**4.3 Patient needs**

Nurses documented and evaluated the needs of 378 patients. Another 106 (21.9%) patients were evaluated during the exploratory data analysis, based on the documented relations between categories within the unit. Unit A had the highest (27%) percentage of patients classified into category 2 – which meant that the patients were assigned by default and received supportive or partial assistance from nurses. In unit B, more than half (55%) of the hospitalized patients were assigned to category 1, which meant that they did not receive assistance with hygiene care, mobility, elimination, and feeding, they did not have infusion lines, and their vital signs were monitored less than six times every 24 hours. A few patients were assigned to the demanding category 3. In unit C, more than two fifths (42%) of patients were assigned to category 3, and these required complete assistance with regard to hygiene care, mobility, elimination, and feeding; the patients received tube care, or their vital signs were monitored more than six times every 24 hours.

The number of required staff was calculated by adjusting the factors from three to two shifts (from 24 to 16 hours) based on the patient needs classification system and the standards of staff requirements [39]. The index of the actual and required quantity of nursing staff showed that the medical ward deficit ranged from 22% to 43%, and none of the observed units had enough nursing staff.



*Congruence of Nurse Staffing and Activities with Patient Needs DOI: http://dx.doi.org/10.5772/intechopen.96589*

*RN, graduated (registered) nurse; NT, nursing technician; Nursing staff, includes RN and NTs; r, Pearson's correlation coefficient; R, Spearman's correlation coefficient; Statistical significance set at.95: \*\* < .00; \* < .050; Correlation strength: .0–.09 not correlated, .1–.3 weak, .31–.6 medium, .61–.1 strong correlation [43]; Patient satisfaction index, includes all 15 variables measuring patient satisfaction.*

#### **Table 3.**

*Relations between the patient satisfaction, nursing staff hours and nursing care activities.*

#### **4.4 The patients' perception of nursing quality**

The respondents were mostly women (n = 82, 56.9%), with an average age of 67.4 years (SD = 14.7). Fifteen (6.9%) questionnaires were filled in by relatives, 95 (43.6%) patients were helped by the researchers to fill in the form, and the remaining 110 (50.5%) questionnaires were filled in by the patients. The variable patient satisfaction was computed by aggregating all the items from the questionnaire.

The mean of the perceived nursing quality rating was 4.74 (*above good/high*) (SD = 0.49) and ranged from 3 (*good*) to 5 (*high*). The highest average score was for the item concerning the nurses' ability to help make the patients feel at ease, but the lowest average score was for the item concerning the nurses' prediction regarding what the patients needed.

Patient satisfaction with nursing care was associated with the respondents' status (patient or relative) (r = 0.278, p < 0.000), negatively correlated with the number of patients present daily at the unit level (r = −0.172; p < 0.00) and was predicted in nearly 10% (R2 = 0.098) from the number of patients in 2nd to 4th category.

In contrast, the patient satisfaction index was positively correlated with the number of nursing care hours per patient day (r = 0.118; p < 0.01), significantly for both profiles. Registered nurses' and nursing technicians' hours per patient day, along with the index of registered nurses' needed (needed vs. real number of registered nurses) predicted 5% (R2 = 0.054) of patient satisfaction with nursing care.

Moreover, *undivided attention* and *explanation* were positively correlated only with the volume of registered nurses' work hours. However, the item *things are done without asking* was negatively correlated with the working hours of nursing technicians. Patients' satisfaction with nursing care was not significantly correlated with the frequency of nursing staff activities in general, while significant correlations were found between the patients' satisfaction variables and the frequency of some direct patient care activities (**Table 3**).

If selected items from the questionnaire are added to the three presented nursing staff structural variables (registered nurses and nursing technicians' hours on patient day, the index of registered nurses' need) – namely *The nurse, helped my outlook become more realistic; Little things were done for me without asking; I was sure that nurses would be there when I needed them; I know that due to the nurses' efforts some problems were avoided; The nursing staff helped me manage the fears I had about my illness; The nurses made me feel relaxed when treatments were being done –* then together they could predict 96% (R2 = 0.961; α = 0.747) of the hospitalized patients' perception of the quality of nursing care.

#### **5. Discussion**

This study describes the correlation between patient perceptions of the quality of nursing care and nurse structure and process variables. Hospitalized patients' perceptions of nursing care quality was measured with a questionnaire, the nursing process was directly observed, and the data on nursing workforce and patient structure were obtained from routine hospital data. The results indicate a significant association between certain constants (actual and needed staffing levels, some nursing activities) and patient satisfaction.

