Health Science Journal

Keywords

Nurses; Hospitals; Nursing

Introduction

Today, the aim of providing health service is to provide health service with high efficiency, low cost, and high quality. Lack of any increase in efficiency and performance, any decrease in medical mistakes, and any increase in patient satisfaction levels despite the increased budget allocated for health spending in many countries have made the changes in health management obligatory [1,2]. Factors like accurate diagnosis and treatment services to meet patients’ expectations, clean and fully equipped hospital setting, smiling healthcare professionals are evaluated as elements of quality in health [3]. The attitudes and behaviors of the healthcare providers and the past experiences and expectations of the service receivers constitute the personal quality perception. The combination of the perceived quality with the quality at technical level determines the overall quality level as low or high. According to the service quality model developed by Parasuraman et al. [4], the perceived service quality is defined as the difference between the individuals’ perceptions and expectations; on the other hand, experiences, needs and communication are emphasized to be the important factors influencing the expectations of individuals. As quality becomes a managerial philosophy, some quality management systems have been developed in order to guide or perform self-control for health institutions in practice. Whether or not the health institutions have reached the specified standards are confirmed by the documents/certifications given by independent organizations.

In the study conducted by Ozucelik [5] to evaluate the information level of the personnel before and after the accreditation, it was determined that while the most positive comments made by the participants about the changes were on drug system and patient rights, the most negative comments about the changes were on the work load regulation and employee rights. It was stated in the study conducted by Greenfield et al. [6] about the benefits of the accreditation that the changes occurred mostly in the organization of nursing services and in the building safety of the hospital, communication among the personnel developed, and personnel management and development were supported in the hospitals receiving the accreditation certificate. While it is stated that doctors experience difficulties in the accreditation perception and compliance all over the world, nurses are seen to be involved in almost all stages of accreditation and adopt the quality works [5].

Background: Nursing profession throughout the world is one of the key determinants of success in delivering healthcare services. Ertem and ve Sevil [7] stated in their study that nursing care given in accordance with the standards increased the patient satisfaction and the quality was an effective way to reach the aimed result measures. Since the nurses spend 90% of their time to provide care to the patients while providing healthcare services, the effects of nursing care are important in getting the quality certificate and maintaining the quality studies [8]. It is emphasized that the experienced nurses play an important role in quality improvement works and in application, control, and maintenance of the accreditation process [5]. For this reason, it is thought in this study that the nurses, who observe/apply the change, occurring in the hospital management and patient care through quality studies, in the best way, will provide guidance in multidimensional evaluation of these studies.

For this reason, it was aimed to answer the following questions in this study:

1. How are the quality perceptions of nurses?

2. What are the personal factors affecting the quality perceptions of nurses?

3. What are the occupational factors affecting the quality perceptions of nurses?

4. What are the organizational factors affecting the quality perceptions of nurses?

Methods

This study was designed as cross-sectional to determine the perception of the nurses about the quality and the factors affecting this perception. In order to conduct the study, ethics approval (Date: 20 February 2015 and No: 99950669/55) from the Ethics Committee of Turgut Özal University and permissions from the hospitals constituting the sample were taken. In addition, written consents were obtained from the nurses who agreed to participate in the study.

Population and sample of the study

The population of the study consisted of nurses working in three hospitals affiliated with a university receiving the quality certificate (JCI and/or ISO), a private hospital and a hospital of the Ministry of Health in Ankara province. A total of 1415 nurses work in these hospitals. By using the formula of sample selection with known population, the sample size was determined as 301 at confidence interval of 95% and deviation of 5% and distributed to the hospitals by their weights.

Data collection tools used in the study

Two forms were used as data collection tools in this study:

Personal Questionnaire: This form prepared by the researchers to determine the quality perception of the nurses consists of two parts. There are 10 questions in the form about the personal characteristics of the nurses such as age, education, marital status and about their organizational characteristics such as their working time in the profession and institution and the quality studies conducted in the institution.

Quality Perception Scale (QPS): There are very few instruments in the literature for healthcare institutions, especially in the context of assessing quality practices and outcomes. There is no tool available worldwide for healthcare facilities. In our work we used scales developed in previous studies.

It was developed by Bayer and Baykal [9] in 2016 to measure the quality perception of the healthcare professionals and its validity and reliability study was conducted. The scale consists of 70 items and seven subscales. It was determined that the Cronbach’s alpha reliability coefficients of the scale were 0.90 in overall scale and varied between 0.78 and 0.97 in the subscales.

