Nursing Patient-Centeredness Improves African-American Female Medicare Patients’ Experience-of-Care

Abstract

BACKGROUND

Along with clinical technical competence, nurses’ interpersonal ability influences patient outcomes. Patient-centeredness, “[p]roviding care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (IOM, 2001, p. 3), is especially important in assuring that African-American Medicare patients achieve the desired outcomes.

PURPOSE(S)

This study was designed to measure the effects of nursing patient-centeredness on African-American female Medicare hospital inpatients across national random test and cross-validation samples; specifically, on their experience-of-care, likelihood of recommending the hospital, and ratings of care. The stability of effects was assessed across samples and a competing model challenge further tested the hypothesis.

HYPOTHESIS

Nursing patient-centeredness improves African-American female Medicare hospital patients’ experience-of-care and increases the likelihood that they will recommend and highly rate their care.

RESULTS

Supporting the hypothesis, the model fit. Nursing patient-centeredness significantly influenced African-American female Medicare hospital patients’ experience-of-care, likelihood of recommending the hospital, and ratings of care (χ² = 39.35, df = 42, p = .588; RMSEA = .000, p =.982 CL90% = .000–.043; CFI = 1.000), explaining 71% of the variance of patients’ experience-of-care (p < .001). A unit increase in nursing patient-centeredness increased patients’ experience-of-care, likelihood of recommending the hospital, and ratings of hospital care by .842, .778, and .798 standardized units, respectively. These results were stable across both the test and cross-validation samples, and the hypothesized model was sustained when compared to the hypothesized competing model (χ²Δ = 10.974, df = 16, p = .811).

DISCUSSION

Nursing performance is often chiefly associated with clinical or technical competence. Patient-centeredness concerns nurses’ ability that affects the quality of their interaction with patients and concomitant outcomes. This study provided empirical evidence that nursing patient-centeredness significantly improves African-American female Medicare hospital patients’ experience-of-care and increases the likelihood that they will recommend and highly rate their care.

INTRODUCTION

The nationwide thrust to improve patients’ experience-of-care requires that physicians, nurses, allied health practitioners, and healthcare administrators rethink the quality of their communication and interaction with patients. With a renewed focus on patient-centered care, national healthcare policy urges providers to improve patients’ experience-of-care and ensure that decisions respect their needs, preferences, and values. Consequently, through the Centers for Medicare & Medicaid Services (CMS), the federal government has implemented mandatory measures to improve patients’ experience-of-care. Scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Consumer Assessment of Health Providers and Systems (CAHPS) surveys are tied to hospital reimbursement. Both contain questions zeroing in on the patient-centered performance of nurses and physicians in hospitals and medical offices; HCAHPS targets hospitals (AHRQ, 2010; CMS, 2013a, 2013b); CAHPS, medical offices (AHRQ, 2013; CMS, 2013).

Nursing, medical institutions, and educators regard patient-centeredness as essential to the delivery of quality care. The Institute of Medicine ([IOM], 2001) equates the value of patient-centeredness with safety, effectiveness, timeliness, and equity. The American Association of Colleges of Nursing (AACN) Quality and Safety in Nursing (QSEN) Education Consortium report recognizes “the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs” (2012, p. 4). An earlier report of the consortium holds that nurses must have the proper knowledge, skills, and attitudes to deliver safe and effective care, including engaging patients in their own healthcare and related care plans; assessing their understanding of their health problems; eliciting their values, preferences, and needs; and developing plans to prevent barriers to patient-centered care (Cronenwett et al., 2009). Another QSEN report (Boykin, 2014) maintains that patient-centered care requires that nurses respect and understand patient differences, values, preferences, and needs; relieve pain and suffering; coordinate continuous care; advocate disease prevention and wellness; listen, inform, educate, communicate with, and involve patients in decision making and the management of their care, which are all precursors of nursing patient-centeredness and patients’ experience-of-care (p. 44).

