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J Nurs Care Qual

Vol. 20, No. 3, pp. 220230

c 2005 Lippincott Williams & Wilkins, Inc.

A Psychometric Analysis of the

Patient Satisfaction With
Nursing Care Quality
An Actionable Approach to
Measuring Patient Satisfaction
Heather Spence Laschinger, PhD, RN;
Linda McGillis Hall, PhD, RN; Cheryl Pedersen, MSc;
Joan Almost, MScN, RN
Patient satisfaction with nursing care quality is an important indicator of the quality of care provided in hospitals. This study tested a newly developed patient-centered measure of patient satisfaction with nursing care quality within a random sample of 14 hospitals in Ontario, Canada. Results
of this study revealed that the newly developed instrument had excellent psychometric properties. Total scores on satisfaction with nursing care were strongly related to overall satisfaction with
the quality of care received during hospitalization. The results of this study yielded actionable,
patient-focused results that can be used by managers to address areas requiring improvement. Key
words: instrument development, nursing care, patient satisfaction, quality of care

ATIENT satisfaction with nursing care

quality is an important indicator of the
quality of care provided in hospitals. This
is not surprising, given the significant role
of nursing in the patient care experience.
As the recipients of nursing and medical
care, patients perceptions of the quality of

From the School of Nursing, University of Western

Ontario, London (Dr Laschinger); University of
Toronto (Dr Hall and Mss Pedersen and Almost);
Nursing Health Services Research Unit, Toronto (Drs
Laschinger and Hall); and the Canadian Institutes of
Health Research (Dr Hall), Ontario, Canada.
This project was funded by the Hospital Report Collaborative: Ontario Hospital Association and Ontario Ministry of Health and Long-Term Care.
Corresponding author: Heather Spence Laschinger,
PhD, RN, School of Nursing, University of Western Ontario, London, Ontario, Canada N6A 5C1 (e-mail: hkl@
Accepted for publication: July 13, 2004


care they experience during hospitalization

are an important component of assessment
of overall hospital quality. This is supported
by previous research that has shown patient satisfaction with nursing care to be the
strongest predictor of dominant influence on
patient overall satisfaction with their hospital
However, many patient satisfaction instruments measure only healthcare providers perceptions of what elements of patient care
are valued by patients. Failure to take into
account factors identified by patients as important to their care is inconsistent with the
notion of patient-centered care and patient
empowerment. In todays consumer-oriented
healthcare markets, a patient-centered measure of satisfaction with the quality of nursing
care received is an important component of
hospital quality management systems. In addition, to be useful tools for quality improvement purposes, patient satisfaction measures

Psychometric Analysis of the Patient Satisfaction Questionnaire

must also produce actionable results. The
purpose of this study was to test a newly developed patient-centered measure of patient
satisfaction with nursing care quality.
Patient satisfaction is often defined in terms
of the match between patients expectations
of care and the actual care received.39 Patient satisfaction with nursing care has been
defined as the patients subjective evaluation
of the cognitive-emotional response resulting
from the interaction between the expectations of nursing care and the perception of
actual nurse behaviors/characteristics.10 A
similar definition was proposed in the health
services literature by Cleary and McNeil.11
In the health services marketing literature,
patient satisfaction is viewed as a mediator
between patients perceptions of quality and
their future intentions to reuse the service or
recommend the service to others.12
Related literature
Antecedents of patient satisfaction with
nursing care
Many factors have been shown to have an
impact on patient satisfaction. Personal characteristics of patients, such as cultural background and degree of social support, and demographic variables, such as age, gender, and
education, have been found to influence patient satisfaction ratings in some studies1315
but not others.16 Pascoe17 found that older
patients tended to report higher satisfaction
with nursing care, whereas a study by Bader18
did not support this finding. Women have
been found to be more satisfied with care than
men in some studies,17,19 while other studies
have found no gender differences.2022
Patient expectations also have been found
to influence satisfaction ratings. Swan9 reported that patients with lower expectations
and less knowledge of available services were
more satisfied with their nursing care. In addition, patient health status has been shown


