Nurse & Patient Satisfaction and Quality of Care in the UAE Hospitals

A Cross-Sectional Study of 24 Hospitals

Ghada Sherry, MEd, RN

March 2013

Introduction

Over the past ten years, the hospital sector in the UAE has been

experiencing rapid growth in response to high patient and

provider demand for excellence. This rapid expansion stressed the

ability of operators to find and recruit qualified staff.

Yet, there is little information on this largely imported nursing

workforce, and its effect on nurse and patient outcomes.

This research study was conducted to identify opportunities for improvement

and to establish an evidence-based foundation for health policy formulation aimed at upgrading nursing and midwifery standards at the

national level

Study Purpose

1. To produce a status report on the quality of care and patient satisfaction in UAE hospitals COMPARED to hospitals in a large sample of European countries* and to explore the relationship between features of the hospital nurse workforce and variation in quality outcomes.

2. To identify effective evidence-based health policies, educational and service delivery strategies for improving quality and safety of care, and increasing nurses retention in the UAE hospitals.

*The RN4CAST is a European Union funded study of nursing and quality of hospital care in 12 countries in Europe (Aiken et al., 2012).

Study Aims 1. To evaluate the characteristics of the hospital nursing workforce and

their association with quality of care.

2. To measure indicators associated with success of nurse recruitment and retention including nurse job dissatisfaction, burnout and intent to leave, and to determine organizational features that promote effective retention.

3. To examine whether and how modifiable features of the hospital work environment affect quality of care and adverse patient outcomes.

4. To provide baseline information on hospital workforce and quality of

care that can be benchmarked against data from other countries (Europe).

Research Team

Role Organization Responsibilities

International Principal Investigator

University of Pennsylvania (Center for Health Outcomes and Policy Research)

Dr. Linda Aiken Leads and directs the International Study; Consults with UAE

UAE Study Principal Investigator

UAE NMC Dr. Fatima Rifai Leads and directs the study in the UAE

Study Manager UAE NMC Ghada Sherry Manages all aspects of the research study

Research Coordinators

MOH MOH DHA SEHA

Amna Mhanna Nazneen Maymoun Felestine Aqel Abeer Al Bloushi

Coordinate study participation, subject enrollment and data collection

Funded By: The Emirates Foundation for Youth and the Ministry of Health

International Hospital Outcomes Study I

USA

CANADA GERMANY

UK

Findings:

• High nurse dissatisfaction and burnout linked to

adverse patient outcomes

• More favorable patient to nurse staffing ratios

associated with lower mortality

• Hospitals with more educated nurse workforce

have lower mortality

Aiken & Sochalski, 1997; Aiken, et al., 2001; Aiken, Clarke, & sloane, 2002)

SWITZERLAND

NEW ZEALAND

Findings

• Confirmed findings from 1st cohort

• Poor work environments associated with high nurse

turnover, patient safety problems, and dissatisfied

patients

• Identified best practices to reform work environments

(common to Magnet Hospitals)

BELGIUM

ICELAND

RUSSIA

ARMENIA

(Aiken, 2002; Finlayson, Aiken, & Nakarada-Kordic, 2007, etc.)

International Hospital Outcomes Study II

Japan

SWITZERLA

ND

Policy Initiatives

• Adoption of BSN as minimum entry level

•Expansion of Magnet as strategic platform for nursing

• Expansion of Scope of Practice models to incorporate advanced practice nursing

• Work rule adjustments to allow part time employment and extend retirement age

• Federal funding expansion for Schools of Nursing

• Creation of national councils and boards to establish nursing strategic agenda

and policies

(Aiken, 2002; Finlayson, Aiken, & Nakarada-Kordic, 2007, etc.)

Evidence-Based Policy

International Hospital Outcomes Study Third Cohort underway now

SOUTH AFRICA

THAILAND

CHINA

EUROPEAN

UNION

COUNTRIES

UNITED

ARAB

EMIRATES

SOUTH KOREA

BOTSWANA

Bringing UAE into Global Study – Launch December 12, 2009

Research Methods and Design Cross-sectional patient and nurse surveys were conducted in 2011 in 24 hospitals.

The design of the study followed the same design and instruments used in the RN4CAST in Europe.

Descriptive statistics were used to summarize demographic and outcomes data.

Contingency tables were used to assess the relationships between patient and nurse outcomes and the quality of the work environment.

Measures Nurse Survey Patient Survey

•Demographic information •Demographic information

•Staffing (Information about last shift) •Patient outcomes: The Consumer Assessment of Healthcare Providers and Systems (CAHPS®)

•Work environment: Practice Environment Scale of the Nursing Work Index (PES-NWI)

•Nurse outcomes: Maslach Burnout Inventory (measures job-related burnout)

•Hospital performance: quality of care on their unit and in the hospital

Pilot Testing

Patient Questionnaire:

After translation and back translation of the patient

questionnaires, the tools were piloted. No changes were required.

