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Primary nursing: an evaluation of its effects on patient perception of care and staff satisfaction
hf. 1. Nurs. Stud., Vol. 20. No. 4, pp. 265-273, Printed in Great Britain
002&7489/83 S3.a) + 0.00 0 1983 Pcrgamon Press Ltd
1983
Primary nursing: an evaluation of its effects onpatientperception of care and staff satisfaction KENNETH J. SELLICK, R.N., Dip. N. Ed., M.Psych., School of Nursing, Lincoln Institute of Health Sciences, Melbourne, Australia.
SHIRLEY RUSSELL, R.N., Dip. Appl. SC. Nurs. (Admin.) and JACQUELINE L. BECKMANN, B. Comm., A.R.M.A. Royal Melbourne Hospital, Melbourne, Australia.
Abstract-A study evaluating the effects of a system of primary nursing on patients’ perception of care and staff satisfaction is described. The study was conducted in a large acute medical-surgical hospital and incorporated a control group and quantitative measures of the variables under investigation. Significantly higher levels of patient and staff satisfaction were shown for the primary nursing unit on items which support the philosophy of primary nursing. Results are compared to previous studies and methodological issues are discussed. Primary nursing is an organizational system of care which emphasizes the delivery of comprehensive, individualized and continuous nursing care through the nurse with the authority and autonomy to plan and implement such care. Since the concept was first introduced by Manthey et al. (1970), there have been numerous reports in the nursing literature proclaiming its benefits as a modality of care, When compared to traditional systems, primary nursing is believed to result in a higher quality of nursing care (Felton, 1975; Eichhorn and Frevert, 1979; Steckel et al., 1980; Hegedus, 1980), greater patient satisfaction (Ciske, 1974; Daeffler, 1975; Watson, 1978; Hegedus, 1979), improved job satisfaction of nurses (Marram et al., 1979; Hegedus, 1980), and to be more cost-effective (Marram, 1976). 265
266
KENNETH
J. SELLICK,
SHIRLEY
RUSSELL
AND JACQUELINE
L. BECKMANN
Despite the widespread acceptance of primary nursing, there have been very few studies which provide convincing evidence that primary nursing is superior to functional, team or case-method systems. To date, the available evidence is based mainly on anecdotal or descriptive reports, rather than sound quantitative data derived from research studies which employ adequate controls, objective measurement of variables, and appropriate statistical analysis of predicted outcomes. Whilst studies evaluating primary nursing have considered its effect on a wide range of variables, most researchers would agree that some measure of outcome is critical to an evaluation of any system of nursing care. Patients’ perception of care and staff satisfaction represent two such outcome variables which could provide a valid measure of the system under investigation, and ones which are readily amenable to quantification. In a search of the literature seven studies were located which evaluated the impact of primary nursing on patients’ perception of care, and five studies which considered its effect on the job satisfaction of nursing staff. In all studies primary nursing was evaluated relative to control or comparison groups, but each varied greatly in its level of research design and methodology, the conclusions that were drawn, and consequently the degree of support for primary nursing. Although studies by Daeffler (1975), Watson (1978) and Hegedus (1979) provide some evidence to suggest patients under a system of primary nursing are more satisfied with the care they receive, or regard it as more personalized, these findings have not been supported by other investigators. Giovannetti (1980), for example, found patients in the control group ‘appeared’ significantly more satisfied when items relating to relief of pain and discomfort, or the amount of information given for home care were considered. Steckel et al. (1980) also failed to obtain a significant difference between primary nursing and control groups on measures of patient satisfaction; a finding that was believed could be attributed to the inadequacy of the assessment tools that were used. Conflicting results are also a feature of those studies which have evaluated the effect of primary nursing on the level of staff satisfaction. In contrast to reports by Ciske (1974) and Marram ei al. (1979), which claimed staff were more satisfied when working under a system of primary nursing, no significant differences could be demonstrated by Steckel et al. (1980) when absenteeism, tardiness and staff turnover were considered as indicators of job satisfaction. Similarly, Giovannetti (1980) found staff satisfaction was significantly greater for the control than the primary nursing group. In a study by Hegedus (1980) using a Herzberg scale to assess job satisfaction, significant differences in favour of primary nurses were found on ‘hygiene’ measures (e.g. salary, supervision, policy) but not on ‘motivational’ measures (e.g. feelings of recognition, achievement, personal growth). In view of the inconsistencies noted in the literature, the lack of substantive evidence in support of the claims that primary nursing is superior to established modalities of care, and the persistent plea for more rigorous research, the present study was undertaken to further evaluate the effects of a system of primary nursing on patients’ perception of care and level of staff satisfaction. Particular emphasis was given to a research design which utilized a control group, provided objective measures of the variables under investigation, and enabled the following hypotheses to be tested using recognized statistical techniques: (1) Patients on the experimental (primary nursing) unit would score higher on a patient satisfaction scale than those on the control unit. (2) Nurses working on the experimental (primary nursing) unit would rate their level of job satisfaction higher than nurses on the control unit.
PRIMAR
Y NURSING:
PATIENT
CARE AND STAFF SA TISFACTION
261
For the purposes of the study, primary nursing is said to exist when one nurse assumes responsibility and accountability for the nursing care of a small group of patients from the time of admission to the time of discharge. The nurse plans with the patient the care that patient should require and delegates the responsibility of that care to associate nurses when she/he is off duty. Method
Setting The study was conducted in a large, acute medical-surgical hospital, situated in the Melbourne Metropolitan area. Two general medical wards were selected on the basis of comparable physical design, bed capacity, patient population (in terms of diagnosis, age distribution and length of stay), and staff establishment. Of the two wards selected, one utilized a traditional system of nursing care, (functional assignment), whilst the other employed a system of primary nursing which was first introduced 3 months prior to the commencement of the study.
