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Patient Satisfaction as an Indicator of the Quality of Nursing Care By Helena Leino-Kilpi and Jaana Vuorenheimo
Biography Helena Leino-Kilpi, PhD., R.N., Assistant professor, University of Turku, Department of Nursing. Jaana Vuorenheimo, MNSc., R.N., Senior lecturer, University of Turku, Department of Nursing, Turku, Finland Abstract This paper deals with the patientsatisfaction, as an indicatorof the qualityof nursingcare. Theliterature review and a Finnish empirical illustra-
Introduction An important priority on the health policy agenda of the 1990s, both in Finland and elsewhere, is the definition, evaluation and assurance of the quality of nursing care. Although the history of quality evaluations goes as far back as nursing care itself, it is only in recent decades that we have seen a more systematic effort both in evaluation and in the use of its results (1, 2, 3, 4). The traditional method employed in research to find out what patients think about the quality of nursing care has been one of indirect inference in the context of some other issue or topic. In recent years, however, there has been an increasing tendency to use the patient perspective for definition and evaluation purposes (1, 5, 6, 7, 8, 9, 10). Patient evaluations have usually been based on the patient's level of satisfaction. Vuori (11) identifies three possible functions for patient satisfaction: it can serve as an attribute of good quality care; as an indicator of good quality care, reflecting the patients' views on different aspects of care; and, third, as a precondition for quality care, the assumption being that satisfied patients are more inclined to follow the instructions given and to come back
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tion, using patient interviews, are included inthe article. The results indicate a high level of satisfaction. However, there is no basis to use the measurement of patient satisfaction as a soleindicator of the quality of care, becausethe satisfied patients expressed also reasons for dissatisfaction. Key words Patient satisfaction, quality indicator, quality assurance.
for care later (see also 12). All of these functions can be identified in previous studies on patient satisfaction. In nursing research, patient satisfaction is used most frequently to evaluate the effects of particular interventions (10). This article looks at patient satisfaction, its content and meaning as an indicator of the quality of nursing care. Our purpose is to discuss the use of satisfaction measures in the evaluation of the quality of care, using an empirical example from our own research project as a case in point (8, 13, 14).
Review of the literature Patient satisfaction has been measured in many different ways with the aim of describing the quantity and quality of satisfaction. We analysed 41 scientific study reports published between 1974 and 1991 in Finland, Scandinavia, UK and USA (Table 1). Most of the reports dealt with both hospital patients and outpatients. The mean sample size was 335 patients, ranging from 20 to 2117 patients. In most cases (N = 33) the data were collected by means of a questionnaire; seven used interviews and one patient letters. We also examined some metaanalyses and summaries of patient
satisfaction studies (10, 12, 15, 16, 17,18,19,20,21). Most of the studies were based on instruments that had been developed earlier and that were now being tested. The most popular scale in our sample (N = 56) was Risser's Patient Satisfaction Instrument (PSI) and its modifications (22,23,24,25, 26, 27, 28). PSI (22) evaluates the patients' attitudes towards nurses and nursing. The instrument consists of 25 items, with a five-level likert-type scale for each item. It is divided into three content areas: 1) technical-professional, 2) educational relationship and 3) trusting relationship. The first content area includes items referring to technical skills, knowledge base and carefulness. The items related to educational relationship measure patient satisfaction with the nurses' teaching and supervision skills and their informativeness. The items in the third content area measure the patient-nurse relationship and the humanity of the nurse. Most PSI modifications have changed the number of items and their content (23, 24, 28). Lucas et al. (27) added one new item to PSI, i.e. overall satisfaction. Another common instrument used in the measurement of patient satisfaction is the Ware Satisfaction