Nurse Questionnaire:

After piloting the nurse questionnaire, few changes were done

mainly to clarify some English terms and to make the tool more

relevant to the nursing practice environment of the UAE.

Study Subjects and Tools Study participants: Patients and Nurses Acute Care Hospitals over 100 beds - A total of 27 government and private hospitals met this criteria across the UAE Self-administered closed-ended questionnaires

The nurse questionnaire was administered in English

The patient questionnaire was administered in English, Arabic and Hindi

Research Ethics Approval

The study was approved by the Research Ethics Committees at the following:

Ministry of Health Dubai Health Authority Health Authority of Abu Dhabi Al Ain Medical District Health Research Ethics Committee

At institutional level, the study had to be submitted and approved by the SKMC Institutional Review Board.

Field Work Introductory sessions: In March 2011, introductory sessions for the CNOs and the Directors of Nursing of the concerned hospitals were conducted across the UAE.

Preparatory sessions: In May 2011, preparatory sessions for the research coordinators and research assistants were conducted. Training included the following:

•Patient/nurse inclusion and exclusion criteria •Patient/nurse enrollment procedure •Reducing survey bias (illiterate patients) •Survey coding •Data collection process •Data confidentiality

Field Work

Data Collection Process • Copies of the surveys were sent to the facilities along with envelopes. • The cover letter attached to the survey explained the purpose of the study, emphasized that participation is voluntary and that electing to participate or not was NOT going to affect the nurse’s employment status or the patient care, and explained how the confidentiality of responses will be protected. • Respondents were requested to complete the survey, seal it in the envelope provided, and deposit it in a secure location. • The hospital research assistants collected and forwarded the sealed envelopes to the research team’s national office in Dubai.

Response Rate

Note: The questionnaires were distributed in 24 hospitals; 3 hospitals refused to participate

NURSES PATIENTS

Number of

Questionnaires

Handed in

(Distributed)

Number of

Questionnaires

Returned back

(Completed)

Number of

Questionnaires

Handed in

(Distributed)

Number of

Questionnaires

Returned back

(Completed)

Total 2306

1971

1673 1409

Response

Rate 85% 84%

Data Confidentiality

Completed nurses and patients surveys in sealed envelops

Research assistant

Research coordinator

UAE NMC office – Dubai

University of Pennsylvania

Sealed Envelopes

Data Analysis and Reporting

In July 2011, thousands of completed surveys were shipped to the University of Pennsylvania in their sealed envelopes for coding, data quality checks and analysis.

Number and Characteristics of Hospitals, Nurses and Patients

Nurse Characteristics

Nurse Characteristics

20%

33% 17%

30%

Country of Nursing Education

UAE

India

Philippines

Other

Patient Characteristics

Distribution of patient outcomes by nurse work environment (n = 1,395 patients)

Classification of Nurse Work

environment

Patient Outcome Poor Mixed Best P-Value

Best hospital rating (9 or 10) 42% 55% 55% <0.001

Definitely recommend hospital 50% 63% 63% <0.001

Pain always well controlled 47% 51% 57% 0.04

Nurses always treat you with

courtesy and respect 74% 77% 85% 0.001

Nurses always listen carefully to

you 70% 70% 79% 0.05

Nurses always explain things in

way you could understand 59% 63% 69% 0.002

Percentage of nurses reporting negative job outcomes by nurse work environment (n = 1,954 nurses)

Classification of Work

Environment

Nurse Outcome Poor Mixed Best P-Value

Dissatisfied with job 52% 48% 20% <0.001

High burnout 47% 39% 20% <0.001

Planning to leave job 62% 52% 35% <0.001

Unit quality-of-care fair

or poor 17% 18% 6% <0.001

Nurse Burnout, Job Satisfaction & Intent to Leave UAE vs. Europe

**The European sample includes 14,639 nurses in 300 hospitals in Belgium, Finland, Germany, Greece, Ireland, Poland, Spain, and Switzerland.

Study Findings

Better work environments are associated with higher patient satisfaction and higher quality of care. Better nurse work environments are also associated with lower nurse job dissatisfaction, lower burnout, and lower rates of intent to leave, all factors associated with nurse retention.

There are some excellent hospitals in the UAE but also considerable variation across different hospitals.

The most problematic component of the nurse work environment is staffing and resource adequacy.

Study Findings

Private hospitals have better nurse staffing than public hospitals and seem to be more successful in creating work environments that nurses rate as good.