The subscales of the scale “management and leadership” (12 items), “the use of human resources” (14 items), “quality training” (6 items), “assessment and evaluation” (6 items), “benefit of institution” (10 items), “benefit of employee” (8 items), “benefit of patient” (14 items) are evaluated in 5-point Likert scale and scored as follows; “1” for “I strongly disagree”, “2” for “I disagree”, “3” for “I partially agree”, “4” for “I agree” and “5” for “I strongly agree”. The total score to be taken from the scale varies from 20 to 100. While low total score taken from the scale and its subscales signifies that the quality perception of the individual is negative, high total score signifies that the quality perception is positive.

Data Collection

The data of the study were collected between November and December 2015 based on self-report of the individuals. After the nurses who agreed to participate in the study were given necessary explanations (the purpose of the study and data collection tools) by the researcher going to the institutions, the forms were delivered and collected back about a week later.

Data Analysis

The data of the study were analyzed using SPSS 0.20 software with the support of a statistical consultant. Data from the study were analyzed exploited by Shapiro Wilk. The interpretation of the results is 0.05. Mann Whitney U test, Kruskal Wallis-H test analyzes to test the independent variables.

Results

Accordingly, it was determined that the majority of the nurses were working in the adult hospital of the university (43%), surgical units (44%) and as service nurses (81%), 53% were in the age group of 31 years and over, 90% were female and 63% had bachelor’s degree, 39% had a total working duration of 11 years and more in the profession, and 47% had a total working duration of 1-5 years in the institution (Table 1).

Table 1 Distribution of the personal and professional status variables of the nurses (n: 301).

Characteristics		Number (n)	%
Age	25 years and younger	30	9.97
	26-30	109	36.21
	31 years and older	162	53.82
	Total	301	100
Gender	Female	272	90.37
	Male	29	9.63
	Total	301	100
Educational Status	Health vocational high School	42	13.95
	Associate Degree	44	14.62
	Bachelor’s Degree	191	63.46
	Graduate Degree	24	7.97
	Total	301	100
Institution	Children’s Hospital	47	15.61
	Oncology Hospital	35	11.63
	Adult Hospital	132	43.85
	Hospital of Ministry of Health	48	15.95
	Private Hospital	39	12.96
	Total	301	100
Unit	Internal medicine	118	39.21
	Surgical	134	44.52
	Special Branch	43	14.29
	Other	6	1.99
	Total	301	100
Position	Service Nurse	245	81.4
	Nurse Manager	56	18.6
	Total	301	100
Working Duration in the Institution	1-5	143	47.51
	6-10	89	29.57
	11 and more	69	22.92
	Total	301	100
Working Duration in the Profession	1-5	87	28.91
	6-10	96	31.89
	11 and more	118	39.21
	Total	301	100

Table 2 shows the distribution of the “Quality Perception Scale” total score and the subscale mean scores of the nurses. Their total mean score of KPS was determined to be at high level (=65.41 ± 13.61). When the subscale scores of the scale were examined, it was found that while “Quality Training” subscale had the highest mean score (=68.54 ± 18.37), the “the use of Human Resources” subscale had the lowest mean score (=58.12 ± 16.76) (Table 2).

Table 2 Distribution of the quality perception scale total and subscale mean scores of the nurses (n: 301).

Scale and Subscale Scores	n	Mean	Median	Min	Max	sd
Management and Leadership	301	66.41	68.33	20	100	16.44
The use of Human Resources	301	58.12	60	20	100	16.76
Quality Training	301	68.54	73.33	20	100	18.72
Assessment And evaluation	301	65.23	66.67	20	100	16.17
Benefit of Institution	301	67.4	70	20	100	15.9
Benefit of Employee	301	67.93	70	20	100	16.41
Benefit of Patient	301	67.74	71.43	20	100	16.24
Total Quality Score	301	65.41	67.14	20	100	13.61

Table 3 shows the comparison of the KPS total and subscale mean scores of the nurses according to their institutions. It was determined as a result of the analysis that there was a significant difference between the mean scores of the management and leadership subscale (p=0.001); the use of human resources subscale (p=0.018), the benefit of institution subscale (p=0.024) and total quality score (p=0.017) according to the institution at which they were working (p<0.05).

Table 3 Distribution of the quality perception scale total and subscale mean scores of the nurses with the institution they work (n:301).