In addition, studies of nursing have illuminated many practices and skills that are likely to improve patients’ experience-of-care. For example, Sidani et al. (2014) posit that patient-centered care must be holistic, collaborative, and responsive. Lusk and Fater note that patient-centered care fosters patient autonomy and individualizes care (2013, p. 94). Berghout, Exel, Leensvaart, and Cramm (2015) cite the importance of respecting patients’ dignity. Vander-boom, Thackeray, and Rhudy recommend that nurses leverage their education and clinical skills to identify and address patients’ physical, mental, social, and cultural needs (2015, p. 23). Esmaelili, Cheraghi, and Salsali (2015) point out potential barriers to nursing patient-centered care, including misunderstanding teamwork, the organization itself, and individual obstacles.

In light of national health policy and the authors’ interest in vulnerable populations, this investigation focused on the effects of nursing patient-centeredness on the experience-of-care of African-American female Medicare patients, using national inpatient data (i.e., randomly selected test and cross-validation samples) from the Press-Ganey Inpatient Hospital Survey Database. It used structural equation modeling (SEM), a second-generation research methodology incorporating a family of multivariate methods to simultaneously estimate, from sample observations, the population values (effects) of directed relationships among variables in hypothesized models. Other advantages of SEM include its power: (a) to model and test a theory, its relationships, and its measurement assumptions against the data; (b) to model directed relationships among observed and/or latent predictor and criterion variables; and (c) to address the ubiquitously ignored problem of measurement error.

Purpose

The primary aim of this study was to determine the effects of nursing patient-centeredness on African-American female Medicare hospital patients’ experience-of-care, likelihood of recommending the hospital, and ratings of their care. Second, the study assessed the stability of these effects across national random test and cross-validation samples. Last, it tested the hypothesized patient-centeredness model (supposing equal effects) across the national random test and cross-validation samples against a competing model (supposing unequal effects) across the samples.

More specifically, the investigation addressed the following questions (hypotheses): (1) Does nursing patient-centeredness influence African-American female Medicare hospital patients’ experience-of-care, likelihood of recommending the hospital, and overall ratings of care? (2) What are the total effects of nursing patient-centeredness on these women’s experience-of-care, likelihood of recommending the hospital, and overall ratings of care? (3) Are these effects stable (the same) across national random samples? And (4) Does the hypothesized nursing patient-centeredness model hold when tested against a competing model? Table 1 shows he study’s key measurement and structural hypotheses.

Table 1.

Key Hypothesis

Independent Variable	Direction of Effect	Dependent Variable
Patient Data	(fits)	Hypothesized Model
Nursing Patient-centeredness	→	Friendliness and courtesy of the nurses
Nursing Patient-centeredness	→	Nurse promptness in responding to calls
Nursing Patient-centeredness	→	Nurse attitude toward requests
Nursing Patient-centeredness	→	Nurse attention to special needs
Nursing Patient-centeredness	→	How well nurses kept patient informed
Patient Experience-of-Care	→	Likelihood of recommending hospital
Patient Experience-of-Care	→	Overall rating of care given

Note: → Reflects direction of effect

METHODS

Instrument and Survey Process

The Press-Ganey Inpatient Hospital Survey is a standardized instrument used nationwide and listed by the National Quality Measures Clearinghouse. It captures hospital patients’ ratings of nursing and physician performance on a 5-point scale ranging from very poor (1) to very good (5). Surveys are mailed continuously throughout the year to randomly selected hospital patients with postpaid return envelopes, addressed to Press Ganey’s corporate office and appropriate cover letters to assure confidentiality. Press Ganey typically receives the surveys within four to five days postdischarge, which is well within the generally accepted six-week standard indicated by research on the reliability of patient responses. Random patient selection within each hospital and automated mailing reduce the potential for selection bias.

Participants and Randomization

Total participants (n = 210), representing unique, randomly selected, coded, African-American female Medicare patients in the Press-Ganey Inpatient Hospital Database, were randomized to test (n1 = 101) and cross-validation (n2 = 109) samples for analysis. All patient and facility identifiers were removed prior to analysis.

Latent and Observed Measures

Table 2 shows the study’s key latent constructs, nursing patient-centeredness (NPC), and patients’ experience-of-care (PEC). Figure 2 shows correspondences between these latent constructs with their observed measures and error terms.

Table 2.