Private hospitals also have better patient outcomes when compared with public hospitals. Patient to nurse ratios on general medical and surgical wards of 6 or more is the break point where nurses and patients both experience greater dissatisfaction. Many nurses do not perceive that management listens and responds to problems nurses identify in patient care, and thus problems persist and result in nurse frustration and inefficiency.

Conclusion: UAE vs. Europe In both the UAE and Europe there is substantial variation in quality and safety of care and in patient satisfaction across individual hospitals. Understanding what accounts for those differences between high performing hospitals and others is the key to improving care in the lower performing institutions.

While there is plenty of room for improvement, overall measures of quality of care and patient safety are roughly comparable in the UAE hospitals to those of hospitals in 12 European countries as a group.

Lack of opportunities for advancement, the absence of career ladders and opportunity for development are problems common to UAE and Europe.

Conclusion: UAE vs. Europe Nurse job dissatisfaction and job-related burnout in UAE hospitals are significantly higher than is the case among hospitals in Europe.

The majority of nurses in UAE hospitals are dissatisfied with their compensation, which is also a problem for hospitals in Europe, although the impact may be greater with a largely imported workforce.

While nurses point to the need for more staff, average patient-to-nurse workloads in UAE hospitals, on average, look comparable to or even better than those observed in Europe.

Policy Implications Attention should be given in the UAE to improving the hospital nurse work environments*, which hold promise for improving nurses’ job satisfaction, reducing nurse burnout (which is a safety hazard and a predictor of voluntary turnover), improving nurse retention and patient experience as well.

*Improving care environment includes greater responsiveness of management to problems identified by nurses, more involvement of nurses in hospital affairs, greater opportunities for advancement and recognition of nurses, and improved mentoring for nurse managers.

?? Pathway to Excellence

?? Magnet Recognition Program

Thank You

References – Aiken, L. H. (2002). Superior outcomes for Magnet hospitals: the evidence base. In M. L. McClure &

A. S. Hinshaw (Eds.), Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses (pp. 61-81). Washington: American Nurses Publishing.

– Aiken, L. H. (2005). Extending the Magnet concept to developing and transition countries. Reflections on Nursing Leadership, 31(1), 16-18.

– Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290(12), 1617-1623.

– Aiken, L. H., Clarke, S. P., & Sloane, D. M. (2002). Hospital staffing, organizational support, and quality of care: cross-national findings.” International Journal for Quality in Health Care, 14(1), 5-13.

– Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J. A., Busse, R., Clarke, H., et al. (2001). Nurses’ reports of hospital quality of care and working conditions in five countries. Health Affairs, 20(3), 43-53

– Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J. A., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987-1993.

– Aiken, L. H. & Sochalski, J. (Eds.). (1997). Hospital restructuring in North America and Europe: Patient Outcomes and Workforce Implications [Supplement]. Medical Care, 35(10).

– Buerhaus, P. , Staiger, D. O., Auerbach, D. I. (2009) The Future of the Nursing Workforce in the US: Data, Trends, and Implications (Boston: Jones and Bartlett Publishers.

– Estabrooks, C. A., Midodzi, W. K., Cummings, G. G., Ricker, K. L., & Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 74-84.

– Finlayson, M., Aiken, L. H., Nakarada-Kordic, I. (2007). New Zealand nurses’ reports on hospital care: international comparisons. Nursing Praxis, 23(1):17-18.

References

– Kane, R.L. et al. Nurse Staffing and Quality of Patient Care (Minneapolis Minnesota Evidence-based Practice Center, March 2007)

– Lake, E. T. (2002). Development of the Practice Environment Scale of the Nursing Work Index. Research in Nursing & Health, 25, 176-188.

– Naylor, M. (2006), “Transitional Care: a Critical Dimension of the Home Healthcare Quality Agenda. Journal of Healthcare Quality 28, no. 1. 48-54.

– Page, A. Ed. Keeping Patients Safe: Transforming the Work Environment of Nurses (Washington National Academies Press, 2004).

– Rafferty, A. M., Clarke, S. P., Coles, J., Ball, J., James, P., McKee, M. & Aiken, L. H. (2007). Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies, 44(2), 175-182.

– Schubert, M., Glass, T., Clarke, S.P., Aiken, L.H., Schaffert-Witvliet, B., Sloane, D.M., & DeGeest, S. (2008). Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study. International Journal for Quality in Health Care, 20(4), 227-237

– Van den Heede, K., Sermeus, W., Diya, L., Clarke, S. P., Lesaffre, E., Vleugels, A., & Aiken, L. H. (in press). Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data. International Journal of Nursing Studies.

– WHO Workforce Statistics: www.who.int/hrh/statistics