to influence satisfaction ratings. That is, patients with good health status postdischarge
report greater satisfaction than those with
poor health status.23,24 Nurses job satisfaction has also been shown to be related to patient satisfaction.227
Consequences of patient satisfaction
with nursing care
Patient satisfaction with nursing care has
been consistently found to be the strongest
predictor of patient satisfaction with the overall healthcare experience.1,2 Several studies
have shown that patients who are more satisfied with their care are more likely to follow medically prescribed regimens.28,29 More
satisfied patients are also more likely to recommend the hospital to family and friends3,30
and have greater intentions to return to the
hospital in the future as opposed to selecting another hospital.31 Finally, Jaipaul and
Rosenthal32 found that hospitals with higher
patient satisfaction with nursing care had
lower severity-adjusted mortality.
Measurement of patient satisfaction
with nursing care
A valid and reliable patient satisfaction
measure used on a regular basis in formal
health services evaluation systems can provide meaningful comparable data over time
and form the basis for continuous monitoring of consumer responses to healthcare
delivery. However, the quality of patient satisfaction with nursing care measures varies considerably and, until recently, few have undergone rigorous psychometric evaluation. The
majority of patient satisfaction instruments in
the literature are not based on explicit theoretical models. A critical feature of a usable
patient satisfaction with nursing care measure
is its ability to yield actionable results, that is,
specific data that can be used by managers
to improve patient care quality. Many existing tools have been criticized for lacking this
Research has also shown that a valid
measure of patient satisfaction with nursing care quality must include both patient



and provider perspectives, since these often

differ.33 In a qualitative study of recently hospitalized patients, Larrabee and Bolden34 identified 5 themes of good nursing care from
the patients perspective: providing for my
needs, treating me pleasantly and with respect, caring about me, being competent
(accurate knowledge and skills), and providing prompt care. In another study, Larrabee
and colleagues35 found that achievement of
patient-identified goals was a strong predictor of patient satisfaction with nursing care
quality (as measured by a modified version of
the Nursing and Daily Care Subscale from the
Patient Judgment of Hospital Quality [PJHQ]
questionnaire).36 Several studies have demonstrated differences between nurses and patients perceptions of important characteristics of care provided by nurses. Nurses in
several studies consistently overestimated the
importance of emotional care for patients in
comparison to patients perceptions.3740 Patients gave higher ratings to the importance
of technical care, such as providing explanations regarding their condition and care, following through, and monitoring. Congruence
between nurse and patient expectations for
good nursing care are important. Kovner41
found that the less patients and nurses disagreed on desirability of outcomes, the more
satisfied patients were with their care. Thus,
it is important for measures of patient satisfaction with nursing care to include patientidentified factors of good nursing care.42
The initial work for this study was a component of a larger project that evaluated the validity of a variety of nurse-sensitive outcomes
to determine the feasibility of collecting these
data on a regular basis as part of the patient discharge abstracting process.43 The literature for several nurse-sensitive outcomes,
including patient satisfaction, was reviewed
for evidence of their relationship to nursing
The review of the patient satisfaction literature included an evaluation of 29 instruments

available in the nursing and health services

literature.44 Several criteria were used to assess the relative value of these tools. First, the
comprehensiveness of the instrument was assessed with regard to factors identified in the
literature as determinants of patient satisfaction with nursing care quality. Also, on the basis of the recommendations in the literature
that measures of patient satisfaction should
reflect both nurse and patient perspectives,
these tools were further evaluated to determine the extent to which quality indicators
that the patients identified in the literature
were included. The instruments were also
evaluated in terms of the availability of psychometric data, readability of items, length
of the tool, ease of scoring, and sensitivity
to actual nursing activities/responsibilities. Finally, the instruments were assessed to determine the extent to which the results of the
responses to items on the questionnaire were
actionable, that is, their usefulness to nursing administrators for improving the patient
care processes.
Few of these instruments addressed all of
the factors found in the literature. On the basis of a review of the literature and initial
feedback from 9 professional practice leaders on the patient satisfaction questionnaires
currently used in their organizations, we decided that the PJHQ questionnaire36 was potentially useful as a measure of patient satisfaction with nursing care. Modifications to
the tool were made to capture a broader
scope of nursing care activities across the entire patient care process from admission to
discharge. The new instrument, the Patient
Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ), was developed with the
intention that this added specificity would
produce results that would be more actionable and, therefore, able to inform quality
improvement initiatives. This study was subsequently designed to determine the psychometric properties of the newly developed
PSNCQQ, as part of a province-wide initiative
designed to assess the performance of hospitals applying a balanced scorecard approach
using the domains of financial performance,

Psychometric Analysis of the Patient Satisfaction Questionnaire

system integration and change, clinical outcomes, and patient satisfaction.4547 We report the results of this study in the remaining
sections of this article.