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. . . - - - - - - - - - - - - - Helena Leino-Kilpi, Jaana Vuorenheimo - - - - - - - - - - - , Scale, which was originally developed in the 1970s (12, 29, 30, 31). Ware et al. (12) created a taxonomy with eight dimensions that form the main source of satisfaction: 1) art of care, 2) technical quality of care, 3) accessibility/convenience, 4) finances, 5) physical environment, 6) availability, 7) continuity and 8) efficacy/outcomes of care. According to Ware et al. (12, see also 32), patients tended to be more satisfied when providers gave more information (33, 37), when they were counselled by a physician, when payment plans were explained, when providers were happier and had more favourable attitudes towards patients, and when providers showed a personal interest. Patients are also more satisfied when the provider has time for them and when the continuity of care is assured. Franklin & McLemore (34), Zyzanski et al. (35) and Hulka et al. (36) used the Thurstone Scale, which was developed in the 1950s. Consisting of 42 items and using the Likert scale, this instrument measures patient satisfaction in three areas: 1) the professional competence of the physician, 2) the personal qualities of the physician and 3) cost/convenience. The results of the satisfaction studies vary depending on the purpose and interests of the study; this is why a comparison of the results is difficult (10, 12, 15, 16). In Finland, the study made by Sarvimaki (37) is especially comparable with this study. She describes (37) the level of satisfaction of Finnish surgical patients (N = 99). As a general rule it seems that most patients are satisfied with the quality of nursing care, as is the case also in the study of Sarvimaki (37, also 43, 44). The level of satisfaction is highest among hospital patients, who also form the biggest target group (1,16). Nonetheless there are also patient groups who are not fully satisfied with the care they receive (15). In the literature, there is a lack of international comparison of this topic. However, Sarvimaki (37) has started the comparison between Finland and Sweden by using the same questionnaire (SPRI).
There are numerous studies that have explored the impact on satisfaction of various socio-demographic factors, such as age, sex, socio-economic status, level of education, marital status, race or ethnic group and family size (12, 38, 39). The role of patient confidence in the health care system and his or her feelings of internal control have also been used as explanatory factors (40). Ware et al. (12) have presented a summary of the results that show an association between certain socio-demographic factors and patient satisfaction. Older patients seem to be more satisfied with the behaviour of health care workers than younger patients, although they are less satisfied with access to health care services and with the outcomes of care (cf. 41). Dissatisfaction with medical care in general and with the behaviour of the providers tend to be more common among those with a lower level of education (see also 42). Family size also seems to be a relevant factor, as patients from bigger families appear to be more dissatisfied with access to care. Further, people in the low income bracket are less satisfied with access and the outcomes of care. Those in higher occupational positions (e.g. 41) and women (e.g. 36) tend to be more satisfied. According to the findings of Ware et al. (12), patient satisfaction is not associated with marital status, race or social class. Hall & Dornan (39) conclude that socio-demographic factors in general have only limited influence on the general level of patient satisfaction.
An empirical illustration Patient satisfaction is also a central concern in our ongoing research project (8, 14), where satisfaction is defined as a key indicator of the quality of nursing care. The project addresses two main questions: 1) What is the level of satisfaction among surgical hospital patients? and 2) What are the reasons for dissatisfaction?
charge from two hospitals in autumn 1990. The background variables used for explaining experiences of satisfaction were sex, age, place of residence, occupation, marital status, payment category, reason for hospitalization, type of anaesthesia, earlier hospitalizations, self-perceived health and restrictions in functional ability at the time of discharge. Men outnumbered women in the sample (54% vs. 46%). The mean age of the patients was 50 years, ranging from 18 to 88 years. One quarter lived in rural areas and three quarters in urban areas. Over half of the patients (58%) represented blue-collar and lower white-collar positions; one quarter (24%) were in upper white-collar positions and 16 % were pensioners. Most of the patients (66%) were married; 25 % were divorced or widowed; and 10 % were not married. Almost one fifth (18%) were private patients. All of the patients in the sample had previous hospitalizations (mean 3-4 times). A wide range of surgical problems were represented: the largest single categories were backoperated (30%) and abdominal surgery patients (24%). Almost all of the patients (94%) had had some operation, usually under general anaesthesia (71 %). Only six patients were in hospital for three days or less: the majority spent 4-7 days in hospital. Three percent of the patients described their condition as excellent; 76% as good; 20% as satisfactory; and two patients as poor. Two thirds (64%) of the patients suffered from some restrictions in functional ability related to the operation; in most cases (52%) these were restrictions in moving.
