Impact of Clinical Pathway Implementation on Quality of Care in Chinese Nurses PDF

Received: 23 November 2023 Accepted: 7 April 2024 DOI: 10.1111/inr.12981 O R I G I NA L A RT I C L E Impact of clinical pathway implementation satisfaction, work engagement, and hospital–patient relationship on quality of care in Chinese nurses Junlong Li PhD Candidate,...

Received: 23 November 2023 Accepted: 7 April 2024 DOI: 10.1111/inr.12981 O R I G I NA L A RT I C L E Impact of clinical pathway implementation satisfaction, work engagement, and hospital–patient relationship on quality of care in Chinese nurses Junlong Li PhD Candidate, Lijia Xiang MPH Qin Li MM Jie Liu MA Jay Pan PhD 1 HEOA Group, West China School of Public Abstract Health and West China Fourth Hospital, Sichuan University, Chengdu, China Aims: This study aimed to investigate how clinical pathway implementation satisfaction, 2 work engagement, and hospital–patient relationship impact the quality of care that is Department of Human Resources, Sichuan Vocational College of Health and Rehabilitation, provided by nurses in public hospitals. Zigong, China Background: Clinical pathways are recommended as a form of quality improvement 3 Department of Infection Management, Chengdu by broader healthcare systems and are widely used in the world. Nurses are the most Second People’s Hospital, Chengdu, China involved group of healthcare professionals in the implementation of clinical pathways in public hospitals. So, it is important to investigate how their satisfaction with the process Correspondence affects the quality of care they provide and influencing factors. Jay Pan, HEOA Group, West China School of Public Health and West China Fourth Hospital, Methods: This descriptive cross-sectional study surveyed nurses practicing across Sichuan University, Chengdu, China. seven tertiary public hospitals in Sichuan Province, China, online. The survey consisted Email: [email protected] of a questionnaire for the general characteristics of the participants and four Chinese maturity scales validated by previous studies: clinical pathway implementation satisfac- Funding information National Natural Science Foundation of China, tion scale, work engagement scale, hospital–patient relationship perception scale, and Grant/Award Numbers: 71874116, 72074163; quality of care scale. The bootstrap method was used to test a moderated mediation Taikang Yicai Public Health and Epidemic Control model using Hayes’ PROCESS macro models 4 and 8. We followed STROBE guidelines Fund, Grant/Award Number: H201203; Sichuan Science and Technology Program, China, to prepare the study report. Grant/Award Numbers: 2022YFS0052, Results: A total of 880 nurses filled out the questionnaires, 821 of which were 2021YFQ0060; Southwest Medical University: regarded as valid. Clinical pathway implementation satisfaction had a positive effect Sichuan Hospital Management and Development Research Center, Key Research Base of Humanities on quality of care (B = 0.873, P < 0.001). Work engagement played a mediation role and Social Sciences of Sichuan Province, between nurses’ clinical pathway implementation satisfaction and the quality of care Grant/Award Number: SCYG2021-28; Zigong (effect = 0.080, Boot 95% CI = [0.023, 0.142]). This mediation model was moderated by Municipal Science and Technology Bureau, Grant/Award Number: 2019rkx08; Health the hospital–patient relationship (P < 0.01). Commission of Zigong, Grant/Award Number: Conclusion: Clinical pathway implementation satisfaction may enhance the quality of 19yb032 care by work engagement of nurses. Moreover, a good hospital–patient relationship can enhance the positive impact of nurses’ satisfaction on work engagement and health service quality. Implications for nursing and nursing policy: Public hospital managers need to pay attention to nurses’ evaluation of and perceptions toward clinical pathway implemen- tation and then take corresponding measures to improve their satisfaction to enhance the quality of care. At the same time, the government, society, and hospitals also need to foster good hospital–patient relationships to ensure that nurses have a high level of work engagement that aids in providing high-quality care services. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2024 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses. Int Nurs Rev. 2024;1–10. wileyonlinelibrary.com/journal/inr   14667657, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/inr.12981 by CochraneUnitedArabEmirates, Wiley Online Library on [21/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  LI et al. K E YWOR D S Clinical pathway, hospital–patient relationship, mediation, moderation, nurses, quality of care, work engagement INTRODUCTION A previous study highlighted that employees’ job satisfac- tion is an important factor that affects the quality of services In the service industry, service quality is a crucial factor that provided (Varey, 1995). Job satisfaction refers to an individ- determines an organization’s success (Srivastava & Prakash, ual’s positive subjective evaluation or attitude toward various 2019). The quality of the service provided by an organization aspects of work, and this can be influenced by several factors to its customers often depends on the organization’s employ- such as the nature of the work, work challenges, salary scheme, ees (Goula et al., 