A descriptive survey design was used to test
the PSNCQQ within a random sample of 14
hospitals in Ontario, Canada, composed of 5
teaching, 5 large community, and 4 small facilities. All medical and surgical patients discharged in April, May, and June of 2002 from
these hospitals constituted the study sample.
Response rates for similar province-wide research initiatives ranged between 31% and
65% for each hospital. On the basis of this
past experience, the expected response was
approximately 100 patients per hospital in
teaching and large community hospitals. In
small hospitals, where fewer patients are discharged each month, more than 100 surveys
were sent to patients from each small facility. Responses from patients who visited small
hospitals were expected to range from 60 to
Patients were eligible if they were older
than 18 years and had not participated in the
annual provincial patient satisfaction survey
less than 2 months prior to the study start
date. To prevent overlap with other provincial research initiatives underway at the time,
psychiatry and obstetrics patients were also
The PSNCQQ was derived from the PJHQ
questionnaire.36 A multidisciplinary research
team at the Hospital Corporation of America developed the original PJHQ instrument.
Items were derived from an extensive literature review, focus groups, and a content analysis of patients verbatim answers to questions
about hospital quality. The goal was to develop a questionnaire that would represent
the patients perspective with content that
represented salient features to patients. The
original tool contained 9 scales: nursing and


daily care, ancillary staff and hospital environment, medical care, information, admissions, discharge and billing, overall quality of
care and services, recommendations and intentions, and overall health outcomes. Previous Cronbach reliability coefficients have
been high, ranging from .90 to .94.25,26,36,48
On the basis of the findings of our critical
review of the literature, items from other subscales of the original PJHQ were adapted to reflect satisfaction with components of nursing
care. Contrary to Larrabee and colleagues35
modification of the Nursing and Daily Care
PJHQ subscale, we adapted selected items
from all 9 PJHQ subscales. The PSNCQQ has
19 items, plus 3 additional questions designed
to tap satisfaction with the overall quality of
care during the hospital stay, overall quality of nursing care, and intention to recommend the hospital to family and friends. Each
item of the PSNCQQ consists of a phrase
to designate the content of the question or
sign-post, followed by a more detailed question or descriptor. For example, in the first
item of the instrument, information you were
given is used as a signpost for the descriptor that follows, How clear and complete the
nurses explanations were about tests, treatments, and what to expect. The item format
of the PSNCQQ can be seen in Table 1.
A 5-point Likert scale ranging from poor
to excellent is used for each item of the
PSNCQQ. There are 2 methods to score the
PSNCQQ. For general results, the scores for
all items can be summed and averaged to
yield a single value for each patient. For detailed feedback and more actionable results,
item means and standard deviations can be
calculated. Another option is to compute the
percentage of strongly agree responses for
each item. These results can be used to track
changes over time or to evaluate the effects
of quality improvement initiatives. The results
can also be used for comparisons between
units and hospitals.
Prior to testing the new questionnaire, 6
face-to-face focus groups with nurse stakeholders across the province were conducted
to obtain feedback on the new instrument.

3.58 (1.11)
3.67 (1.05)
4.13 (0.99)
3.91 (1.06)
3.35 (1.17)
3.69 (1.08)
3.54 (1.11)
3.87 (1.13)
3.69 (1.13)
4.00 (1.02)
3.81 (1.07)
3.59 (1.16)
3.82 (1.03)
3.83 (1.17)
3.53 (1.26)

3.64 (1.12)
3.72 (1.00)
4.19 (1.02)
3.94 (1.08)
3.39 (1.17)
3.75 (1.12)
3.62 (1.13)
3.98 (1.11)
3.65 (1.17)
4.02 (1.03)
3.84 (1.07)
3.63 (1.11)
3.90 (1.00)
3.78 (1.22)
3.58 (1.25)

indicates Patient Satisfaction with Nursing Care Quality Questionnaire.

3.91 (0.98)
3.80 (1.00)
3.74 (1.06)

3.91 (1.07)
3.90 (1.07)
3.76 (1.07)


3.88 (0.98)

3.93 (1.03)

1. Information You Were Given: How clear and complete the nurses explanations were
about tests, treatments, and what to expect.
2. Instructions: How well nurses explained how to prepare for tests and operations.
3. Ease of Getting Information: Willingness of nurses to answer your questions.
4. Information Given by Nurses: How well the nurses kept them informed about your
condition and needs.
5. Involving Family or Friends: How well the nurses kept them informed about your
condition and needs.
6. Involving Family or Friends in Your Care: How much they were allowed to help in your
7. Concern and Caring by Nurses: Courtesy and respect you were given; friendliness and
8. Attention of Nurses to Your Condition: How often nurses checked on you and how well
they kept track of how you were doing.
9. Recognition of Your Opinions: How much nurses ask you what you think is important and
give you choices.
10. Consideration of Your Needs: Willingness of the nurses to be flexible in meeting your
11. The Daily Routine of the Nurses: How well they adjusted their schedules to your needs.
12. Helpfulness: Ability of the nurses to make you comfortable and reassure you.
13. Nursing Staff Response to Your Calls: How quick they were to help.
14. Skill and Competence of Nurses: How well things were done, like giving medicine and
handling IVs.
15. Coordination of Care: The teamwork between nurses and other hospital staff who took
care of you.
16. Restful Atmosphere Provided by Nurses: Amount of peace and quiet.
17. Privacy: Provisions for your privacy by nurses.
18. Discharge Instructions: How clearly and completely the nurses told you what to do and
what to expect when you left the hospital.
19. Coordination of Care After Discharge: Nurses efforts to provide for your needs after you
left the hospital.