In the researched medical ward the average number of patients per registered nurse was high, and only a third of the overall nursing hours were conducted by nurses with a bachelor's degree. Although, the number of staff did not deviate from that expected in European hospitals [44], the observed staffing levels could provoke rushed judgments about low quality of care. However, it should be noted that in the observed hospital the management calculates the number of registered nurses and nursing technicians together (as nursing staff), ignoring evidence on higher nurse staffing levels being reflected in better patient outcomes [8, 15, 18, 45, 46]. With the use of two profiles of nursing staff, the productivity levels, number of nurse working hours and nurse–patient ratios appear to be good. But this hospital is employing cheaper nursing technicians instead of registered nurses, and this lowcost approach ignores actual patients care needs, actual unit occupancy rates, and staff competences and, as a consequence, the graduate staff are overloaded.

This study showed also that patients were more satisfied when the proportion of baccalaureate nurses in the nursing workforce was higher. While these results support the findings of previous studies [10, 47, 48], there is limited evidence correlating hospital nurse staffing with patient satisfaction in the literature [8, 30, 49, 50]. This study also found that patient satisfaction is positively correlated with the number of registered nurse working hours, with the index of actual and required registered nurses, and with the number of registered nurse and nursing technician working hours per patient day. Research reports positive patient outcomes when staffing levels allow a maximum of six patients to one registered nurse on a medical ward [51]. Similarly, other research finds that more patients per nurse result in higher rate of care left undone [19].

Observations suggest that registered nurses need to engage in a great variety of tasks, and spend a great deal of time locating the information needed for individual

#### *Congruence of Nurse Staffing and Activities with Patient Needs DOI: http://dx.doi.org/10.5772/intechopen.96589*

patients. Health education, clinical references, consulting, and coaching were the least frequent activities in the registered nurses' working days. We were not able to observe a fifth of the registered nurses' activities, as these were done outside the medical ward. These activities could thus not be classified in the observations, but were described by the staff as nursing tasks on other medical units, meetings with management, quality teams, and so on. Moreover, the results show that the patients noticed the individual attention they received from registered nurses while they cared for them, and that their explanations helped them feel more at ease. Nurses are known to spend more time with patients than other health professionals, and that enables them to show the caring attitude which is sensitive to patients' reports of quality of nursing care [52]. Registered nurses have a wide range of nursing knowledge and good communication skills, are alert to changes in the patients' status and have the competencies needed to do all the activities that arise in nursing care. Nursing technicians have fewer competencies, and care for fewer patients than registered nurses – certain tastes are thus not delegated from registered nurses to technicians, but the vice versa. This could mean that patients would benefit if mixed staffing models, like the one observed in this study, would include more nurses with bachelor's degrees.

We used a hierarchical four-grade nursing care classification system to assess nursing care levels for patients at different acuity levels. This system identifies the staffing levels required to achieve appropriate nursing care, although unfortunately it is not used in practice yet. When we compared the actual nursing levels, the conventional patient-to-nurse ratio and the nurses needed on the basis of patients' classification, we found severe shortages. Individual patient requirements were not respected, as a 38% shortage of registered nurses was measured. Therefore, nursing staff requirements should be considered as a predictor of the quality of nursing services [53], and having enough nurses to meet patient needs could be reflected in higher patient satisfaction with nursing care [8, 54].

According to the findings of the current study, patient satisfaction was not correlated with the frequency of contact care activities performed by the entire nursing staff. Contrary to what is documented in studies in high-income countries [13, 21], where the time that nurses spend in direct care activities was found to be a determinant of patient satisfaction, our patients valued the number of hours worked by nurses. The proportion of direct patient care activities performed by all nursing staff was higher (36.8%) than that documented previously [29]. However, the majority of observed contacts included hands-on-care and were focused on the patient's physical needs (e.g. hygiene, food intake, mobility, medical/technical procedures), while a limited proportion of activities was devoted to regular patient observations, communication, or support. In contrast, some authors [55] have found that nurses spend most time communicating with patients and charting or reviewing information. The different findings could be the result of different research protocols, where communication is documented as an individual task, as in our study, instead of being a part of a multitasking activity.

The results of the correlations also revealed three process items (*undivided attention, explanation,* and *things are done without asking*) that are the special strengths of nursing care. Some authors [33, 56] have also stated that the most important factors that influence patient satisfaction are perceived nurse caring, nursing kindness, and the technical aspects of care, while others focus on individual patient characteristics [2, 30, 31].

In general, the patients in this study reported high satisfaction with the nursing care they received. Some previous research also reported a comparable average satisfaction index, ranging from 4.0 to 4.5 [3], but other studies also reported lower perception levels [48, 57]. It was found that the quality of bedside nursing care is also affected by the related hospital services such as the quality of beds,

the quality and cleanliness of bed linens, the number of bathrooms available, and the quality of the bathrooms available, cleanliness of the toilets, and ventilation and lighting in the wards [52]. The high satisfaction perceived by our patients could therefore reflect good hospital services or, at contrary, a paternalistic perspective, where patients believe that healthcare workers are doing their best with the limited resources available [58], and therefore are less demanding.