2022). In the healthcare service industry, interpersonal relationships, working conditions, work moti- service quality describes the extent to which medical workers vation, and organizational environment (Geese et al., 2022; are able to provide health services that meet patients’ needs Penconek et al., 2021). The job satisfaction of nurses is and achieve positive health effects (Jin et al., 2018; Woo & reflected in their positive evaluation or attitude toward all Choi, 2021). It is a crucial indicator of the efficiency of med- aspects of the healthcare services in which they participate. ical workers and the effectiveness of their services and has A previous study suggested that job satisfaction and work direct implications on patient diagnosis, treatment safety, and engagement should be researched in tandem as they are overall health outcomes (Jin et al., 2018; Woo & Choi, 2021). closely linked to individual motivation (Schaufeli & Bakker, Nurses are among the essential participants in the healthcare 2004). Work engagement is defined as a positive, emotional service industry, and they significantly contribute to health- motivational state of work-related well-being characterized care service quality (Abdullah et al., 2021). However, Goula by vitality, dedication, and concentration (Szilvassy & Širok, et al. (2022) showed that most studies on healthcare ser- 2022), and it has been demonstrated to be closely related to vice quality focused on patients, with few examining how job satisfaction (Ofei-Dodoo et al., 2020). Work engagement healthcare professionals evaluate healthcare service quality. is determined using the job demands-resources theoretical Therefore, studying healthcare service quality and related model, which assumes that engagement depends on work influencing factors from the nurses’ perspective may enhance demand and work resources (Mazzetti et al., 2023). The level the provision of high-quality services. of work engagement can be enhanced by various resources In the health service industry, a diagnosis and treatment within the organization, such as support from colleagues modelclinical pathway is being widely promoted. Clinical and superiors, enhanced role clarity, feedback on work, and pathway refers to a standardized service plan for patients with team supervision (Foà et al., 2020). Job satisfaction generally a specific disease and is formulated by a group of multidisci- encompasses nine dimensions, which are salary, promotion plinary professionals. It is a tool used to guide evidence-based opportunities, fringe benefits, rewards, supervision, inter- healthcare with the aim to promote organized and efficient personal relationships, nature of work, communication, and patient care (Wind et al., 2022). Clinical pathways are rec- working conditions (Li et al., 2019a, 2019b). Interpersonal ommended as a form of quality improvement by broader relationships, communication, fringe benefits, and working healthcare systems and are widely used in the world. In fact, conditions are explicit sources of support from colleagues over 80% of hospitals in the United States reported to have and superiors, while salary, promotion opportunities, and implemented clinical pathways in 2003 and most European rewards fall under feedback on work. In other words, high job countries have used them in 2019 (Sun et al., 2021). In China, satisfaction correlates with increased satisfaction with work 91.3% of two-level and above public hospitals implemented resources, which can effectively stimulate work-related moti- clinical pathways by the end of 2021 (National Health Com- vation in employees, thereby further enhancing their work mission of the People’s Republic of China, 2022), covering engagement. Work engagement is one of the most important over 1,000 types of diseases (Li et al., 2021). Therefore, the factors that aid success in any work environment, consider- effects of clinical pathway implementation in hospitals reflect ing that it is associated with positive work outcomes (Gillet the level of healthcare service quality to some extent. How- et al., 2019). The outcome variables of work engagement con- ever, a previous study showed that some health staff are not sist of organizational efficiency and performance (Zhang et al., proactive in promoting the clinical pathway, and this may limit 2020b). Organizational efficiency and performance reflect its effectiveness upon implementation (Wang et al., 2014). the quality of healthcare services in the healthcare service Implementing clinical pathways is a special work that involves industry (Jin et al., 2018). Thus, work engagement may medi- diagnosis, treatment, and nursing. Since nurses are one of the ate the association between clinical pathway implementation most involved healthcare professionals in the implementa- satisfaction and quality of care. tion of clinical pathways in public hospitals, it is important to In addition, the hospital–patient relationship is one of the investigate how their satisfaction with the process affects the focal points of concern in the healthcare service industry. The quality of care. hospital–patient relationship is a work-oriented interpersonal  14667657, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/inr.12981 by CochraneUnitedArabEmirates, Wiley Online Library on [21/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License CLINICAL PATHWAY