**Abstract**

This study aimed to discover the correlation between patient satisfaction with nursing care activities and staffing patterns. The research was conducted at the medical ward of a secondary care regional hospital in Slovenia over one month. Data was collected with regard to the following: (1) patients cared for daily and number of hours/patients day at the ward level, (2) patient needs (using a classification system), (3) nurse activities as observed at 10-minute intervals, and (4) the Patient Perception of Hospital Experience with Nursing tool. A total of 218 patients were involved, and their satisfaction with nursing care was found to be high. Patient satisfaction was negatively correlated with the number of patients cared for at the unit daily, but positively with the number of care hours per patient day, the proportion of registered nurses in the nursing team, the realized percentage of the registered nurse personnel requirements, and with some direct care activities. The correlation also revealed three process items (undivided attention, explanation, and things are done without asking) being the special strengths of nursing care activities. The results show that nurse-staffing and process patterns affect patient experience. It is thus recommended to increase the amount of nursing care offered by registered nurses, while nurses' competences can affect the process of care, and thus patient satisfaction.

**Keywords:** evidence-based healthcare management, nursing service hospital, patient satisfaction, quality of healthcare

## **1. Introduction**

Patient satisfaction with hospital care has been defined as the degree of alignment between the care expected and actual care received, as perceived by patients [1]. Nurses have thus been recognized as the key factors influencing patient satisfaction because they are involved in almost every aspect of the healthcare process [2]. Although nursing care processes are integrated with other healthcare processes, when the quality of nursing care is poor, patients' satisfaction has been found to be low [3].

The use of a good structure increases the likelihood of good processes, and good processes increase the likelihood of good outcomes [4]. The best criteria with regard to reflecting the structure and process of nursing care and the related patient outcomes are the nursing-sensitive indicators [5]. The literature describes two general nursing-sensitive patient outcomes: adverse and positive. Some adverse patient outcomes that are potentially sensitive to nursing care are urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding, longer hospital stays, failure to rescue, and 30-day mortality [6]. The main positive nursing-sensitive patient outcome is patient satisfaction with nursing care quality.

Structure in a healthcare context refers to the attributes of various material resources (facilities, equipment, money), human resources (supply of nursing staff, the skill level of staff, education of staff), and organizational factors (staff organization, methods of peer review, methods of reimbursement). In contrast, process denotes what is done in giving and receiving care. It includes patient activities in seeking care and receiving it, as well as practitioner activities in making the diagnosis and recommending or implementing treatment. An outcome denotes the effects of care on the health status of patients, including improvements in the patients' knowledge, and positive changes in their health status and behavior, as well as greater patient satisfaction with care [4].

According to the Donabedian model [7], some nursing care structural and process features are associated with the quality of care and thus capable of increasing patient satisfaction in hospitals. Regarding structure, the number of patients per nurse in a hospital [8–10], the nursing care hours per patient day [11], the proportion of registered nurses [8, 12], and the presence of registered or specialist nurses [13–15] all influence the quality of care as perceived by patients. Researchers have also associated nurse staffing with various patient, suggesting that a higher proportion of registered nurses could reduce preventable in-hospital deaths [8, 16–18], prevent falls [15], decrease the percentage of care left undone [19], and increase patient satisfaction [8–10]. Regarding the relevant processes, the total amount of direct patient care [20, 21], frequency of communication [22, 23], and organizational priorities with regard to the quality of care [8] have also been documented as affecting patients' satisfaction with nursing care.

However, the amount of nursing care and the mix of skills of the staff providing it are only proxy measures for what the nursing staff actually does daily at the bedside, and nursing activities can include both contact and no-contact time, as well as unproductive time [24]. In fact, according to published studies hospital nurses spend from 7.3% [25] to 54.2% [26] of their time on direct patient care, from 0% [27] to 59% [28] on indirect care, and from 14% to 17% on personal time [29]. Patient satisfaction is influenced by factors identified at the patient level [2, 30–33] along with nurses' kindness and competence with regard to performing technical procedures [34]. When items in the instrument represent patients' perceptions, there are no criteria against which criterion-related validity could be tested [3].

In Slovenia, a post transitional European country, the number of practicing nurses per 1 000 population is 8.8, and the ratio of nurses to physicians is 3.2 [35]. The problem is that when officially counting the number of nursing professionals, the nursing assistants (called health technicians) are included, and therefore the ratio between registered nurses and health technicians (which is currently 35:65) is in favor of the latter [36]. The Slovenian Chamber of Nursing and Midwifery prepared a proposal of human norms, where one of the four basic criteria was the calculation of staff needs resulting from patient classification system [37]. But although the percentage of categorized patients in hospitals is high, the collected data are not used for staff planning [38].

### **2. Aim**

This study aimed to examine the connection between nurse staffing patterns, their process characteristics and the quality of care with regard to patient satisfaction with the nursing care received.

The specific objectives of this study were: [1] to identify the relevant nursing staff structural conditions (patient to nurse ratios, skill mix, and educational level); [2] to examine the nursing care activities performed by distinguishing

those direct and indirect care activities; [3] to examine patients' actual nursing care needs; and [4] to measure patient outcomes (with a focus on satisfaction with the nursing care received).

It was assumed that higher nurse staffing and more direct care activities are associated with an increased likelihood of meeting patient needs, and that higher perceptions of fulfilled needs would be reflected in higher patient satisfaction with nursing care.