Data The data were collected by interviewing a random sample of 132 surgical hospital patients upon dis-
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Table 1. Summary of instruments and dimensions measuring patient satisfaction with nursing care
Investigators
Scaling method
Aday & Andersen (1975)
Faktor Analytic/ Likert
Abramovitz et al. (1987)
Faktor Analytic/ Likert
Bader
Patient
(1988)
Satisfaction Instrument (PSI) Likert
Brody et al. (1989)
ware Satisfaction Scale (modified) Likert
Carey & Posavac (1982)
Printed survey Factor Analytic
Chew (1989)
Semistructured interviews Content Analysis
Dimensions 1) AccessNinances 2) Art ofcare/ technical Quality
Items
Sample size
Investigators
Scaling method
Dimensions
Items
11
2000
Courts (1988)
Combined Likert, Patient and family 9 satisfaction with care open-ended, "checklist" inrehabilitation hospital
1) Admission 35 2) Attending physicians 3) House staff 4) Nurses 5) Nurse's aides 6) Housekeeping 7) Food services 8) Escort 9)Other staff 10) Miscellaneous services
841
Dayton (1988)
Yes/no-checklist, Satisfaction with open-ended, outpatient care multiple choice Questionnaire
1) Technicalprofessional area 2) Patient education area 3) Trusting area
25
50
1) Examination 10 2) Tests 3) Medications 4) Nondrug treatments 5) Education 6) Stress counseling 7) Negotiation
118
1) Admissions 2) Nursing care 3) Housekeeping 4) Food services 5) Hospital services as a whole
176
54
1) Food 2) Toilet/washing facilities 3) Cleanliness ofthe ward 4) Bed 5) ward routines 6) Nurse response to request 7) Rapport with staff 8) Provision of information 9) Discussion ofcare being provided 10) Physical care 11) Technical care 12) Discharge arrangements 13) Overall satisfaction
Cleary & LeRoy (1989)
Combined Likert, Overall satisfaction with care in hospital open-ended, "checklist"
Collins (1975)
Interview
11
DiMatteo et al. Structured (1980) interwiev
1) Communication skills 2) Techn ical skills 3) Art of care
3
462
DiMatteo et al. Visit-spesific (1986) Satisfaction Scale/ Likert
1) Communication skills 2) Affectiv care 3) Technical care
25
329
Doering (1983)
Structured Questionnaire
1) Hospital 11 environment 2) Food services 3) Information 4) Treating 5) Needs 6) Willingness to return 7) Overall satisfaction
656
Engstrom (1984)
Interview
Satisfaction with information
120
Eriksen (1987)
1) The plan of 49 136 The Patient nursing care Satisfaction with 2) Attending physical Nursing care needs Check list 3) Attending non-physical Check list needs 4) Evaluation of achievement ofnursing care objectives 5) Protection ofall patients by following the unit procedures 6) Administration and managerial services
Feletti et al. (1986)
6-step Likert
Ferguson (1983)
Yes/no-checklist, Patient concerns with hospital care comments
Ferrans (1987)
Structured interview/ Likert Faktor Analytic
Franklin & McLemore (1970)
Thurstone Scale I General satisfaction Likert
43
41
Satisfaction with 20 nursing care in hospital
Sample size
8
1) Ideal physician 10 503 2) Latest consultation with primary care physician 26
27 Overall and spesific satisfaction with hospital care of haemodialysis patients 20
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Helena Leino-Kilpi, Jaana Vuorenheimo Investigators
Scaling method
Dimensions
Items
Gamotis et al. Patient (1988) Satisfaction Instrument (PSI)
1) Technical25 professional relationship 2) Education relationship 3) Trusting relationship
Guzman (1988)
Patient Satisfaction Questionnaire (PSQ)
Satisfaction with services and personal interactions in hospital
Structured questionnaire
Hospital services: 1) technical quality 2) functional quality 3) organizational image