IMPLEMENTATION SATISFACTION  relationship established between the health staff and patients, all eligible nurses. The Strengthening the Reporting of Obser- along with their families through diagnosis, treatment, and vational Studies in Epidemiology (STROBE) guidelines were nursing activities (Ozaras & Abaan, 2018). It is an inevitable followed. aspect of the process of diagnosis, treatment, and nursing, running through the medical activities of patients and directly affects treatment and rehabilitation outcomes (Gou et al., Measures 2021). In recent years, the hospital–patient relationship has become a general concern in societies due to increased vio- The survey consisted of four Chinese maturity scales vali- lence against medical professionals (Zhang et al., 2021). Effec- dated by previous studies and a questionnaire for the general tive hospital–patient interactions are associated with a wide characteristics of the participants (S1). range of positive work behaviors, such as improving diag- nostic accuracy, health resource utilization, and medical care. Conversely, poor relationships may reduce healthcare quality Clinical pathway implementation satisfaction (Molina-Mula & Gallo-Estrada, 2020). Furthermore, a study confirmed that the hospital–patient relationship is strongly The Clinical Pathway Implementation Satisfaction Scale, related to job satisfaction and work engagement (Zhang et al., developed by Li et al. in 2021, comprises three dimensions: 2020a). Prior studies on quality of healthcare service, job organizational support, process identification, and effect per- satisfaction, and work engagement have primarily examined ception. This scale includes 21 items (Li et al., 2021). The Likert the hospital–patient relationship as a predictor or outcome five-level scoring method is used in this scale, and all items are variable. There are no studies that explored the impact of scored positively. The rating ranges from “very dissatisfied” healthcare service quality predictors on healthcare service to “very satisfied,” with 1–5 points. The higher the score, the quality at different levels of hospital–patient relationships. greater the satisfaction level. The Cronbach’s alpha coefficient Therefore, this study mainly focuses on how clinical pathway was 0.978 (Li et al., 2022) and 0.983 in this study. implementation satisfaction by nurses affects the quality of care at varying levels of hospital–patient relationships. In conclusion, we put forward the following hypotheses to Work engagement determine the potential impact mechanism of nurses’ satis- faction with clinical pathway implementation on the quality Work engagement was measured using the Work Engage- of care. ment Scale that was developed by Schaufeli et al. in 2002 T1 and revised by Li et al. in 2006. The scale is comprised of Hypothesis . Nurses’ clinical pathway implementation satis- three dimensions: vitality, dedication, and concentration, with faction can positively influence the quality of care.T3 a total of 16 items (Li et al., 2006). The scale uses a Likert T2 seven-level scoring method, with scores ranging from “never” Hypothesis . Nurses’ work engagement plays a mediating to “always,” assigned 1–7 points, respectively. All items are role in the relationship between clinical pathway implementa- scored positively, and the higher the score, the greater the tion satisfaction and quality of care. level of work engagement. The Cronbach’s alpha coefficient T2 was reported at 0.930 (Liu et al., 2017) and 0.967 in this Hypothesis . Hospital–patient relationship moderates the study. association between clinical pathway implementation satis- faction and work engagement and the connection between clinical pathway implementation satisfaction and quality of Hospital–patient relationship care. The Hospital-Patient Relationship Perception Scale was devel- oped by Hahn et al. in 1996 and revised by Yang in 2011. This METHODS scale is comprised of three dimensions: subjective experience, perception of patients’ objective behavior, and the combi- Design and participants nation of subjective experience and perception of patients’ objective behavior, with a total of 8 items (Yang, 2011). The A descriptive cross-sectional design was used for this study. scale adopts a Likert five-level scoring method, with scores Nurses practicing in seven tertiary public hospitals in Sichuan ranging from “completely inconsistent” to “very consistent,” China, and who met eligibility criteria, were surveyed using an each represented by 1–5 points, respectively. The reverse items online questionnaire from March to June 2022. The inclusion are scored in reverse order. The higher the score, the worse the criteria included having worked for at least one year, holding a level of hospital–patient relationship perception. The Cron- nurse practice certificate, and participating in clinical pathway bach’s alpha coefficient was 0.705 (Chen, 2016) and 0.942 in implementation. Participation in the study was voluntary for this study.  