Sample All patients on the two units who were mentally alert and oriented, could speak and read English, and had a minimal length of stay of 4 days were included in the patient sample. Admission of patients to the two units was determined by respective medical specialists and not according to the system of nursing care in operation. The sample of nurses consisted of all nurses who were working on both units over the period of study. The final samples consisted of 28 patients and 17 nurses in the experimental (primary nursing) group, and 31 patients and 20 nurses on the control group. Characteristics of the two patient groups, as presented in Table I, show similar age, sex ratio, and length of stay distributions. Table 1. Patient characteristics of primary nursing (PN) and control (C) groups PN
C
Age
Mean SD Range
52.71 18.10 21-81
58.06 16.13 21-86
Length of stay (days)
Mean SD Range
11.71 1.24 4-31
12.03 8.64 4-37
Sex
Male Female
12 16
14 17
Instrumentation Patient satisfaction was measured using the patient questionnaire. This instrument was developed for the purpose of the study and contained a total of 11 items, ten of which related to the patients’ perception of the nursing care they received. These ten items covered a variety of nursing care dimensions and were not biased in favour of either the primary nursing or traditional system of care. Four of the items were designed to elicit a yes/no response, while the remaining six items asked the patient to rate their perceptions on a three-point scale. The remaining item (item 1) was selected from the study by Watson (1978), and invited the patient to indicate the number of nurses who had provided care in
268
KENNETH J. SELLICK. SHIRLEY RUSSELL AND JACQUELINE L. BECKMANN
the past 24 h. During the development of the questionnaire, two standardized patient outcome tools were considered; the Volicer Hospital stress scale used in the study by Hegedus (1979), and the patient satisfaction tool designed and tested by Risser (1975). The first was rejected as too specific a measure and the second because of its focus on a specialized care setting. Measurement of the job satisfaction of nursing staff working on the experimental and control wards was obtained by means of the staff satisfaction scale. This instrument was also designed specifically for the study, and included 23 items constructed into two subscales. Scale A consisted of 17 items presented as a seven point Likert scale and measured aspects of the work situation such as personal development, interpersonal relationships, supervision and pay. Scale B was made up of six items which used a four-point Likert scale to elicit staff responses to task factors. The choice of scale items was strongly influenced by the tools used in the study by Nichols (1971), and a non-specific job satisfaction questionnaire published in Psychology Toduy (1977). In order to ensure there were no measurement problems both instruments had been administered to pilot samples not associated with the study. Procedure Primary nursing was introduced to the experimental unit for a trial period of 6 months. To reduce the possibility of result contamination from a novelty effect, data were collected only over the last 3 months. The patient questionnaire was given to all patients on the experimental and control units who met the criteria for inclusion during the period of study. The questionnaire was administered on the day of the patient’s discharge by an interviewer who was not a nurse, was not involved with the analysis of data, but was aware of the two study groups. Each patient was informed that participation was voluntary and that anonymity was assured. A total of 28 patients from the primary nursing unit and 31 patients from the control unit participated in the study. There were no refusals on either of the two units. All nursing staff who worked on the experimental and control units during the evaluation period were given the staff satisfaction scale to complete during the last 12 weeks of the study. The scales were again administered by a non-nurse with assurance of anonymity and confidentiality. A total of 17 nurses from the primary nursing unit and 20 nurses from the control units completed the scale, which was a response rate of 100% for both units. Data from the two instruments were collated and analysed to enable comparisons to be made between the experimental and control groups. Results
To test the hypothesis that patient satisfaction with nursing care would be greater on the experimental (primary nursing) unit when compared with patients on the control unit, the ten items on the patient questionnaire relating to patient perception of care were analysed. Response frequency for items 3,4, 6, 8 and 8a were calculated and differences between the two groups were analysed using the Fisher exact probability test for items 3,4, 8 and 8a, and the chi-squared test for item 6 (Siegel, 1956). The Fisher test was chosen for the former items because expected frequencies of less than 5 occurred in one or more cells. As shown in Table 2, the number of ‘Yes’ responses was greater for the experimental
PRIMARY
NURSING:
PATIENT
CARE AND STAFF SA TISFACTION
Table 2. Response frequency on patient questionnaire primary nursing (PN) and control (C)groups
(3)
(4)
(6)
(8)
(8a)
Yes
No
PN
27
1
C PN
27
3
27
1
C
25
3
Has a nurse talked to a member of your family or friends about your illness and hospitalization?
PN
18
8
C
12
17
Did the nurses spend time with you discussing your condition/illness?
PN
27
1
C
22
9
If yes, did you find this information helpful?
PN
24
1
C
18
3
Did you feel free to express your concerns to the nurse? Were special needs cared for to your satisfaction?
items for
Significance level
Response Group
Item
269
NS
NS
P < 0.05
P < 0.01
NS
NS = non-significant (P > 0.05).
group on all items. When differences in response frequency between the two groups were statistically analysed, a significant difference was found for item 6 (P < 0.05) and item 8 (P < 0.01). The response frequency for the remaining items on the patient questionnaire was also calculated, and differences in rankings between the experimental and control groups analysed using the Mann-Whitney U test for large samples (Siegel, 1956). Data presented in Table 3 show a higher mean rank for the primary nursing group on all items (except item 2) with a significant difference between the two groups on items 5 (U= 336,2= 2.65, P < O.OOS),7 (U=239.5, Z=3.08, P < O.OOl), 10 (U=253.5, Z=2.47, P < 0.01) and 11 (U= 135.5, z=2.39, P < 0.01). In order to test the second hypothesis; that nurses working on the primary nursing unit would record a higher level of job satisfaction compared to the control group, rankings for items on job satisfaction scales A and B were calculated and differences between the two groups analysed using the Mann-Whitney U test. As shown in Table 4, a significant difference in favour of primary nursing was found for items 2 (U=71.0, P < O.Ol), 10 (U= 88.5, P < 0.025) and 16 (U=73.5, P < 0.005) on scale A and item 23 (U= 100, P < 0.05) on scale B. The only significant difference recorded in favour of the control group was for item 17 (U=68.5, P < 0.001) on scale B. Examination of mean rankings show a higher ranking for the primary nursing group on 17 of the 23 items. Diiussioa
The results of the present study provide some support for the hypothesis that patients nursed under a system of primary nursing would report greater satisfaction with the care they received than patients nursed under a traditional system. Statistically significant differencesbetween the two groups in favour of primary nursing were evident on six of
270
KENNETHJ.