Harju (1991)
183
Patient Satisfaction Instrument (PSI)
Hulka et al. (1975)
Thurstone Scale 1) Physicians 42 Likert professional competence 2) Physicians personal qualities in relationship with the pa tient 3) Accessibility to care (cost, convenience)
1713
Structured questionnaire
1112
Kovner (1989)
Scaling method
Like & Zyzanski (1987)
Patients' 1) Request for Perspective services Interview, 2) Received services Patient Request for Services Schedule, Patient Services Received Schedule
82
Linn (1975)
Structured questionnaire
Satisfaction with medical and nursing care inan outpatient clinic
21
Littlefield & Questionnaire! Adams (1987) Likert
Satisfaction with birthing experience and postpartum hospital stay
97
Lucas et al. (1988)
1) Technicalprofessional 2) Educational 3) Trusting area 4) Overall satisfaction
25
68
MacKeigan & ware Larson Satisfaction (1989) Scale! Likert
1) Explanation 44 2) Consideration 3) Technical competence 4) Financial aspects 5) Accessibility 6) Drug efficacy 7) Product availability 8) Quality of the drug product
1102
Mangen & Griffith (1982)
Sructured interview and questionnaire
Satisfaction with the perceived therapeutic relationship and overall satisfaction with care
11
McGivern (1972)
Questionnaire! Likert
1) Patient-nurse relationship 2) Patient-physician relationship 3) Information 4) Education 5) Overall satisfaction with received care
21
Satisfaction with received care
52
70
22
1) Length of the 5 consultation 2) Ability to communicate with the physician
559
Patient Satisfaction Instrument (PSI)
1) Technicalprofessional 2) Educational 3) Trusting area
22
laMonica et al. Patient (1986) Satisfaction Instrument (PSI)
1) Technicalprofessional 2) Educational 3) Trusting area
42
885
Larsson & Starrin (1990)
"Face Scale"
Interaction between patient and nurse
2
32
Leonard (1975)
Affect Expression Checklist
Patient attitudes toward direct and indirect nursing interventions
11
Ley et al. (1976)
6 questionnares
1) Overall satisfaction inhospital 2) Communication
Patient Satisfaction Instrument (PSI)! Likert
73
Moore & Structured Cook-Hubbard questionnaire (1975) and interview
Dimensions
Items
Sample size
Investigators
30
Hinshaw & Atwood (1981)
Hull & Hull (1984)
1) Technicalprofessional area 2) Educational area 3) Trusting area
Sample size
144
59
118
103 Morgan (1986)
Yes!No-checklist, Satisfaction with nursing activities in comments hospital emergency department
Nelson (1989)
Questionnaire! Likert
10
63 Satisfaction with care and hospital services
68
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Investigators
Scaling method
Niemela & Structured Makinen (1982) interview
Noon & Davero Questionnaire! (1987) open ended! Likert
Dimensions
Items
1) Access to care, 109 reception, discharge 2) Information 3) Services and treatment 1) Preoperative contact with nurse 2) Service departments 3) Day surgery unit 4) Nursing care 5) Postoperative teaching 6) Overall satisfaction with care
Questionnaire! 1) Services 5-step Likert 2) Request for information and Spielberger's 3) Received Anxiety Inventory information 4) Fears 5) Quality of care
120
Ostrowski & Routhier (1972)
Interview
Satisfaction with direct and indirect patient care in hospital
100
Pankratz (1981)
Questionnaire! Rating scale
Satisfaction with conditions, and treatmen!, trust, confidence, skill, competence, and interest of nurses and physicians
Oberst (1984)
Pienschke (1973)
Pope (1978)
Putterman (1990)
Sample size 600
48
20
14
