Progress in applying patient experience in nursing quality improvement

Accepted Manuscript Progress in applying patient experience in nursing quality improvement Cheng-Shuang Wang, Mei-Zhen Zhao, Tie-Ying Zeng PII:

S2095-7718(17)30004-X

DOI:

10.1016/j.cnre.2017.03.001

Reference:

CNR 76

To appear in:

Chinese Nursing Research

Received Date: 20 June 2016 Revised Date:

14 August 2016

Accepted Date: 5 December 2016

Please cite this article as: Wang CS, Zhao MZ, Zeng TY, Progress in applying patient experience in nursing quality improvement, Chinese Nursing Research (2017), doi: 10.1016/j.cnre.2017.03.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT This project was supported by General Project of the National Natural Science Foundation of China (No. 71573097). *Corresponding author. E-mail address: [email protected] (T. -Y. Zeng). Peer review under the responsibility of Shanxi Medical Periodical Press. ☆

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Cited information: Wang CS, Zhao MZ, Zeng TY. Progress in applying patient experience in nursing quality improvement. Chin Nurs Res. 2017; 1: xx-xx. Review article

Progress in applying patient experience in nursing quality improvement ☆

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Cheng-Shuang Wang a, Mei-Zhen Zhao b, Tie-Ying Zeng b, * a School of Nursing, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China b Nursing Department, Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei 430030, China

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Keywords Patient experience Service quality Quality improvement Quality standards Precautions

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ARTI C LE I N FO Article history: Received 20 June 2016 Received in revised form 14 August 2016 Accepted 5 December 2016 Published 20 March 2017

ABSTRACT Background: Improving and sustaining the quality of nursing care is an intractable and persistent challenge. The patient experience of nursing care can give a different perspective on nursing quality and help clinical nursing staff to direct quality improvement. Attempts to identify what is patient experience, the relationship with nursing care, and the application of patient experience in nursing quality improvement practice, in order to provide advices for constructing the quality standards and quality improvement strategies of nursing care. Methods: We conducted a literature review of original research publications. The databases Pubmed, Web of Science, CNKI and Wanfang were searched from inception until end of August 2015. After screening retrieved articles, 40 sources

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(articles and organizational websites) were selected for analysis for the connotation, development and application of patient experience in nursing quality researches. Results: Our study identified several concepts about patient experience, roughly sorted out the development path of patient experience in worldwide and the application of patient experience in nursing quality improvement. It points out four precautions when applying patient experience in nursing quality improvement, which are differentiating patient satisfaction and patient experience, choosing appropriate data collection method and appropriate feedback time, and the last but the most important, applying theories to actual clinical practice. Conclusions: Professional indexes is important to maintain the care quality, but it cannot fully reflect quality of nursing care, which need patient experience as the supplement. Nursing staffs need to make more efforts to enhance patient’s nursing care experience, and apply the research results to clinical practice, and finally make patient-centered care come true. For future study, the evaluation system and management strategies about patient experience need to be developed to guide nursing quality improvement. 1. Introduction

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Patient experience, one theme of the quality of care, 1 is consistent with the idea of “patient-centered care”, and it has been considered an important indicator of medical service quality. In recent years, it has been playing an increasingly significant role in the quality assessment and quality improvement of medical care and has been increasingly used worldwide. The International Joint Commission includes patient experience as an evaluation criterion in the accreditation of healthcare organizations. 2 The National Health and Family Planning Commission and State Administration of Traditional Chinese Medicine is implementing a plan called “To further improve the medical service action” to improve the patient experience in China. However, there is limited research on predicting and improving the nursing quality and patient experience in China. This article reviews the progress and application of the patient experience in nursing quality improvement in recent years to provide suggestions for developing nursing quality standards and strategies for nursing quality improvement. 2. Connotation and development of patient experience 2.1. Connotation of patient experience The concept of patient experience was proposed in the 1980s. 3 The National Health Service Constitution (NHS) for England considers a good patient experience as the basic element of good quality of care. 4 Shale 5 asserted that the patient experience included the physical illness experience, service experience and life experience with the disease. Additionally, the Beryl institute defines the patient experience as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care”, which includes four key elements: interaction, culture, perceptions and continuum of care. 6 To date, there is