SELLICK,
SHIRLEYRUSSELL
AND JACQUELINEL.
BECKMANN
Table 3. Mean ranks and Z values on patient questionnaire items for primary nursing (PN) and control (C)groups Group
N
Mean ranks
How often was a nurse available when you wished to talk to her?
PN
28
29.50
C
30
29.50
How well do you think the nurses understood you?
PN
28
33.50
C
31
26.84
How much interest did the nurses show as to the effects of your illness on your family?
PN
27
34.13
C
29
23.26
How did you like your stay here, apart from the discomfort of your illness and being away from home?
PN
27
33.02
C
31
26.44
How much did the nursing care contribute to this?
PN
28
33.45
C
28
23.55
How well has a nurse helped you prepare and plan for when you leave hospital?
PN
26
25.29
C
17
16.97
Items
(2)
(5)
(7)
(9)
(10)
(11)
Z*
Significance level
0.00
NS
2.65
P < 0.005
3.08
P < 0.001
1.70
NS
2.47
P < 0.01
2.39
P < 0.01
*Corrected for ties. NS = non-significant (P > 0.05).
the 11 items which examined patients’ perception of care. Additional support is suggested by the absence of significant differences in the direction of the control group, and with the trend reflected in the higher ratings recorded on ten of the 11 items by the primary nursing group. Detailed examination of the items which were significantly different show that nurses on the primary nursing unit were perceived to have a greater understanding of the patient (item 5), showed more concern and communciated more with the patient’s family (items 6 and 7), were more likely to give information to the patient regarding his/her illness or condition (item 8), tended to contribute more to a positive experience of hospitalization (items 9 and lo), and gave greater consideration to discharge planning (item 11). These findings are compatible with the basic philosophy of primary nursing, which emphasizes accountability, patient-centred individualized care, and continuity of care from admission through to discharge (Marram van Servellen, 1980). That the perception of care under a system of primary nursing is more individualized is also noted in the response to item 1, where patients stated the number of nurses who provided their care over a 24 h period. The result recorded was a mean of 3.4 nurses for the primary nursing group compared to a mean of 6.9 for the control group. A similar result has also been reported by Watson (1978) where ‘patients in the primary units were very clear in stating that three nurses per day looked after them’ (p. 31). However, this finding is inconclusive in that it assumes a significant correlation between the number of nurses providing care and the level of patient satisfaction.
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Table 4. Mean ranks and II values for items on job satisfaction scales for primary nursing (PN) and control (C)groups
N Scale A (I) The opportunity to develop your skills and abilities (2) The chances you have to accomplish something worthwhile (3) The chances you have to do the things you do best (4) The chances you have to do something that makes you feel good as a person (5) The amount of pay you get (6) The amount of information you get about how well you are doing your job (7) The opportunity to change assignments periodically (8) The amount of job security you have (9) The degree of challenge in your job (IO) The opportunity to voice opinions (I 1) Work assignments according to preference (12) The way you are treated by the people you work with (I 3) The respect you receive from the people you work with (14) The friendliness of the people you work with (IS) Personal recognition within your work situation (16) The chances you have to take part in making decisions (17) Independence in making professional decisions Scale B (I 8) I have to work very fast (19) I have to have a high level of skill (20) I have to be creative (21) I have to do a variety of different tasks (22) I have to use all my skills and training (23) I set the pace of my work
PN Mean ranks
N
C Mean ranks
Mann- Significance Whitney level U test* NS
17 22.03 I6 22.06
20 16.42 20 13.44
118.5 71.0
P < 0.01
I6 19.06 I6 19.84
20 18.05 20 17.42
151.0 138.5
NS NS
I7 17.47 I7 18.74
20 20.30 I8 19.22
144.0 165.5
NS NS
I6 I6 I6 I7 16 I7 I6 16 I7 I7 I7
18.09 19.56 20.00 22.79 17.97 19.29 17.97 19.94 18.65 24.68 21.47
I8 20 19 19 I9 20 I9 I9 20 20 20
16.97 17.65 16.32 14.66 18.03 17.79 18.03 16.37 18.37 14.17 16.90
134.5 143.0 120.0 88.5 151.5 148.0 151.5 121.0 159.0 73.5 128.0
NS NS NS
I7 I7 17 I6 I7 I7
13.03 16.79 21.56 18.50 18.88 22.12
19 19 19 I9 19 19
23.39 19.14 15.76 18.50 16.28 15.26
68.5 132.5 109.5 161.5 122.0 100.0
-
P < 0.025
NS NS NS NS NS P < 0.005
NS P < 0.001
NS NS NS NS P < 0.05
*Corrected for ties. NS = non-significant (P< 0.05).
