustain itself after acute care discharge and does it have a lasting impact on long-term satisfaction and follow-up care? In practice, where time and resource constraints exist in fast-paced environments, nurse managers can focus on the interaction points at admission and discharge to encourage personal connection, leading to better understanding of pre- and postoperative expectations. As a key element related to patient satisfaction, nurse managers can prioritize effective communication strategies.20
Although collecting patient feedback is an important hospital practice, patient satisfaction may not be discussed adequately at the unit level. Dialogue between nurse managers and clinical nurses must go beyond scores to delve deeper into nurse and patient expectations of care and solicit nurses' reflections on the quality of the patient experience.21 Nurse managers should look for opportunities to share patients' appreciation for nursing care and provide recognition when nurses are attentive to patient needs and convey information effectively. Meaningful recognition of and reflection on positive nurse-patient relationships can translate into greater nurse satisfaction and encourage a better workplace culture.22,23 Furthermore, nurse managers should engage nurses on how to be attuned to and ask about patient expectations, affirming a positive experience, making adjustments during the care stay, or assisting patients in realigning their expectations if necessary. Lastly, this study points to the significance of the nurse-patient interaction at discharge as an opportune time to create a lasting impression of nursing care.
Limitations
Limitations of this study included sample size, response bias, and time. It was estimated that a sample size of 17 participants per group would be the minimum to identify a one-point mean difference in rating, using a two-sample t-test power analysis with alpha = .05 and power of 80%. Although the sample size was large enough to identify this difference, a larger sample size would have provided more robust data and allowed for more stratifications. When administering the surveys, investigators attempted to reduce response bias by offering the survey around the time of discharge after care was complete. It was beneficial to the study to administer the survey on the hospital campus to increase participation rates and reduce recall bias. However, on-site methods may also lead to bias and possibly positive-skewed results that are subject to social desirability bias. This bias could also have been present for nurses. Despite coding the hardcopies to anonymize the survey results, the investigators thought that nurses may feel pressure to rate themselves more positively. Moreover, time and resources hindered participation. Nurse participants reported survey fatigue after completing multiple surveys per day during the 2-week data collection period and the fast-paced, high-turnover surgical service environment wasn't conducive to thoughtful and lengthy feedback.
Making a connection
This study highlights the complexity of patient satisfaction in the hospital setting. Results suggest that there's a gap between what patients are expecting and what nurses believe patients are expecting. There's an opportunity for nurses to improve their understanding of patient expectations to ensure satisfaction is met for every patient interaction, despite overall high patient satisfaction. Human connectedness remains a key underlying element for greater satisfaction among both nurses and patients. Nurses feel most satisfied when they're appreciated and their nursing care is acknowledged, whereas patients feel most satisfied when they're cared for, comforted, and heard.
INSTRUCTIONS Examining agreement between nurse and patient perceptions of nursing care attributes in the surgical setting
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