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no uniform definition of the patient experience because it is multi-structured and multi-dimensioned. 3 Most researchers tend to agree that the patient experience has the following characteristics: occurs throughout the process of care, is aligned with patient-centered care principles, emphasizes the patient and their families’ expectations, focuses on individualized care, and incorporates more than patient satisfaction. 7 2.2. Development of the patient experience In the last two decades, the patient experience has received special attention in medical care. Substantial research on quality evaluation and improvement of medical care based on the patient experience has been performed. The framework, quality standards and clinical guidelines 8 of nursing care were established by the Institute of Medicine (IOM), 9 Picker Institute, 10 Picker Institute Europe, 11 and National Quality Board (NQB) of England. 12 They are also applied in clinical practice to improve the quality of clinical care. 13, 14 Since the 1980s, China’s healthcare institutions and related researchers have mainly performed studies on patient satisfaction to improve the quality of care, but there have been few reports on the patient experience. Tian et al. 15 used the SERVQUAL model and the concept of patient experience to establish medical services, such as quality key indicator systems, and formulated the patient experience questionnaire, which includes six dimensions, namely, tangibles, reliability, responsiveness, assurance, empathy and continuity, and 50 items with factual options. In 2015, the implementation of the “To further improve the medical service action” plan placed the patient experience improvement project on the health care reform agenda. Patient experience has become increasingly prominent in healthcare quality improvement efforts. 3. Application of patient experience in nursing quality improvement

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3.1. Relationship between patient experience and nursing quality IOM considered good care quality as care in which healthcare institutions made use of existing expertise to provide continuous service for individuals or groups as well as improve patients’ health outcomes. 16 Chinese nursing researchers generally believe that quality of care is the synthesis of the effect of nursing care technology and the extent of the satisfaction of patients’ needs. In 2012, the good quality of nursing service action advocated by the Ministry of Health of China stressed that all nursing activities should be performed with the patient-centered principle. Nursing care activities are centered on patient, and the above definitions and policies reflect that quality improvement should be based on patient needs and expectations. However, the demands and expectations directly expressed by patients are not always reasonable, which may interfere with nursing care content, and quality improvement is difficult to achieve. However, the patient experience is evaluated with a post-event survey that reflects whether patients’ expectations are satisfied after nursing services are completed, which can make the patient’s needs and expectations be described as more reasonable. Patient experience not only reflects the patient’s perception and

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concerns with nursing care but can also expose the inadequacies in both the process of nursing activities and the construction of the medical environment. In care quality assurance, patient experience is necessary to the supervision and evaluation of current quality improvement projects. 3.2. Research status on patient experience in nursing quality improvement When the patient experience was applied to guide health care quality reform, studies on refining the content of the patient’s nursing experience gradually emerged, which covered a number of specific nursing care areas. The factors influencing the patient experience were expanded and induced by collecting patient’s opinions on nursing care related activities in hospitals. Environment, staff characteristics, direct nursing hours, patient involvement, information, communication skills, response time, empathy, respect for family members and awareness of patient needs were considered as predictors of a good patient experience. 17-21 Meanwhile, Rantz et al. 22, 23 designed the Observable Indicators of Nursing Home Care Instrument (OIQ) based on the elderly resident perceptions. The instrument contains multidimensional aspects of nursing home care quality, such as the staff, care, family involvement, communication, homelike feeling and environment. Additionally, the conclusions of Rantz’ study were supplemented with the nurse-patient interaction by Nakrem. 24 Trust, being treated as a person and self-esteem were emphasized in home care as well. 25 All efforts have been made to improve the patient experience in clinical practice, and Pemberton et al. 26 successfully improved the patient experience and quality of care through establishing a quality improvement model based on prior scientific studies. Researchers in China have also made unremitting efforts to improve the quality of nursing care. Yang et al. 27 combined nursing home care quality indicators with the environment, nursing professional competence, quality management, basic human rights, caregivers’ attitudes, social interaction and resident’s needs being met based on the views of residents. In recent years, mainland scholars have mainly explored the feasibility of using patient expectations and perceptions to guide nursing quality improvement in general hospitals. The perceived nursing service instrument was formulated based on the Two-factor Theory and SERVQAUL models to compare the patient expectations and patient perceptions. 28 Studies on constructing theoretical nursing care quality evaluation systems 29, 30 and describing current nursing care quality 31 were widely conducted. Chang et al. 32 used the nursing quality criteria proposed by IOM as a framework and built an inpatient satisfaction scale that contains 11 dimensions and 47 items. Additionally, 4 Likert-type factual questions were used in the investigation, and respondents were asked to answer questions about the nursing activities they experienced. Compared with other countries, China rarely explores themes related to a patient’s nursing care experience, and the experiences in nursing homes and community nursing care also require further study. In addition, the effect of applying research results to clinical nursing quality improvement is rarely reported. We need to pay close attention to these features in the future. 4. Precautions for applying patient experience in nursing quality improvement