Scale and its Subscales		Employed Institution						Kruskal Wallis H Test
		n	Mean	Median	Min	Max	sd	Mean rank	H	p
Management and Leadership	Children’s Hospital1	47	59.5	58.3	25	100	17.59	114.73	19.57	0.001
	Oncology Hospital2	35	64.5	65	22	93	15.94	140.67
	Adult Hospital3	132	70.4	71.6	22	98	15.33	171.6
	Ministry of Health4	48	61.4	64.1	20	98	17.82	129.28
	Private Hospital5	39	68.7	66.6	33	92	13.13	160.99
	Total	301	66.4	68.3	20	100	16.44	1<3 4<3
Use of Human Resource	Children’s Hospital1	47	56.6	60	23	99	18.08	144.26	11.92	0.018
	Oncology Hospital2	35	54.7	58.5	27	87	15.84	131.64
	Adult Hospital3	132	59.9	61.4	21	94	16.29	161.39
	Sağlık Bakanlığı4	48	52.8	55	23	83	17.14	123.18
	Private Hospital5	39	63.1	64.2	26	99	15.23	175.58
	Total	301	58.1	60	21	99	16.76	4<3 4<5 2<5
Quality Training	Children’s Hospital	47	68.5	73.3	20	100	19.54	148.77	2.97	0.562
	Oncology Hospital	35	67.9	73.3	20	100	18.21	143.43
	Adult Hospital	132	69.9	73.3	20	100	17.94	159.8
	Ministry of Health	48	65.9	70	20	100	18.91	136.89
	Private Hospital	39	67.3	73.3	20	97	20.97	148.09
	Total	301	68.5	73.3	20	100	18.72
Assessment and Evaluation	Children’s Hospital1	47	62.4	63.33	23	93	15.66	135.26	3.3	0.509
	Oncology Hospital2	35	65	66.6	20	100	18.74	149.17
	Adult Hospital3	132	66.9	66.6	20	100	14.78	160.19
	Ministry of Health4	48	64.2	66.6	30	93	16.98	146.99
	Private Hospital5	39	64.1	63.3	23	100	17.88	145.45
	Total	301	65.2	66.6	20	100	16.17
Benefit of Institution	Children’s Hospital1	47	64.6	66	32	100	15.53	130.94	11.26	0.024
	Oncology Hospital2	35	64.6	66	22	86	15.36	136.19
	Adult Hospital3	132	70.1	74	20	100	15.81	167.81
	Ministry of Health4	48	63.2	61	20	90	16.62	130.6
	Private Hospital5	39	68.8	72	34	96	14.91	156.69
	Total	301	67.4	70	20	100	15.9	4<3 1<3
Benefit of Employee	Children’s Hospital1	47	66.6	67.5	23	100	17.53	145.2	9.34	0.053
	Oncology Hospital2	35	63.8	70	23	88	15.19	128.14
	Adult Hospital3	132	70.7	72.5	28	98	14.99	165.12
	Ministry of Health4	48	63.8	60	20	100	18.66	129.23
	Private Hospital5	39	68.8	72.5	23	100	16.62	157.51
	Total	301	67.9	70	20	100	16.41
Benefit of Patient	Children’s Hospital1	47	65.3	67.1	27	100	16.68	134.68	6.89	0.141
	Oncology Hospital2	35	66.5	70	20	94	16.97	144.49
	Adult Hospital3	132	69.5	72.1	26	94	14.87	159.98
	Ministry of Health4	48	63.6	65	20	93	19.05	132.9
	Private Hospital5	39	70.7	74.29	30	94	15.04	168.4
	Total	301	67.7	71.43	20	100	16.24
Total Score	Children’s Hospital1	47	62.6	63.43	31	87	13.26	130.97	12.107	0.017
	Oncology Hospital2	35	63.2	67.14	23	89	14.47	138.01
	Adult Hospital3	132	67.8	70	29	94	13.08	166.36
	Ministry of Health4	48	61.3	62	27	86	14.71	126.67
	Private Hospital5	39	67.5	70	30	81	12.02	164.76
	Total	301	65.4	67.14	23	94	13.61	4<5 4<3 1<3

Table 4 shows the comparison of the positions of the nurses with total and subscale mean scores of the quality perception scale. In the statistical examination, a significant difference was found between mean scores of the assessment and evaluation (p=0.029), benefit of institution (p=0.01) and benefit of patient (p=0.005) subscales in terms of the positions at which the nurses were working (p<0.05).

Table 4 Distribution of the quality perception scale total and subscale mean scores of the nurses with their position (n: 301).