The degree to which the results support the second hypothesis is difficult to ascertain. Tentative support could be derived from the results on individual items, which show primary nurses were significantly more satisfied with their job in terms of the opportunity to accomplish something worthwhile (item 2), to voice opinions and participate in decision-making (items 10 and 16), and to set the pace of their work (item 23). In contrast to these findings, the control group recorded a higher ranking on six of the 23 items, only one of which was found to be statistically significant (item 18). It is important to note that items rated significantly higher by primary nurses accord with the philosophy of primary nursing, whereas the higher rating by the control group emphasizes task characteristics. Thus, it could be argued this finding represents support for, rather than against, the research hypothesis. A common feature of research evaluating primary nursing is the wide variation in subject populations and research methodology. This creates major problems when attempting valid comparisons across studies, despite the fact that a number of studies report findings which are notably similar to the results obtained in this study. In the research by Daeffler (1975), where similar questions were used to obtain a measure of patients’ perception of care, patients in a primary nursing unit were found to be signifi-
272
KENNETHJ.
SELLICK,
SHIRLEYRUSSELL
AND JACQUELINEL.
BECKMANN
cantly better informed about their illness and aspects of care. Similarly, patients in the survey conducted by Watson (1978) perceived primary nurses as more understanding of their needs, and as showing greater consideration for the family. The degree to which the measure of staff satisfaction ‘compared’ with other studies could not be established because of the absence of universally accepted measures of job satisfaction and the tendency of the various measures to register different levels of response (Giovannetti, 1980). Another feature of the research which attempts to explore important nursing questions in the clinical field is the difficulty of controlling for extraneous variables, of obtaining reliable measures of experimental variables, and consequently the degree to which results can be generalized to other settings. This study is not exempt from these limitations, and at best could only be seen to meet the criteria of a quasi-experimental design. Sample selection was seen to be a major limitation as administrative procedure did not allow patients and staff to be randomly assigned to either the experimental or control units, and the possibility of selective recruitment could not therefore be excluded. Patients and staff were also aware that a study was being conducted; a situation which could result in a ‘Hawthorne’ effect or a bias resulting from the opportunity nurses from both units had to discuss their involvement in the study. The commencement of the study 3 months after primary nursing was introduced on to the experimental unit may have lessened the possibility of a novelty effect influencing the results. A second limitation relates to the measurement tools used to evaluate outcome variables. Although it was the aim to use measurement instruments which would yield quantitative data, and were sensitive enough to identify existing differences between the two groups, these fell short of the ideal standardized instrument. In the design of the questionnaires, an attempt was made to construct comprehensive items which had face validity, but unfortunately items were not given individual weighting, nor were the questionnaires subjected to validity and reliability checks. Likewise, the sensitivity of the instruments could be improved with more neutral wording of two items on the patient questionnaire (items 9 and 1l), greater specificity of some response options, and clearer instructions to overcome the problem where 11 subjects (3 experimental, 8 control) failed to respond to one or more items on the staff satisfaction scale. Finally, questionnaires were administered to patients on the day of discharge, but as Ciske (1974) points out, patients may be reluctant to criticize nursing care because of the power differences seen to exist between nurse and patient. It may be more appropriate for patients to complete the questionnaire following discharge from hospital to avoid the possibility of bias. Despite these methodological problems an attempt has been made to evaluate the effects of primary nursing on two important outcome variables using a relatively rigorous research design with appropriate statistical analysis. Although this study provides some support for the beneficial effects of primary nursing as a system of care, it also highlights an obvious need for more stringent research to systematically evaluate the many questions which remain unanswered. References Ciske, K. L. (1974). Primary nursing evaluation. Am. J. Nurs. 74,1436-1438. Daeffler, R. J. (1975). Patients’ perception of care under team and primary nursing. J. Nurs. Admin. 5,20-26. Eichhorn, M. L. and Frevert, E. I. (1979). Evaluation of a primary nursing system using the Quality Patient Care Scale. J. Nurs. Admin. 9, 1I-13.
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Felton, G. (1975). Increasing the quality of nursing care by introducing the concept of primary nursing: A model project. Nurs. Rex 24,27-32. Giovannetti, P. (1980). A comparison of team and primary nursing care systems. Nurs. Dim. 7,96-100. Hegedus, K S. (1979). A patient outcome criterion measure. Sup. Nurse 10,40-45. Hegedus, K. S. (1980). Primary Nursing: Evaluation of professional nursing practice. Nurs. Dim. 7,85-89. Hopkins, K. D. and Glass, G. V. (1978). Basic Statistics for the Behavioral Sciences. p. 322. Prentice-Hall, Englewood Cliffs. Manthey, M. and Kramer, M. (1970). A dialogue on primary nursing. Nurs. For. 9,356-363. Manthey, M., Ciske, K., Robertson, P. and Harris, I. (1970). Primary nursing a return to the concept of ‘my nurse’ and ‘my patient’. Nurs. For. 9.65-83. Marram, Cl. (1976). The comparative costs of operating a team and primary nursing unit. J. Nurs. Admin. 6, 21-24.
Marram, G., Barrett, M. W. and Bevis, E. 0. (1979). Primary Nursing: A model for individual care. C. V. Mosby, St. Louis. Marram Van Servellen, G. (1980). Evaluating the impact of primary nursing: Outcomes. Nurs. Dim. 7,48-50. Nichols, G. A. (1971). Job satisfaction and nurses’ intention to remain with or to leave an organization. Nurs. Res. 20,218-228. How do you like your job? (1977) Psychology Today 11,73-79. Risser, N. L. (1975). Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nurs. Res. 24,45-52. Siegel, S. (1956). Nonparametric Statistics for the Behavioral Sciences. McGraw-Hill Kogakusha, Tokyo. Steckel, S. F., Barnfather, J. and Owens, M. (1980). Implementing primary nursing within a research design. Nurs. Dim. 9,78-81. Watson, J. (1978). Patient evaluation of a primary nursing project. Aust. Nurs. J. 8,30-33. (Received 24 November
1982; acceptedforpublication
8 August 1983)
002&7489/83 S3.a) + 0.00 0 1983 Pcrgamon Press Ltd
1983
Primary nursing: an evaluation of its effects onpatientperception of care and staff satisfaction KENNETH J. SELLICK, R.N., Dip. N. Ed., M.Psych., School of Nursing, Lincoln Institute of Health Sciences, Melbourne, Australia.