Satisfaction with 28 nurses and physicians giving cancer patients information about their diagnosis and prognosis 15 Two question1) Technical quality naires openand competence ended! structured! 2) Access to the system for routine care rating scales 3) Access to the system in acute need 4) Cost in relation with benefits 5) The physicianpatient relationship 6) Patient corve nience and comfort 1) Surgical care 17 Questionnaire! 2) Nursing care rating scales 3) Anesthesia 4) Medications 5) Outcomes of care 6) The treatment as awhole Structured questionnaire! open ended! rating scales
1) Expectations Rempusheski Patient letters! et al. (1988) Grounded theory 2) Received care
3521
Scaling method
Dimensions
Risser (1975)
Patient Satisfaction Instrument (PSI) Factor Analytic! Likert
1) Technicalprofessional 2) Educational 3) Trusting area General satisfaction with care
25
138
3
1100
Sarvimaki (1990)
Structured questionnaire (SPRI)
1) Information 2) Nursing care 3) Services 4) Environment 5) Term of adress
63
99
Shukla & Turner (1984)
Questionnaire! Checklist of Patients
1) Satisfaction with care 2) Perceived omissions in care
50
56
Sinkkonen et al. (1988)
Structured questionnaire
1) Physical care 2) Psychological care 3) Social care 4) Spiritual care 5) Interaction, communication, social support 6) General satisfaction
206
Sutherland et al. (1989)
Two questionnaires Rating scales
1) Staff attitudes 2) Control over treatment decisions 3) Continuity of medical supervision
30
Tessler & Mechanic (1975)
Two homeinterviews! Factor Analytic
Satisfaction with medical care received by patient and family
386
Volicer (1974)
Interview! rating scales
Stress-producing events during hospitalization
Rojek et al. (1975)
Ware &Snyder Ware Satisfaction 1) Availability 2) Accessibility (1975) Scale!Likertl Faktor Analytic 3) Continuity 4) Finances 5) Art of care 6) Technical quality White (1972)
145
Items
Sample size
Investigators
Questionnaire! Likert
Zyzanski et al. Thurstone (1974) Scale! Likert
Satisfaction with nursing activities
45
47
19
433
50
42 1) Professional competence 2) Personal qualities 3) Accesslfinances 4) General satisfaction
426
63
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. - - - - - - - - - - - Helena Leino-Kilpi, Jaana Vuorenheimo - - - - - - - - - - - - , Results Overall satisfaction was measured with one structured question. Over half of the patients (53%) were very satisfied with the nursing care they received and 41% fairly satisfied (Table 2). These results are consistent with the findings of many previous studies of patient satisfaction (37, 43, 44). Table 2. Overall satisfaction with surgical nursing care (N = 132)
Satisfaction level
%
Very satisfied Satisfied Fairly satisfied Not at all satisfied
53 41 6
a
This general picture of patient satisfaction is supported by the finding that 50% of the patients spontaneously said that allthe nurses and 49% that part of them had been good/ professional/com petent. However, some of our interviewees also had complaints about the quality of nursing (Table 3). Almost one third of the patients (28%) said they had not received enough information during their stay in hospital. About one fifth complained that they had had problems getting into hospital, that they sensed an atmosphere of indifference on the part of the nursing and medical staff, and that they remained uninformed about the results of care. Lack of space and peace and quiet were also fairly common complaints. Table 3. Reasons for dissatisfaction (N=132)
Reason Lack of information during hospital stay Problems with access Indifferent staff attitudes Uncertainty about results of care Hospital environment Incompetent care Level of care in general Problems getting home
%
28 21 19 17 14 7 7 2
No statisticallysignificant correlations were found between the background variables analysed and experiences of satisfaction.