Measures

Code	Description
NPC	Nursing Patient-Centeredness (.97, .85)a
n1	Friendliness and courtesy of the nurses
n2	Nurses’ promptness in responding to calls
n3	Nurses’ attitude toward requests
n4	Nurses’ attention to special needs
n5	How well nurses kept patient informed
PS	African-American female Medicare patients’ experience-of-care (.93, .87)a
o3	Likelihood of recommending the hospital
o4	Overall rating of care given

^aConstruct reliability/AVE

Figure 2.

Hypothesized model

Measured by patients’ ratings of their nurses’ friendliness and courtesy (n1), promptness in responding to calls (n2), attitude toward requests (n3), attention to special needs (n4), and keeping them informed (n5), NPC was specified by the model to have a direct effect on African-American female PEC. The NPC scale exhibited good construct validity and reliability as evidenced by its average variance extracted and composite reliability (AVE = .97, CR = .85), where .7 and .5 are the criterion thresholds. The PEC also reflected good psychometric properties, with an average variance extracted of .93 and composite reliability of .87. This construct was measured by the likelihood that patients would recommend the hospital (o3) and their overall ratings of care (o4). Each of the seven observed measures was also specified to have an unobserved exogenous variable capturing its measurement error (e1-e5, eo3, and eo4). PEC was specified with an attendant error term (eo1) that captures any disturbance in the structural model’s prediction equation. These two constructs, their definitions, directed interrelationships, and attendant observable measures and error terms were consistent with the Primary Provider Theory, the study’s underlying theoretical framework, which holds that patient-centeredness and patients’ experience-of-care occur at the nexus of provider power and patient expectations. Where patients’ experience-of-care is principally the function of an underlying network of interrelated constructs—the patient-centeredness of and satisfaction with the primary provider, waiting time, and the provider’s assistants (Aragon, 2003, p. 225).

Modeling Procedures

Model design

A two-factor, multigroup, structural equation modeling (SEM) design was used with national, randomly selected, test and cross-validation samples of African-American female Medicare hospital patients. First, a goodness-of-fit experiment tested the empirical congruence between the hypothesized model and the patients’ responses. Second, a measurement-invariance experiment tested the stability or equality of the effects across the samples. Last, a competing-model challenge tested the hypothesized model, with equal effects across samples against a rival model with unequal effects across samples. Missing information was handled with full information maximum likelihood (FIML) estimation (Wothke, 1998) using AMOS 16.0.1. The investigation was approved by Winston-Salem State University’s Institutional Review Board (IRB# 2986–07-0035).

Model specification and estimation

The model was specified according to the Primary Provider subproposition, which holds that the patient-centeredness of providers significantly explains and predicts patients’ experience-of-care, and consequent hypotheses (see Table 1 and Figure 1). To test their stability or measurement invariance, model parameters (i.e., measurement weights, structural weights, structural covariances, structural residuals, and measurement residuals) were fixed to equality across the two national random samples. Mardia’s coefficient of multivariate kurtosis was used to assess data normality. Assuming normality, it is scaled to have a mean of zero, but since it exceeded 64 for both samples (p < .05), asymptotic, distribution-free estimation was used to obtain 14 parameters with 42 degrees of freedom. SPSS 16 and Amos 16.0.1 were used for sampling, randomization, model specification, and estimation. Figure 2 reflects the hypothesized model.

Figure 1.

Primary Provider Theory Model

Model evaluation

The model was evaluated based on empirical goodness-of-fit, the size and significance of its effects, interpretability, ability to explain the sample population’s experience-of-care, and congruence with the Primary Provider Theory, its subpropositions, and related predictions. Goodness-of-fit was determined by the chi-square (χ²) and root mean squared error of approximation (RMSEA) tests and the confirmatory fit index (CFI). A chi-square difference test (χ²Δ) was used to assess the stability of effects across samples and the robustness of the hypothesized model compared to the competing model. The power to reject a false model was ≈ 1.00, assuming a false model would elicit a RMSEA ≥ .10.

RESULTS

Does nursing patient-centeredness influence African-American female Medicare hospital patients’ experience-of-care, likelihood of recommending the hospital, and overall ratings of care?

