Measuring Hospital Climate for the Delivery of Patient- and Family-Centered Care

A Dissertation Presented to the Faculty of The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.

Establishing patient- and family-centered care (PFCC) as the standard in health care is an important direction taken by many health care delivery sites. However, little research exists to demonstrate that these efforts will produce the necessary organizational change for improving quality and patient outcomes. Perspectives for PFCC delivery are based primarily on studies with patients and physicians and measurements of PFCC are derived mainly from surveys of patient satisfaction or descriptions of hospital attributes such as facilities and services. Two key elements are missing from research on PFCC: (1) nurses’ perspectives on PFCC and (2) their assessment of how the organizations in which they work affect the delivery of PFCC. Addressing these concerns is important, as nurses remain the critical workforce for delivering care to patients in hospitals.

This dissertation addresses these gaps in the literature by measuring nurses’ perceptions of the delivery of PFCC in hospitals. The study draws on the culture and climate theories of Schein (1985; 2004) and Glisson (2002). Their research suggests that the culture, informal structure and climate of an organization shape work performance, the delivery of health care and the health of patients in hospitals. The study developed a conceptual model drawing on these theories to:

1. Guide the development of a survey instrument, which measures nurses' perceptions of the hospital (a) culture, (b) informal structure and (c) climate for the delivery of PFCC (explanatory variables) and nurses' perceptions of (d) hospital patient- and family-centeredness (outcome variable).
2. Estimate associations of the explanatory variables to the outcome variable.

A self-administered online survey was used to collect data from registered nurses working in five Massachusetts hospitals (n=884) during May-August, 2008. Thirteen principal component factor scores, reduced from 78 individual survey items and a full set of dummy variables for hospital site, work status, age and specialty practice were used in standard ordinary least squares regression models. 

The final regression model showed that an increase of one standard deviation in nurses’ rating of leader’s respect for diversity was associated with a 0.30 point increase (scale 1 to 10) in nurses’ rating of hospital patient- and family-centeredness (p=0.002). An increase of one standard deviation in nurses’ rating of respect for individuals was associated with a 0.26 point increase in nurses’ rating of hospital patient- and family-centeredness (p=0.007). An increase of one standard deviation in nurses’ rating of collaboration and coordination activities was associated with a 0.49 point increase in nurses’ rating of hospital patient- and family-centeredness (p=0.001). An increase of one standard deviation in nurses’ rating of patient- and family-centered behaviors was associated with a 0.51 point increase in nurses’ rating of hospital patient- and family-centeredness (p=0.001).

Additional analysis showed that the grouped culture items (speaking up for diversity, leader’s respect for diversity, peer’s respect for diversity, negative behaviors, respect for individuals, respect for personal wellbeing) bore a statistically significant association with nurses’ perceptions of hospital patient- and family-centeredness (F=2.49, p=0.022). The grouped climate items (collaboration and coordination activities, patient- and family-centered care behaviors, patient-centered care behaviors) also bore a statistically significant association with nurses’ perceptions of hospital patient- and family-centeredness (F=20.71, p=0.000).

The lack of statistically significant associations between some of the culture attributes and the informal structure attributes with nurses’ perceptions offers new insights for patient- and family-centeredness. These findings suggest that aspects of the work environment for nurses be considered to improve PFCC within hospitals. Therefore, as hospitals strive to be more patient- and family-centered, the importance of the nurses’ work environment including working conditions, resources and educational support should be recognized. Study findings have implications for hospital practice and healthcare policy. For example, mean ratings of individual items on the survey can be used as benchmarks for specific quality domains. Also, future research can examine the correlation of these measures with other hospital quality data such as patient satisfaction scores. This would support the development, implementation and evaluation of interventions for improving quality and outcomes within hospitals. For healthcare policy, findings identify the need to assure quality of the practice environment for supporting nurses’ capacity to deliver PFCC in hospitals. They represent an opportunity for hospitals to improve nurses training and educational opportunities for supporting PFCC, provide necessary support for the professional development of nurses, engage nurses to participate in management decision-making processes, and establish equitable work relations among patient-care team members. These findings suggest that mechanisms for promoting nurse engagement in PFCC and quality improvement activities may be a likely way to improve PFCC climate and culture in hospitals.