Discussion Patient satisfaction has here been
discussed and examined as an indicator of the quality of nursing care. In the light of this indicator and our empirical data, the quality of surgical nursing in Finnish hospitals is very good indeed: the vast majority of our patients were very satisfied with the care they received. The results are similar with other studies made in Finland (37, 43, 44). However, there are various problems involved in the use of patient satisfaction as a sole measure of the quality of nursing care (11, 15, 16, 45,46,47). One obvious indication of this is that many satisfied patients also had various complaints. Most of the studies have been done with hospital patients. Thus their fear of being punished may influence on their answers (10, 48, 49). Satisfaction itself involves two profoundly subjective elements: the patients' expectations with regard to nursing care and their evaluation of how it is actually implemented (11). Therefore a number of scholars and research teams have drawn serious attention to the reliability and validity of the various instruments used in the measurement of satisfaction, which, it is argued, have not been evaluated to the extent necessary (10,11,12,15,16,35). The commonest reason for dissatisfaction among our patients were lack of information during the hospital stay (33, 50), problems with access and treatment by the medical and nursing staff - all factors that have been included in previous satisfaction measurement tools (12, 22). On this basis it seems that Finnish evaluations of the quality of nursing care could make better use of these tools and their modifications. The meaning and role of satisfaction measurements in the effort to improve the quality of nursing care is not fully understood. Vuori (11), for instance, has criticized development programmes of nursing quality for their failure to make systematic satisfaction measurements. In the absence of systematic measurements, it is impossible to establish the true influence of these programmes on patient satisfaction or to identify the factors underlying patient satisfaction. Redfern & Norman (12) have also pointed out that the
quality of care is a broader concept than satisfaction and that satisfaction should therefore be seen as only one component of quality (see also 15,42,45). Most instruments used in the measurement of satisfaction are rigidly structured, and therefore they lend themselves to easy testing in different groups. At the same time, this rigidity has its negative side as well, for it imposes strict limits on the expression of satisfaction experiences (10). What is more, many of these instruments measure only the quantity of satisfaction rather than its content or the underlying cause of satisfaction (2,12). In any event, it is clear that patient satisfaction is fundamentally a matter of subjective views, and something that nursing staffs should take seriously (51). Whether the patient is right or wrong is really of no consequence; what matters is the patient's subjective experience. It is one indicator of the quality of nursing care. In future, there is a need for international and Scandinavian comparisons.
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litetsikringsarbeidet og arbeider med a klargjrore egne verdier, holdninger, ledelsesprinsipper og rolle. Kvalitetssikring skal innebeere at sykepleiere utvikler ny kunnskap, sterre ansvarlighet og profesjonell praksis. Dette er grunnelementer for a sikre og bedre kvaliteten i sykepleien. Valg av frernqanqsrnate er imidlertid helt avgjrorende for hvorvidt kvalitetssikringsarbeidet vii fere til bedre kvalitet. Skal rnalet vrere a forbedre omsorgen for pasientene, kan dette neppe skje gjennom direktiver fra ledelsen. Det ma vokse frem gjennom aktiv deltakelse og faglig stimulering av pleiepersonalet i deres daglige arbeid. Dette stiller nye krav til ledere: Det betyr en omstilling fra tradisjonelle lederroller og organisasjonsstrukturer til nyere former for ledelse med vekt pa delt ansvar og beslutningsmyndighet blant de ansatte. Det forutsetter videre en ledelsesfilosofi som er rotfestet i det samme verdi- og tenkningsgrunnlaget som den sykepleiepraksis ledelsen skal administrere, og organisasjonsformer som er i samsvar med dette. Dette er ikke bare viktig i forhold til kvaliteten i sykepleien. Det er ogsa vesentlig for a mete de utfordringer som sykepleietjenesten i dag star overfor og for a kunne tydeliggjrore viktigheten av sykepleiens bid rag i et sam let helsetilbud. Hvis sykepleietjenesten i fremtiden skal hevde seg som selvstendig profesjon og sykepleieledere skal utvikle en sykepleietjeneste av hey profesjonell kvalitet basert pa et eget sykepleiefaglig fundament, ma kunnskap om fag og verdier integreres med kunnskap om ledelse og organisasjon.
