gms | German Medical Science

Background: In recent decades patient-centered care (PCC) has gained increasing interest from policy makers, researchers and clinicians because of its association with improved patient-reported, clinical and economic outcomes. PCC is one key element of high-quality healthcare and defined as care where ‘patients’ values guide all decisions’. Beside the two fundamental dimensions “unique person” and “involvement in treatment and care”, the dimensions “patient information” and “clinical-patient communication” complete the PCC construct. The multilevel construct is determined by individual, structural and process factors. However, while studies have been shown that hospital-level characteristics influence patients’ perceptions regarding PCC, little evidence is available on the association of PCC with unit level characteristic such as the nurse work environment or implicit rationing of nursing care.

Research questions:

1.

How patients perceive the level of PCC in Swiss hospitals?

2.

Is there an association between patients’ perception on PCC, nursing work environment and implicit rationing of nursing care in Swiss hospitals?

Methods: For this cross-sectional multi-center study, we included 2073 patients (hospitalized for at least 24 hours and ≥ 18 years of age) and 1810 registered nurses (working in direct patient care) from 123 units of 23 Swiss hospitals from all three of Switzerland’s language regions. Patients` perceptions of PCC were assessed with questionnaires using four items from the Generic Short Patient Experiences Questionnaire. From the same hospital units, nurses completed questionnaires assessing perceived staffing and resource adequacy, adjusted staffing, leadership ability and level of implicit rationing of nursing care. Hospital-level data (size, ownership status, type) were provided by the Swiss Federal Statistical Office. We applied a Generalized Linear Mixed Models for analysis including individual-level patient and nurse data aggregated to the unit level.

Results: Patients reported high levels of PCC: 90% easily understood nurses, 91% felt the treatment and care were adapted for their situation, 82% received sufficient information, and 70% felt involved in treatment and care decisions. Higher staffing and resource adequacy was associated with higher levels of PCC, e.g., sufficient information (beta 0.638 [95%-CI: 0.30 – 0.98]). Higher leadership ratings were associated with sufficient information (beta 0.403 [95%-CI: 0.03 – 0.77) and adapted treatment and care (beta 0.462 [95%-CI: 0.04 – 0.88]). Furthermore, higher levels of implicit rationing of nursing care were associated with lower levels of PCC, e.g., adapted treatment and care (beta -0.912 [95%-CI: -1.50– -0.33]). Adjusted staffing levels and hospital characteristics were not associated with PCC.

Discussion: Overall Swiss hospitals have high levels of PCC, but there is room for improvement overall and especially for patient involvement in decisions of care and treatment. Nurse reported staffing and resource adequacy and PCC are strongly associated, whereas adjusted staffing (i.e., the adjusted patient to registered nurse ratio) was not associated with any PCC dimension. Additionally, adequate staffing levels effects quality of care by reducing the levels of implicit rationing of nursing care. The lower the level of implicit rationing of nursing care, the better patients understood their nurses, felt sufficiently informed and recognized that they were receiving highly individualized treatment. Supportive leadership is a building block for healthcare changes such as ‘living a PCC culture’. Leadership is positively linked to patient perceptions on the adequacy of provided information and the adaptation of treatment and care. To improve PCC, the nurse work environment and the level of implicit rationing of nursing care should be taken into consideration.

Practical implication: Clinicians need to reflect on their communication with patients, assuring that the information each patient receives is adequate and tailored according to the patient’s needs and situation. For a successful shift from paternalistic healthcare to care with patient involvement, hospital managers need to ensure that every employee with patient contact is trained in patient-centered communication and shared decision making. A prerequisite for implementation of PCC is that nursing staff feels staffing and resources are sufficient. Hospital managers need to provide work environments which allow nurses to spent time to do patient-centered communication. At the levels of the CEO, department and unit, leadership training must be provided to develop competent and supportive leaders who will enable and promote a healthy work environment. This work environment should include explicit, high-priority attention to nurses’ perceptions of staffing and resource needs. The overall target is that well-led, engaged staff will accept, embrace, and live a PCC culture.