14667657, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/inr.12981 by CochraneUnitedArabEmirates, Wiley Online Library on [21/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  LI et al. Quality of care factor analyses of quality of care were conducted using the independent-sample t test and one-way ANOVA. The The study adopted the Healthcare Service Quality Scale that bootstrap method was used to test a moderated media- was developed by Yang et al. in 2018 (Yang et al., 2018) and tion model using Hayes’ PROCESS macro models 4 and 8. made appropriate adjustments to the items to adapt to the The statistically significant variables in the univariate anal- survey of quality of care. The scale includes three dimensions ysis (educational background, job income, and position) of psychosocial care, diagnosis, and treatment care, as well as were included as control variables in the regression mod- quality assurance, with a total of 13 items. The scale uses a Lik- els. P < 0.05 (two-tailed) was considered as an indication of ert five-level scoring method, with scores ranging from “very statistical significance. bad” to “very good,” represented by 1–5 points, respectively. All items are scored positively, and the higher the score, the better the quality of the care works’ self-assessment. The Cron- Ethical considerations bach’s alpha coefficient was reported at 0.984 (Li et al., 2022) and 0.986 in this study. This study was approved by the Ethics Committee of Sichuan Vocational College of Health and Rehabilitation (CWKY- 20211214-28). Informed consent was required on the first page Participants’ general characteristics of the survey. Respondents formally participated in the survey by selecting the option “Informed and agreed to participate This part of the questionnaire was designed by the researchers voluntarily in the survey.” Completing the set of self-report of this study. It included factors such as gender, age, mari- questionnaires was the expression of consent to participate tal status, education, work income, professional title, working in the study. The survey did not obtain the names and other years, position, and whether they are establishment personnel identifying information of the respondents, and all data were or not. anonymous and confidential. Data collection RESULTS Due to health restrictions and protocols related to the Participant characteristics COVID-19 pandemic, a field investigation was not conducted for this study. The data were collected using an online ques- A total of 880 questionnaires were collected, though 821 were tionnaire survey platform called Questionnaire Star. The valid after excluding the unqualified ones, with an effective hyperlinks for accessing the questionnaire and QR codes were rate of 93.30%. Table 1 displays the descriptive characteris- disseminated among nurses in seven public hospitals. Low tics of the respondents (n = 821). The study group included response rate, representativeness, and item-response are typ- 17 males (2.07%) and 804 females (97.93%). The average age ical problems with online surveys (Grande et al., 2022). To of the respondents was (32.06 ± 6.36) years. mitigate these issues and improve the quality and effectiveness of the survey, several steps were taken. First, the question- naire provided a clear description of the completion process, Single-factor analysis of quality of care informing respondents of the study’s purpose and signifi- cance. Respondents participated in the survey after selecting The results are shown in Table 1. The differences in the qual- the option “Informed and agreed to participate voluntarily in ity of care with varying educational statuses (P < 0.001), work the survey.” Second, the language that is appropriate to nurses income (P < 0.05), and positions (P < 0.001) were statisti- was used to describe questions and options, while avoiding cally significant. However, the differences in the quality of care the use of grids or matrices to represent the Likert’s scale with dissimilar genders, ages, marital statuses, professional answers (Grande et al., 2022). Finally, after the survey, the titles, work years, and establishment personnel status were not data were exported from the Questionnaire Star website before statistically significant (P > 0.05). being reviewed and sorted. Incomplete forms and outliers were deleted. The mediating effects of work engagement Data analysis The statistically significant variables in the univariate anal- ysis, which are educational background, job income, and IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., position, were included as control variables in the regres- Armonk, NY, USA) was used to enter and analyze the data. sion model. The aim was to test the mediating effect of The general data were described by frequency and con- work engagement. As shown by the results that are presented stituent ratio (%). The total and item scores on each scale in Table 2, the clinical pathway implementation satisfaction were represented as means (± standard deviations). Single- of nurses was found to be a positive predictor of quality  14667657, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/inr.12981 by CochraneUnitedArabEmirates, Wiley Online Library on [21/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License CLINICAL PATHWAY IMPLEMENTATION SATISFACTION  TA B L E  Participant characteristics. Variables N (%) M ± SD t/F P Gender −1.424 0.155 Male 17(2.07) 4.317 ± 1.017 Female 804(97.93) 4.550 ± 0.659 Age (yrs old) 1.181 0.316 20–30 482(58.71) 4.560 ± 0.625 31–40 247(30.09) 4.532 ± 0.664 41–50 70(8.53) 4.571 ± 0.814 ≥51 22(2.67) 4.294 ± 1.024 Marital status −0.170 0.865 Other marital status 263(32.03) 4.539 ± 0.698 Married 558(67.97) 4.548 ± 0.654 Education 9.372