Referanser 1. Porter-O-Grady 1. Creative Nursing Administration. Participative Management into the 21st Century. Rochville, Aspen Publications, 1986. 2. Stevens B. Applying Nursing Administration Theory in Nursing Administration, in Chaska, Norma: A Time to Speak. London, McGraw Hill,1983. 3. Rossvrer T. Organisasjonsteorier i sosiologisk belysning, Tano 1987. 4. Joiner C, van Sevellen GM. Job Enrichment in Nursing. A Guide to
Improving Morale, Productivity, and Retention. Rockville, An Aspen Publication, 1984. 5. Herzberg F. Work and Nature of Man. The World Publishing, New York,1966. 6. Lancester J. Creating a Climate for Excellence. The Journal of Nursing Administration 1985; 1:18-9. 7. Peterson M, Allen D. Shared Governance: A Strategy for Transforming Organizations. The Journal of Nursing Administration 1986; 2: 11-6. 8. Kramer M., Schmalenberg C. Magnet hospitals Part I. Institutions of Excellence I. The Journal of Nursing Administration 1988; 2:13-4. 9. Kramer M, Schmalenberg C. Magnet hospitals Part I. Institutions of Excellence II: The Journal of Nursing Administration 1988; 2:1-19. 10. Holter 1M. Critical Theory: An Introduction and an Exploration of its Usefulness as a Philosophical Foundation for Developing Nursing Theories and for Guiding Nursing Practice and Administration. Oslo, Institutt for Sykepleievitenskap, Publikasjonsserie 1987; 10. 11. Hegyvary S. The Nursing Administrator: Advocate or Adversary. Kap. 49 in Chaska N. A Time to Speak. London, McGraw - Hill, 1983. 12. Miller K. The Human Care Perspective in Nursing Administration. The Journal of Nursing Administration 1987; VoI.17/2. 13. Norsk sykepleierforbund.KiH Kvalitet i helsetjenesten - et brukerfokusert system for kontinuerlig forbedring av kvalitet i helsetjenesten. 1991.
Patient Satisfaction as an Indicator of the Quality of Nursing Care Fortsat fra side 28 veystieteen lisensiaatintutkimus, Kuopion yliopisto. Kuopio 1987. 43. Niemela P. & Makinen A. Miten HYKStoimii. Osa3: Potilaiden kokemukset ja tyytyvaisyys hoitoon ja palveluihin sairaalassa. HYKS - Tutkimusjulkaisuja 2/1982. Helsinki. 44. Sinkkonen S., Paunonen M., Kinnunen J. & Laitinen A. Hoitotyon laadun maarittely ja mittaaminen tarveteoriaun pohjalta. Sairaanhoidon vuosikirja XXIV, SHKS, Helsinki 1988, p 105-143. 45. Eriksen L. Patient Satisfaction: An Indicator of Nursing Care Quality? Nursing Management 1987, Vol. 8, No.7, P 31-35. 46. Richards D. & Lambert P. The nursing process: the effect on patients' satisfaction with nursing care. Journal of Advanced Nursing 1987, Vol. 12, P 559-562. 47. Vuori H. Patient Satisfaction - An Attribute or Indicator of the Quality of Care? Quality Review Bulletin 1987, Vol. 13, No.3, P 106-108. 48. Pearson A., Durand I. & Punton S. Determining quality in a unit where nursing is the primary intervention. Journal of Advanced Nursing 1989, Vol. 14, P 269-273. 49. Virtanen V. Laakarin ja potilaan hoitosuhde. Tutkimus perusterveydenhuollon laakarin ja potilaan vuorovaikutuksesta. Acta Universitatis Ouluensis 1991, Series D, Medica 218. University of Oulu. 50. Engstrom B. The patients' need for information during hospital stay. International Journal of Nursing Studies 1984, Vol. 21, No.2, P 115130. 51. Harper-Petersen M. Measuring Patient Satisfaction: Collecting Useful Data. Journal of Nursing Quality Assurance 1988, Vol. 2, No.3, P 25-35.
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