Yes. Supporting acceptance of the investigation’s omnibus hypothesis, the model empirically fit, providing evidence that nursing patient-centeredness influenced African-American female Medicare hospital patients’ experience-of-care, likelihood of recommending the hospital, and ratings of care (χ² = 39.35, df = 42, p = .588; RMSEA = .000, p =.982 CL90% = .000–.043; CFI = 1.000). Nursing patient-centeredness explained 71% of patients’ experience-of-care (p < .001).

What are the total effects of nursing patient-centeredness on these women’s experience-of-care, likelihood of recommending the hospital, and overall ratings of care?

Sustaining acceptance of the related hypotheses, a standardized increase in nursing patient-centeredness increased African-American female patients’ experience-of-care, likelihood of recommending the hospital, and ratings of hospital care by .842, .778, and .798 standardized units, respectively (see Table 3 and Figure 3). In addition, nurses’ patient-centeredness—measured by the common variance of their friendliness and courtesy, promptness in responding to calls, attitude toward patients’ requests and special needs, and how well they kept patients informed— significantly predicted the female patients’ ratings of their nurses’ care (p < .001).

Table 3.

Total Standardized Effects of Nursing Patient-Centeredness on African-American Female Medicare Patients’ Experience-of-Care, Likelihood of Recommending the Gospital, and Overall Rating of Care

Variables	Nursing Patient-Centeredness
AA female Medicare patient experience-of-care	.842
Likelihood of recommending the hospital (o3)	.778
Overall rating of care given (o4)	.798

Note: Above effects are significant at the 0.001 level (two-tailed).

Figure 3.

Standardized Results

Were these effects stable across the national random samples?

Yes. Sustaining acceptance of the investigation’s measurement invariance hypothesis, the total effects of nursing patient-centeredness on the African-American female Medicare hospital patients’ experience-of-care were stable across both the test and cross-validation samples (χ²Δ = 10.974, df = 16, p = .811).

Did the hypothesized model of nursing patient-centeredness hold when tested against a competing model in another national random cross-validation sample?

Yes. When tested against its rival, the hypothesized model held (χ²Δ = 10.974, df = 16, p = .811).

DISCUSSION

The hypothesized model and resulting effects show the relationship between nursing patient-centeredness and patients’ experience-of-care. The results provide empirical evidence that nurses’ patient-centeredness positively influences African-American female Medicare patients’ experience-of-care, likelihood of recommending the hospital, and overall ratings of care. This outcome is important to hospitals because reimbursements are based on responses to HCAHPS surveys asking patients to evaluate nurses’ patient-centeredness in terms of how often nurses treated them with courtesy and respect, listened carefully to them, and explained things in a way they could understand.

In light of the nationwide effort to improve patients’ experience-of-care, should nurses rethink the quality of their communication with patients? Over the course of a career, nurses have a huge number of communications with patients and families (e.g., patient education; taking histories and vital signs; performing physicals; explaining tests, treatments, and medications; managing intravenous lines; and monitoring conditions), and these interactions do not include simply chatting, body language, telephone calls, texts, emails, or nurse-family meetings. In fact, the most common nursing procedure of all is communicating. A nurse’s communications can have only three possible outcomes (effects) on patients’ experience-of-care—a positive effect (+) effect, a negative effect (−1), or no effect (0). Only one of these three outcomes will increase patients’ experience-of-care scores.

The results presented here reflect the benefits of nursing patient-centeredness that improve African-American female Medicare patients’ hospital experience. Nurses may have to change their behavior to achieve these improvements, and eliciting all of a patient’s concerns and apprehensions may require more personal acknowledgment, listening, empathy, vulnerability, time, and effort. Including patients and their families in the clinical decision-making process will require sharing control and power, abandoning the lofty position of a clinical superior to establish a mutually beneficial partnership. Nursing performance is too often thought of in terms of technical clinical competence alone. Patient-centeredness encompasses the quality of nurses’ interaction with patients, which has a strong effect on their experience-of-care.

This study demonstrated that nursing patient-centeredness, measured by their friendliness and courtesy, promptness in responding to calls, attitude toward patients’ requests and special needs, and how well they keep patients informed, improved African-American female Medicare hospital patients’ experience-of-care scores, their likelihood of recommending the hospital to others, and overall ratings of care. Future research warrants examination of other nursing communication behaviors that may improve both patients and families experience-of-care.