SHIRLEY RUSSELL, R.N., Dip. Appl. SC. Nurs. (Admin.) and JACQUELINE L. BECKMANN, B. Comm., A.R.M.A. Royal Melbourne Hospital, Melbourne, Australia.
Abstract-A study evaluating the effects of a system of primary nursing on patients’ perception of care and staff satisfaction is described. The study was conducted in a large acute medical-surgical hospital and incorporated a control group and quantitative measures of the variables under investigation. Significantly higher levels of patient and staff satisfaction were shown for the primary nursing unit on items which support the philosophy of primary nursing. Results are compared to previous studies and methodological issues are discussed. Primary nursing is an organizational system of care which emphasizes the delivery of comprehensive, individualized and continuous nursing care through the nurse with the authority and autonomy to plan and implement such care. Since the concept was first introduced by Manthey et al. (1970), there have been numerous reports in the nursing literature proclaiming its benefits as a modality of care, When compared to traditional systems, primary nursing is believed to result in a higher quality of nursing care (Felton, 1975; Eichhorn and Frevert, 1979; Steckel et al., 1980; Hegedus, 1980), greater patient satisfaction (Ciske, 1974; Daeffler, 1975; Watson, 1978; Hegedus, 1979), improved job satisfaction of nurses (Marram et al., 1979; Hegedus, 1980), and to be more cost-effective (Marram, 1976). 265
266
KENNETH
J. SELLICK,
SHIRLEY
RUSSELL
AND JACQUELINE
L. BECKMANN
Despite the widespread acceptance of primary nursing, there have been very few studies which provide convincing evidence that primary nursing is superior to functional, team or case-method systems. To date, the available evidence is based mainly on anecdotal or descriptive reports, rather than sound quantitative data derived from research studies which employ adequate controls, objective measurement of variables, and appropriate statistical analysis of predicted outcomes. Whilst studies evaluating primary nursing have considered its effect on a wide range of variables, most researchers would agree that some measure of outcome is critical to an evaluation of any system of nursing care. Patients’ perception of care and staff satisfaction represent two such outcome variables which could provide a valid measure of the system under investigation, and ones which are readily amenable to quantification. In a search of the literature seven studies were located which evaluated the impact of primary nursing on patients’ perception of care, and five studies which considered its effect on the job satisfaction of nursing staff. In all studies primary nursing was evaluated relative to control or comparison groups, but each varied greatly in its level of research design and methodology, the conclusions that were drawn, and consequently the degree of support for primary nursing. Although studies by Daeffler (1975), Watson (1978) and Hegedus (1979) provide some evidence to suggest patients under a system of primary nursing are more satisfied with the care they receive, or regard it as more personalized, these findings have not been supported by other investigators. Giovannetti (1980), for example, found patients in the control group ‘appeared’ significantly more satisfied when items relating to relief of pain and discomfort, or the amount of information given for home care were considered. Steckel et al. (1980) also failed to obtain a significant difference between primary nursing and control groups on measures of patient satisfaction; a finding that was believed could be attributed to the inadequacy of the assessment tools that were used. Conflicting results are also a feature of those studies which have evaluated the effect of primary nursing on the level of staff satisfaction. In contrast to reports by Ciske (1974) and Marram ei al. (1979), which claimed staff were more satisfied when working under a system of primary nursing, no significant differences could be demonstrated by Steckel et al. (1980) when absenteeism, tardiness and staff turnover were considered as indicators of job satisfaction. Similarly, Giovannetti (1980) found staff satisfaction was significantly greater for the control than the primary nursing group. In a study by Hegedus (1980) using a Herzberg scale to assess job satisfaction, significant differences in favour of primary nurses were found on ‘hygiene’ measures (e.g. salary, supervision, policy) but not on ‘motivational’ measures (e.g. feelings of recognition, achievement, personal growth). In view of the inconsistencies noted in the literature, the lack of substantive evidence in support of the claims that primary nursing is superior to established modalities of care, and the persistent plea for more rigorous research, the present study was undertaken to further evaluate the effects of a system of primary nursing on patients’ perception of care and level of staff satisfaction. Particular emphasis was given to a research design which utilized a control group, provided objective measures of the variables under investigation, and enabled the following hypotheses to be tested using recognized statistical techniques: (1) Patients on the experimental (primary nursing) unit would score higher on a patient satisfaction scale than those on the control unit. (2) Nurses working on the experimental (primary nursing) unit would rate their level of job satisfaction higher than nurses on the control unit.
PRIMAR
Y NURSING:
PATIENT
CARE AND STAFF SA TISFACTION
261
For the purposes of the study, primary nursing is said to exist when one nurse assumes responsibility and accountability for the nursing care of a small group of patients from the time of admission to the time of discharge. The nurse plans with the patient the care that patient should require and delegates the responsibility of that care to associate nurses when she/he is off duty. Method
Setting The study was conducted in a large, acute medical-surgical hospital, situated in the Melbourne Metropolitan area. Two general medical wards were selected on the basis of comparable physical design, bed capacity, patient population (in terms of diagnosis, age distribution and length of stay), and staff establishment. Of the two wards selected, one utilized a traditional system of nursing care, (functional assignment), whilst the other employed a system of primary nursing which was first introduced 3 months prior to the commencement of the study.