Scale and Subscales		Your Position						Mann Whitney U Test
		n	Mean	Median	Min	Max	sd	Mean rank	z	p
Management and Leadership	Service Nurse	245	65.48	68.33	20	100	16.84	147.28	-1.552	0.121
	Nurse Manager	56	70.51	66.67	42	97	13.93	167.28
	Total	301	66.41	68.33	20	100	16.44
The Use of Human Resources	Service Nurse	245	58	60	21	99	16.93	150.51	-0.204	0.838
	Nurse Manager	56	58.62	58.57	26	94	16.12	153.14
	Total	301	58.12	60	21	99	16.76
Quality Training	Service Nurse	245	67.89	73.33	20	100	19.15	148.27	-1.145	0.252
	Nurse Manager	56	71.37	75	27	100	16.56	162.96
	Total	301	68.54	73.33	20	100	18.72
Assessment and Evaluation	Service Nursea	245	64.16	63.33	20	100	16.22	145.77	-2.188	0.029
	Nurse Manager b	56	69.88	68.33	33	100	15.19	173.9
	Total	301	65.23	66.67	20	100	16.17		a
Benefit of Institution	Service Nursea	245	66.28	68	20	100	16.03	144.82	-2.579	0.01
	Nurse Managerb	56	72.32	76	36	100	14.4	178.03
	Total	301	67.4	70	20	100	15.9		a
Benefit of Employee	Service Nurse	245	67.5	70	20	100	16.88	149.06	-0.811	0.417
	Nurse Manager	56	69.82	71.25	38	100	14.18	159.5
	Total	301	67.93	70	20	100	16.41
Benefit of Patient	Service Nursea	245	66.54	68.57	20	100	16.62	144.2	-2.835	0.005
	Nurse Managerb	56	72.98	75.71	40	93	13.36	180.73
	Total	301	67.74	71.43	20	100	16.24		a
Total Score	Service Nurse	245	64.63	66.57	23	89	13.84	146.34	-1.941	0.052
	Nurse Manager	56	68.83	71.71	39	94	12.08	171.37
	Total	301	65.41	67.14	23	94	13.61

Discussion

The results of the quality perception scale applied to determine the quality perception of the nurses were evaluated. It was observed that the total score of the nurses from the Quality Perception Scale (=65.41 ± 13.61) was higher than the mean and their quality perceptions were positive. In the study by El-Jardalı et al. [8] it was stated that accreditation affected positively the quality perception of the nurses. This was important because it showed that nurses actively participated in the quality studies in the hospitals where the study was conducted.

It was determined in the study that the “Quality Training” subscale had the highest mean score (=68.54 ± 18.72) (Table 1). It was seen in the study conducted by Dogan and ve Kaya [10] with administrators of eight hospitals affiliated with the Ministry of Health in Aksaray province that they emphasized lack of training, lack of personnel, and financial difficulties respectively as the most important barriers of TQM application. Similarly, in this study, no difference was found between the quality trainings given in the hospitals.

In the study, it was determined that the “Assessment and Evaluation” subscale score (=65.23 ± 16.17) was lower than the other subscales (Table 1). In the study conducted by Bircan and ve Baycan [11] on efficiency and quality system in a university hospital, it was found that the patients had the most negative impression about the outpatient clinic registration procedures. It was determined in the study conducted by Isık [12] in a university hospital that the doctors’ option “hospital records, presence of the past and current hospital records and their easy usage” was the third item in the ranking of the worst quality area of the hospital. Burucu et al. [13] concluded upon investigation of the follow-ups and records conducted for four months in order to evaluate the nursing services in primary, secondary, and tertiary intensive care units in a training and research hospital that the nursing services were inadequate. Low quality perceptions of the nurses about the assessment and evaluation in this study suggest that the continuous improvement activities in the quality studies conducted in the hospitals should be enhanced.

It was determined in the study that the score of the “management and leadership” subscale was in the fifth place compared to the other subscales and there was a significant difference between hospitals (Table 1). The reason for this difference was that the management and leadership subscale mean scores of the employees working in the Children’s Hospital of the University and in the Ministry of Health Hospital were significantly lower (p<0.001) than those working in Adult Hospital of the University. This result can be evaluated as the fact that the management of the Children’s Hospital of the University effectively led in the quality activities.

Leadership of the management plays an active role in the success of quality applications. In order to enhance the service quality in health institutions, it is necessary to direct the employees first in line with the mission and vision, to ensure their effective participation in the decisions and to increase their satisfaction levels. It is stated that the employees who have adapted into the organizational culture, are supported to participate in the decisions and know to be valued by the senior management are working more and more every day to increase the service quality and cause a customer satisfaction over the expectations [3,14].

