The Relationship between Nurse Staffing and Patient Satisfaction in Emergency Departments by Imtiaz Daniel A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Institute of Health Policy, Management and Evaluation University of Toronto © Copyright by Imtiaz Daniel, 2012 ii The Relationship between Nurse Staffing and Patient Satisfaction in Emergency Departments Imtiaz Daniel Doctor of Philosophy Institute of Health Policy, Management and Evaluation University of Toronto 2012 Abstract Patient satisfaction is a key outcome measure being examined by researchers exploring the relationships between patient outcomes and hospital structure and care processes. Only a few non-generalizable studies, however, have explored the relationship of nurse staffing and patient satisfaction with nursing care in emergency departments of hospitals. This dissertation aims to address that gap. Using more than 182,000 patient satisfaction surveys collected over a five-year period from 153 emergency departments (EDs) in 107 hospitals throughout Ontario, this study explores the relationship between nurse staffing and patient perceptions of nursing care in a range of Canadian ED settings, including urban and rural, community and academic, and small and large healthcare institutions with varying sizes and case mix. Using an established conceptual framework for investigating the relationship between nurse staffing and patient outcomes, nineteen nurse staffing variables were initially investigated. Ultimately, however, only five staffing variables were used in the multi-level regression analyzes. These five variables included registered nurse (RN) proportion, RN agency proportion, percent full-time nurse worked hours, RN worked ii iii hours per patient length of stay and registered practical nurse (RPN) worked hours per length of stay. Emergency department case mix index, patient age and gender, hospital peer group, size, wait times, cleanliness of the emergency department, physician courtesy, and year of measurement were controlled to account for their effect on the relationship between nursing staffing and patient satisfaction in the ED. The study revealed a subset of six patient satisfaction variables representing the overall variation in patient satisfaction with nursing care in the ED. Although RN proportion and RPN worked hours per length of stay were found to have a statistical association with patient satisfaction in the ED, the association was weak and not administratively actionable. Interpersonal and environmental factors such as physician and nurse courtesy, ED cleanliness and timeliness, however, were areas which hospital administrators should consider since they were highly associated with patient satisfaction in EDs. iii iv Acknowledgments I would like to express my sincere gratitude to my supervisor, Jan Barnsley, and my committee members, Linda McGillis Hall, George Pink, and Antoni Basinski for providing support and guidance throughout the research process. Special thanks to Jan for keeping me focused and moving forward. I also wish to thank the Ontario Ministry of Health and Long-Term Care, the Canadian Institute of Health Information, and the Ontario Hospital Association for providing access to data required for this research. Special thanks to Carey Levinton and Kevin Yu for their advice on data linkage and analysis. I am grateful to Carol Brewer from the University of Buffalo and Sean Clarke from the Faculty of Nursing for serving as my examiners and for their valuable suggestions for subsequent research. I am very grateful to my late father, Sonny, my beloved mother, Shaira, and my entire family for their support, encouragement and assistance. My wife, Yen, provided inspiration, encouragement and motivation. Without her, this thesis would not have been possible. To my daughter, Kaitlyn: I adore you and appreciated having you in my office, colouring my text books, while I was working on my thesis. iv v Table of Contents ACKNOWLEDGMENTS........................................................................................................................................ IV LIST OF TABLES.................................................................................................................................................... VI LIST OF FIGURES.................................................................................................................................................VII LIST OF APPENDICES....................................................................................................................................... VIII CHAPTER 1 INTRODUCTION................................................................................................................................1 1.1 STATEMENT OF THE PROBLEM.....................................................................................................................1 1.2 AIM OF STUDY.............................................................................................................................................2 1.3 SIGNIFICANCE OF STUDY .............................................................................................................................3 1.4 CONCEPTUAL FRAMEWORK ........................................................................................................................5 1.5 HYPOTHESES ...............................................................................................................................................8 CHAPTER 2 LITERATURE REVIEW..................................................................................................................10 2 OVERVIEW.....................................................................................................................................................10 2.1 BACKGROUND - EMERGENCY DEPARTMENTS ...........................................................................................11 2.2 STAFFING MODELS....................................................................................................................................14 2.3 NURSE STAFFING METHODOLOGY ............................................................................................................17 2.4 FACTORS INFLUENCING NURSE STAFFING.................................................................................................20 2.5 NURSE STAFFING MEASURES ....................................................................................................................22 2.6 PATIENT SATISFACTION WITH NURSING CARE ..........................................................................................33 2.7 INSTRUMENTS FOR MEASURING PATIENT SATISFACTION WITH NURSING CARE .......................................36 2.8 FACTORS ASSOCIATED WITH PATIENT SATISFACTION WITH NURSING ......................................................40 2.9 NURSE STAFFING THEORETICAL FRAMEWORKS........................................................................................49 2.10 SUMMARY .................................................................................................................................................51 CHAPTER 3 METHODS AND PROCEDURES ...................................................................................................53 3 OVERVIEW.....................................................................................................................................................53 3.1 STUDY DESIGN..........................................................................................................................................53 3.2 SAMPLE.....................................................................................................................................................58 3.3 POWER ANALYSIS .....................................................................................................................................59 3.4 DATA COLLECTION ...................................................................................................................................59 3.5 DATA ACCESS ...........................................................................................................................................67 3.6 DATA ANALYSIS .......................................................................................................................................67 CHAPTER 4 RESULTS ...........................................................................................................................................79 4 OVERVIEW.....................................................................................................................................................79 4.1 PATIENT SATISFACTION ............................................................................................................................79 4.2 EMERGENCY DEPARTMENT CHARACTERISTICS.........................................................................................87 4.3 RESEARCH QUESTIONS ANALYSIS.............................................................................................................96 4.4 SUMMARY ...............................................................................................................................................107 CHAPTER 5 DISCUSSION AND CONCLUSION..............................................................................................115 5 OVERVIEW...................................................................................................................................................115