Sample All patients on the two units who were mentally alert and oriented, could speak and read English, and had a minimal length of stay of 4 days were included in the patient sample. Admission of patients to the two units was determined by respective medical specialists and not according to the system of nursing care in operation. The sample of nurses consisted of all nurses who were working on both units over the period of study. The final samples consisted of 28 patients and 17 nurses in the experimental (primary nursing) group, and 31 patients and 20 nurses on the control group. Characteristics of the two patient groups, as presented in Table I, show similar age, sex ratio, and length of stay distributions. Table 1. Patient characteristics of primary nursing (PN) and control (C) groups PN
C
Age
Mean SD Range
52.71 18.10 21-81
58.06 16.13 21-86
Length of stay (days)
Mean SD Range
11.71 1.24 4-31
12.03 8.64 4-37
Sex
Male Female
12 16
14 17
Instrumentation Patient satisfaction was measured using the patient questionnaire. This instrument was developed for the purpose of the study and contained a total of 11 items, ten of which related to the patients’ perception of the nursing care they received. These ten items covered a variety of nursing care dimensions and were not biased in favour of either the primary nursing or traditional system of care. Four of the items were designed to elicit a yes/no response, while the remaining six items asked the patient to rate their perceptions on a three-point scale. The remaining item (item 1) was selected from the study by Watson (1978), and invited the patient to indicate the number of nurses who had provided care in
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KENNETH J. SELLICK. SHIRLEY RUSSELL AND JACQUELINE L. BECKMANN
the past 24 h. During the development of the questionnaire, two standardized patient outcome tools were considered; the Volicer Hospital stress scale used in the study by Hegedus (1979), and the patient satisfaction tool designed and tested by Risser (1975). The first was rejected as too specific a measure and the second because of its focus on a specialized care setting. Measurement of the job satisfaction of nursing staff working on the experimental and control wards was obtained by means of the staff satisfaction scale. This instrument was also designed specifically for the study, and included 23 items constructed into two subscales. Scale A consisted of 17 items presented as a seven point Likert scale and measured aspects of the work situation such as personal development, interpersonal relationships, supervision and pay. Scale B was made up of six items which used a four-point Likert scale to elicit staff responses to task factors. The choice of scale items was strongly influenced by the tools used in the study by Nichols (1971), and a non-specific job satisfaction questionnaire published in Psychology Toduy (1977). In order to ensure there were no measurement problems both instruments had been administered to pilot samples not associated with the study. Procedure Primary nursing was introduced to the experimental unit for a trial period of 6 months. To reduce the possibility of result contamination from a novelty effect, data were collected only over the last 3 months. The patient questionnaire was given to all patients on the experimental and control units who met the criteria for inclusion during the period of study. The questionnaire was administered on the day of the patient’s discharge by an interviewer who was not a nurse, was not involved with the analysis of data, but was aware of the two study groups. Each patient was informed that participation was voluntary and that anonymity was assured. A total of 28 patients from the primary nursing unit and 31 patients from the control unit participated in the study. There were no refusals on either of the two units. All nursing staff who worked on the experimental and control units during the evaluation period were given the staff satisfaction scale to complete during the last 12 weeks of the study. The scales were again administered by a non-nurse with assurance of anonymity and confidentiality. A total of 17 nurses from the primary nursing unit and 20 nurses from the control units completed the scale, which was a response rate of 100% for both units. Data from the two instruments were collated and analysed to enable comparisons to be made between the experimental and control groups. Results
To test the hypothesis that patient satisfaction with nursing care would be greater on the experimental (primary nursing) unit when compared with patients on the control unit, the ten items on the patient questionnaire relating to patient perception of care were analysed. Response frequency for items 3,4, 6, 8 and 8a were calculated and differences between the two groups were analysed using the Fisher exact probability test for items 3,4, 8 and 8a, and the chi-squared test for item 6 (Siegel, 1956). The Fisher test was chosen for the former items because expected frequencies of less than 5 occurred in one or more cells. As shown in Table 2, the number of ‘Yes’ responses was greater for the experimental
PRIMARY
NURSING:
PATIENT
CARE AND STAFF SA TISFACTION
Table 2. Response frequency on patient questionnaire primary nursing (PN) and control (C)groups
(3)
(4)
(6)
(8)
(8a)
Yes
No
PN
27
1
C PN
27
3
27
1
C
25
3
Has a nurse talked to a member of your family or friends about your illness and hospitalization?
PN
18
8
C
12
17
Did the nurses spend time with you discussing your condition/illness?
PN
27
1
C
22
9
If yes, did you find this information helpful?
PN
24
1
C
18
3
Did you feel free to express your concerns to the nurse? Were special needs cared for to your satisfaction?
items for
Significance level
Response Group
Item
269
NS
NS
P < 0.05
P < 0.01
NS
NS = non-significant (P > 0.05).
group on all items. When differences in response frequency between the two groups were statistically analysed, a significant difference was found for item 6 (P < 0.05) and item 8 (P < 0.01). The response frequency for the remaining items on the patient questionnaire was also calculated, and differences in rankings between the experimental and control groups analysed using the Mann-Whitney U test for large samples (Siegel, 1956). Data presented in Table 3 show a higher mean rank for the primary nursing group on all items (except item 2) with a significant difference between the two groups on items 5 (U= 336,2= 2.65, P < O.OOS),7 (U=239.5, Z=3.08, P < O.OOl), 10 (U=253.5, Z=2.47, P < 0.01) and 11 (U= 135.5, z=2.39, P < 0.01). In order to test the second hypothesis; that nurses working on the primary nursing unit would record a higher level of job satisfaction compared to the control group, rankings for items on job satisfaction scales A and B were calculated and differences between the two groups analysed using the Mann-Whitney U test. As shown in Table 4, a significant difference in favour of primary nursing was found for items 2 (U=71.0, P < O.Ol), 10 (U= 88.5, P < 0.025) and 16 (U=73.5, P < 0.005) on scale A and item 23 (U= 100, P < 0.05) on scale B. The only significant difference recorded in favour of the control group was for item 17 (U=68.5, P < 0.001) on scale B. Examination of mean rankings show a higher ranking for the primary nursing group on 17 of the 23 items. Diiussioa
The results of the present study provide some support for the hypothesis that patients nursed under a system of primary nursing would report greater satisfaction with the care they received than patients nursed under a traditional system. Statistically significant differencesbetween the two groups in favour of primary nursing were evident on six of
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KENNETHJ.