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4.1. Patient experience vs. patient satisfaction For a long time, the concepts of patient experience and satisfaction were difficult to distinguish, and some researchers thought that patient satisfaction is equivalent to the patient experience. However, the meaning of the patient experience goes far beyond patient satisfaction. 33 Patient satisfaction describes the patient feelings about nursing issues. The results of patient satisfaction surveys can indicate whether patients are satisfied with nursing issues, but what patients are actually concerned about has been ignored. For this reason, satisfaction reports do not imply the causes of unsatisfied conditions, and they cannot direct what we can do to improve patient satisfaction. By contrast, the patient experience is the patient’s perception about caring behavior based on the statement of facts, 34 which can demonstrate deficiencies in the process of nursing care. We can clarify factors that influence the patient experience and determine nursing service quality defects according to the real experiences and feelings provided by patients. 21 Patient experience surveys can do better than patient satisfaction in helping nursing managers improve the nursing quality. 4.2. Data collection method To find the direction of nursing quality improvement, quantitative and qualitative research methods are used. The questionnaires were nearly self-designed in quantitative surveys, which contained factual options (yes / no / no need, or fact statement), and they were analyzed using relevant statistical methods. 35 The analyzing processes of quantitative studies are simple, and the results can be replicated. However, the limitation of quantitative studies is that they can rarely explore new themes of patient experience because most items in the questionnaires were derived from prior studies and the researchers’ work experiences. Qualitative studies were conducted through focus groups and personal interviews, 17, 19 and patient interview data can be analyzed in more depth, helping us comprehensively understand the connotation of patient experience. However, the results of qualitative studies are regional and are therefore difficult to replicate, and the research process is relatively cumbersome. 36 Therefore, if we want to improve nursing quality, we need to describe the patient experience through qualitative with quantitative research methods. To obtain the connotation themes of patient experience through qualitative interviews, nursing quality defects were searched and the effect of nursing quality improvement measures was evaluated by questionnaire-based quantitative investigations. 4.3. Experience feedback time There is no definite conclusion about the best feedback time to obtain the patient experience. In general, feedback is preferably collected immediately after a patient has experienced a certain type of care. However, we recommend caution for temporary emotional fluctuations generated from other reasons that may confuse the patient experience. Feedback time delays can make patients calm down to think about whether the nursing care they received is good or bad. However, if the data collection time is delayed too long, it is likely to cause recall bias, and the patients’ perceptions of their experiences will be slowly forgotten. 37 Considering the above factors, the

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data collection time needs to be appropriately extended; however, “appropriately”, it is not easy to grasp. Edwards 38 chose to collect the patient experience within 2 weeks after the patient was discharged from the hospital. Additionally, the data of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) were collected in a range of time from 48 hours after admission to 42 days after discharge. 39 To improve the credibility of the research results and obtain more reliable patient experiences, the feedback time must be considered. 4.4. Directions for nursing quality supervision Many studies focus on the development of patient satisfaction, nursing behavior perception and patient experience assessment tools. 15, 28 However, in the complex work of improving quality of care, we also need to create suitable quality improvement strategies to enhance the patient experience. Focusing on the patient experience throughout the whole process of care and creating management strategies are the concrete implementations of patient-centered principles in nursing care. Scientifically and practically applying theories to actual work rather than floating on the surface seems to be more meaningful to nursing quality improvement. At the same time, we need to realize that the action for improving the patient experience not only requires patient involvement, it requires the active participation of nursing staff members 26 who are an integral part in the process of nursing quality reforms. 5. Conclusions

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In conclusion, nursing staff have been striving for nursing quality improvement for a long time, and they have produced a series of nursing quality sensitive indexes. 40 However, these professional indexes do not fully reflect the quality of care, which requires patient experience as a supplement. However, studies on patient nursing care experiences are rare in China, and the nature and connotation of the patient’s nursing care experience has not previously been reported. Therefore, to further improve the quality of nursing care, nursing staff need to make more efforts to enhance patients’ nursing care experiences and apply the research results to clinical practice, which will eventually make patient-centered care possible. Conflicts of interest

All contributing authors declare no conflicts of interest.

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