It was determined in the study that the “use of human resources” subscale had the lowest mean score compared to the other subscales and in the comparison, a statistically significant difference was found between the institutions (p<0.01). In the advanced analysis, the difference was found to be due to the fact that the employees working in the Ministry of Health Hospital obtained significantly lower scores (p<0.01) than the employees working in the Adult Hospital of the University and in the Private Hospital. The use of human resources subscale score of the employees working in Oncology Hospital of the University was determined to be significantly lower than those working in the Private Hospital (p<0.01). In Is [12] study investigating the evaluation of the doctors working in a university hospital having quality certificates about the quality of the hospital, it was emphasized that doctors considered especially the number of nurses and auxiliary personnel inadequate. In terms of ensuring the continuity of quality studies, the adequacy of human resources is important but the number of nurses working in the hospitals is seen to be inadequate.

In the study, the score of the “benefit of patient” subscale was in the third order compared to the other subscales and there was a statistically significant difference in the comparison on the position of the nurses (p<0.005). Teng et al. [15] found in their study that patient safety and satisfaction levels increased with increasing level of application of the quality standards by the nurses. In the study conducted by Konca et al. [16] to investigate the inpatients’ satisfaction, the patients were found to be generally satisfied with hospital staff and hospital services and this was thought to be associated with the quality studies conducted in the hospital. In the study conducted by Schmaltz et al. [17] on hospitals with and without quality certificate, there were increases in the customer satisfaction and nurse care quality of the hospitals with quality certificate. When considering the goals of enhancing the quality of care and ensuring patient safety which are among the most important objectives of the quality works conducted in the hospitals, it is an expected situation for nurses to keep the patient benefits ahead in the quality studies.

In the study, it was found that score of “benefit of institution” subscale was in the fourth grade among the other subscales and there was a statistically significant difference in the comparison made on position of the nurses (p<0.01). This difference may be due to the fact that the manager nurses taking part in the quality studies may observe the benefits of the quality studies for the institution better.

When the quality perception scale total and subscale mean scores were compared with the positions of the nurses via Mann Whitney U test (Table 4), a statistically significant difference was found in the assessment and evaluation subscale (p<0.05). This difference was due to the fact that the scores of service nurses were statistically significantly lower compared to the manager nurses (p<0.02). In the study conducted by Dogan and ve Kaya [10] to determine the willingness levels of the hospital staff for the quality works, those who were not in the management position were determined to have lower mean score than the managers. It was determined in the study by Sonmez [18] that 38 out of 68 enrollment forms held by nurses were not related to their profession. It is stated that the nurses are responsible for filling many forms that are not related to nursing services, which is an important factor affecting negatively the quality and quantity of nursing services along with increasing their work load. It can be asserted that this difference in the study was caused by the fact that the manager nurses are responsible for keeping the records timely and accurately.

A statistically significant difference was determined between the positions of the nurses and the benefit of institution subscale score and the score of the service nurses was found to be significantly lower than the manager nurses (p<0.01). The fact that the manager nurses take part in the quality studies personally and better observe the changes in the institution and their benefits to the institution is asserted to be effective in obtaining this result.

A statistically significant difference was found between the nurses’ positions and the benefit of patient subscale scores (p<0.005). The score of service nurses was found to be significantly lower than manager nurses (p<0.005). In the study conducted by [19] to evaluate the factors affecting the service quality, it was determined that the rates of agreeing with the expressions including “leadership, commitment and support, strategic quality planning, quality management department, data usage, employee participation, accreditation benefits” were higher in nurses with administrative duties than the nurses who had no administrative duties. Service nurses were thought to perceive the quality studies negatively due to the reasons for increasing work load. In the study by Costa et al. [20], nurses expressed that they did not feel like a part of the quality studies and the quality studies made the institutional development difficult [21].

Conclusion

This study was conducted to determine the quality perception of the nurses for evaluation of quality studies in the field of health. It was found that the quality perceptions of the nurses were higher than the average and the working institution and the working position affected the quality perception. Studies to be conducted with different healthcare professionals are thought to contribute to evaluating the quality works.

In accordance with the results obtained from the study, it can be recommended to recognize that the nurses are important human resources in quality improvement studies, quality certification processes and developing the service quality, to determine the appropriate supportive approaches, and to employ personnel proper for quality and quantity by considering the excessive work load.

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