SELLICK,
SHIRLEYRUSSELL
AND JACQUELINEL.
BECKMANN
Table 3. Mean ranks and Z values on patient questionnaire items for primary nursing (PN) and control (C)groups Group
N
Mean ranks
How often was a nurse available when you wished to talk to her?
PN
28
29.50
C
30
29.50
How well do you think the nurses understood you?
PN
28
33.50
C
31
26.84
How much interest did the nurses show as to the effects of your illness on your family?
PN
27
34.13
C
29
23.26
How did you like your stay here, apart from the discomfort of your illness and being away from home?
PN
27
33.02
C
31
26.44
How much did the nursing care contribute to this?
PN
28
33.45
C
28
23.55
How well has a nurse helped you prepare and plan for when you leave hospital?
PN
26
25.29
C
17
16.97
Items
(2)
(5)
(7)
(9)
(10)
(11)
Z*
Significance level
0.00
NS
2.65
P < 0.005
3.08
P < 0.001
1.70
NS
2.47
P < 0.01
2.39
P < 0.01
*Corrected for ties. NS = non-significant (P > 0.05).
the 11 items which examined patients’ perception of care. Additional support is suggested by the absence of significant differences in the direction of the control group, and with the trend reflected in the higher ratings recorded on ten of the 11 items by the primary nursing group. Detailed examination of the items which were significantly different show that nurses on the primary nursing unit were perceived to have a greater understanding of the patient (item 5), showed more concern and communciated more with the patient’s family (items 6 and 7), were more likely to give information to the patient regarding his/her illness or condition (item 8), tended to contribute more to a positive experience of hospitalization (items 9 and lo), and gave greater consideration to discharge planning (item 11). These findings are compatible with the basic philosophy of primary nursing, which emphasizes accountability, patient-centred individualized care, and continuity of care from admission through to discharge (Marram van Servellen, 1980). That the perception of care under a system of primary nursing is more individualized is also noted in the response to item 1, where patients stated the number of nurses who provided their care over a 24 h period. The result recorded was a mean of 3.4 nurses for the primary nursing group compared to a mean of 6.9 for the control group. A similar result has also been reported by Watson (1978) where ‘patients in the primary units were very clear in stating that three nurses per day looked after them’ (p. 31). However, this finding is inconclusive in that it assumes a significant correlation between the number of nurses providing care and the level of patient satisfaction.
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Table 4. Mean ranks and II values for items on job satisfaction scales for primary nursing (PN) and control (C)groups
N Scale A (I) The opportunity to develop your skills and abilities (2) The chances you have to accomplish something worthwhile (3) The chances you have to do the things you do best (4) The chances you have to do something that makes you feel good as a person (5) The amount of pay you get (6) The amount of information you get about how well you are doing your job (7) The opportunity to change assignments periodically (8) The amount of job security you have (9) The degree of challenge in your job (IO) The opportunity to voice opinions (I 1) Work assignments according to preference (12) The way you are treated by the people you work with (I 3) The respect you receive from the people you work with (14) The friendliness of the people you work with (IS) Personal recognition within your work situation (16) The chances you have to take part in making decisions (17) Independence in making professional decisions Scale B (I 8) I have to work very fast (19) I have to have a high level of skill (20) I have to be creative (21) I have to do a variety of different tasks (22) I have to use all my skills and training (23) I set the pace of my work
PN Mean ranks
N
C Mean ranks
Mann- Significance Whitney level U test* NS
17 22.03 I6 22.06
20 16.42 20 13.44
118.5 71.0
P < 0.01
I6 19.06 I6 19.84
20 18.05 20 17.42
151.0 138.5
NS NS
I7 17.47 I7 18.74
20 20.30 I8 19.22
144.0 165.5
NS NS
I6 I6 I6 I7 16 I7 I6 16 I7 I7 I7
18.09 19.56 20.00 22.79 17.97 19.29 17.97 19.94 18.65 24.68 21.47
I8 20 19 19 I9 20 I9 I9 20 20 20
16.97 17.65 16.32 14.66 18.03 17.79 18.03 16.37 18.37 14.17 16.90
134.5 143.0 120.0 88.5 151.5 148.0 151.5 121.0 159.0 73.5 128.0
NS NS NS
I7 I7 17 I6 I7 I7
13.03 16.79 21.56 18.50 18.88 22.12
19 19 19 I9 19 19
23.39 19.14 15.76 18.50 16.28 15.26
68.5 132.5 109.5 161.5 122.0 100.0
-
P < 0.025
NS NS NS NS NS P < 0.005
NS P < 0.001
NS NS NS NS P < 0.05
*Corrected for ties. NS = non-significant (P< 0.05).
The degree to which the results support the second hypothesis is difficult to ascertain. Tentative support could be derived from the results on individual items, which show primary nurses were significantly more satisfied with their job in terms of the opportunity to accomplish something worthwhile (item 2), to voice opinions and participate in decision-making (items 10 and 16), and to set the pace of their work (item 23). In contrast to these findings, the control group recorded a higher ranking on six of the 23 items, only one of which was found to be statistically significant (item 18). It is important to note that items rated significantly higher by primary nurses accord with the philosophy of primary nursing, whereas the higher rating by the control group emphasizes task characteristics. Thus, it could be argued this finding represents support for, rather than against, the research hypothesis. A common feature of research evaluating primary nursing is the wide variation in subject populations and research methodology. This creates major problems when attempting valid comparisons across studies, despite the fact that a number of studies report findings which are notably similar to the results obtained in this study. In the research by Daeffler (1975), where similar questions were used to obtain a measure of patients’ perception of care, patients in a primary nursing unit were found to be signifi-
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SELLICK,
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AND JACQUELINEL.
BECKMANN
cantly better informed about their illness and aspects of care. Similarly, patients in the survey conducted by Watson (1978) perceived primary nurses as more understanding of their needs, and as showing greater consideration for the family. The degree to which the measure of staff satisfaction ‘compared’ with other studies could not be established because of the absence of universally accepted measures of job satisfaction and the tendency of the various measures to register different levels of response (Giovannetti, 1980). Another feature of the research which attempts to explore important nursing questions in the clinical field is the difficulty of controlling for extraneous variables, of obtaining reliable measures of experimental variables, and consequently the degree to which results can be generalized to other settings. This study is not exempt from these limitations, and at best could only be seen to meet the criteria of a quasi-experimental design. Sample selection was seen to be a major limitation as administrative procedure did not allow patients and staff to be randomly assigned to either the experimental or control units, and the possibility of selective recruitment could not therefore be excluded. Patients and staff were also aware that a study was being conducted; a situation which could result in a ‘Hawthorne’ effect or a bias resulting from the opportunity nurses from both units had to discuss their involvement in the study. The commencement of the study 3 months after primary nursing was introduced on to the experimental unit may have lessened the possibility of a novelty effect influencing the results. A second limitation relates to the measurement tools used to evaluate outcome variables. Although it was the aim to use measurement instruments which would yield quantitative data, and were sensitive enough to identify existing differences between the two groups, these fell short of the ideal standardized instrument. In the design of the questionnaires, an attempt was made to construct comprehensive items which had face validity, but unfortunately items were not given individual weighting, nor were the questionnaires subjected to validity and reliability checks. Likewise, the sensitivity of the instruments could be improved with more neutral wording of two items on the patient questionnaire (items 9 and 1l), greater specificity of some response options, and clearer instructions to overcome the problem where 11 subjects (3 experimental, 8 control) failed to respond to one or more items on the staff satisfaction scale. Finally, questionnaires were administered to patients on the day of discharge, but as Ciske (1974) points out, patients may be reluctant to criticize nursing care because of the power differences seen to exist between nurse and patient. It may be more appropriate for patients to complete the questionnaire following discharge from hospital to avoid the possibility of bias. Despite these methodological problems an attempt has been made to evaluate the effects of primary nursing on two important outcome variables using a relatively rigorous research design with appropriate statistical analysis. Although this study provides some support for the beneficial effects of primary nursing as a system of care, it also highlights an obvious need for more stringent research to systematically evaluate the many questions which remain unanswered. References Ciske, K. L. (1974). Primary nursing evaluation. Am. J. Nurs. 74,1436-1438. Daeffler, R. J. (1975). Patients’ perception of care under team and primary nursing. J. Nurs. Admin. 5,20-26. Eichhorn, M. L. and Frevert, E. I. (1979). Evaluation of a primary nursing system using the Quality Patient Care Scale. J. Nurs. Admin. 9, 1I-13.
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Felton, G. (1975). Increasing the quality of nursing care by introducing the concept of primary nursing: A model project. Nurs. Rex 24,27-32. Giovannetti, P. (1980). A comparison of team and primary nursing care systems. Nurs. Dim. 7,96-100. Hegedus, K S. (1979). A patient outcome criterion measure. Sup. Nurse 10,40-45. Hegedus, K. S. (1980). Primary Nursing: Evaluation of professional nursing practice. Nurs. Dim. 7,85-89. Hopkins, K. D. and Glass, G. V. (1978). Basic Statistics for the Behavioral Sciences. p. 322. Prentice-Hall, Englewood Cliffs. Manthey, M. and Kramer, M. (1970). A dialogue on primary nursing. Nurs. For. 9,356-363. Manthey, M., Ciske, K., Robertson, P. and Harris, I. (1970). Primary nursing a return to the concept of ‘my nurse’ and ‘my patient’. Nurs. For. 9.65-83. Marram, Cl. (1976). The comparative costs of operating a team and primary nursing unit. J. Nurs. Admin. 6, 21-24.
Marram, G., Barrett, M. W. and Bevis, E. 0. (1979). Primary Nursing: A model for individual care. C. V. Mosby, St. Louis. Marram Van Servellen, G. (1980). Evaluating the impact of primary nursing: Outcomes. Nurs. Dim. 7,48-50. Nichols, G. A. (1971). Job satisfaction and nurses’ intention to remain with or to leave an organization. Nurs. Res. 20,218-228. How do you like your job? (1977) Psychology Today 11,73-79. Risser, N. L. (1975). Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nurs. Res. 24,45-52. Siegel, S. (1956). Nonparametric Statistics for the Behavioral Sciences. McGraw-Hill Kogakusha, Tokyo. Steckel, S. F., Barnfather, J. and Owens, M. (1980). Implementing primary nursing within a research design. Nurs. Dim. 9,78-81. Watson, J. (1978). Patient evaluation of a primary nursing project. Aust. Nurs. J. 8,30-33. (Received 24 November
1982; acceptedforpublication
8 August 1983)