3.61 (1.12)
3.96 (1.11)
3.71 (1.14)
4.04 (1.02)

3.65 (1.23) 3.57 (1.25)

3.91 (1.03) 3.66 (1.12)

4.05 (0.95) 3.89 (1.01)
3.95 (1.10) 3.83 (1.18)

4.04 (1.02) 3.86 (1.07)

3.79 (1.11)
4.12 (1.06)
3.94 (1.05)
4.20 (0.98)

3.95 (1.07) 3.76 (1.10)

3.56 (1.13) 0.40 (1.17)

4.09 (1.04) 3.95 (1.07)

4.28 (0.94) 4.19 (0.10)

3.82 (1.02) 3.72 (1.02)

3.82 (1.00) 3.64 (1.10)

4.09 (0.83) 3.94 (1.00)

4.06 (0.95) 3.89 (1.04)
4.04 (0.95) 3.79 (1.05)

4.02 (0.87) 3.93 (0.99)

M (SD)

PSNCQQ items

Table 1. PSNCQQ item means and standard deviations by hospital type and total sample

Psychometric Analysis of the Patient Satisfaction Questionnaire

The panel participants felt that the new instrument accurately reflected what nurses do,
and they repeatedly commented on the clarity
of the language used in the instrument. They
also felt that it was advantageous that the instrument had already been tested for reliability and validity.
Data collection
Questionnaire packages were mailed to
3,036 patients with a letter of explanation,
the PSNCQQ instrument, and a researcheraddressed stamped return envelope. Strategies suggested by Dillman49 to improve the return rate were used in an attempt to maximize
the response rate. Three mailings were conducted in September, October, and November
2002. A reminder letter was sent 3 weeks after
the first mailing, and a second questionnaire
was mailed 3 weeks later. Completed questionnaires were returned to the professional
survey organization that handled the data collection process. Data was entered into an SPSS
data file and cleaned prior to data analysis.
The final sample consisted of 1041 patients
(34% response rate), with 492 patients from
teaching hospitals, 385 patients from large
community hospitals, and 164 patients from
small hospitals. The overall average patient
age was 63, with slightly more females (n =


525) than males (n = 445); the average length

of stay was 6.8 days. Patient demographics
did not differ significantly by hospital type
(Table 2).
Data analysis
Descriptive statistics and reliability analyses were conducted. Construct validity was
established through exploratory factor analysis and confirmatory factor analysis. After riskadjusting for length of stay, gender, age, and
self-rated health, we examined the extent to
which the PSNCQQ predicted overall satisfaction with care received during the hospital experience, overall satisfaction with nursing care, and intent to recommend the hospital to family and friends. Subgroup analyses
to examine differences among hospital groups
were conducted using analysis of variance
(ANOVA) procedures.
Descriptive statistics
The means and standard deviations for
the total PSNCQQ scale, overall satisfaction
with care measures, and intentions to recommend the hospital to family or friend subscale are presented in Table 3. Consistent with
previous studies found in the literature, the

Table 2. Patient demographics

M (SD)

Age (years)
Length of stay (days)

Marital Status


F test, P > .05.

2 test, P > .05.





61.94 (16.92)
7.34 (13.78)

63.80 (15.70)
6.71 (9.48)

63.66 (16.18)
5.45 (7.08)

62.94 (16.35)
6.81 (11.45)

n (%)

n (%)

n (%)

n (%)

269 (54.7)
223 (45.3)

167 (53.2)
147 (46.8)

89 (54.3)
75 (45.7)

525 (54.1)
445 (45.9)

170 (57.6)

218 (74.7)

63 (60.6)

451 (65.3)



Table 3. Means and standard deviations of patient satisfaction scores by hospital type
M (SD)
Overall perceptions



Total Patient Satisfaction with Nursing Care

Quality Questionnaire
Overall quality of care and services you
received during your hospital stay
Overall quality of nursing care you received
during your hospital stay
On the basis of nursing care I received, I
would recommend this hospital to my
family and friends

3.19 (0.92)

3.76 (0.88)

3.98 (0.82) 3.81 (0.89)

4.06 (1.04)

3.97 (1.01)

4.16 (1.01) 4.04 (1.02)

4.04 (1.06)

4.03 (0.99)

4.23 (0.96) 4.06 (1.02)

4.38 (1.04)

4.17 (1.12)

4.32 (1.07) 4.30 (1.08)

responses to all items in the PSNCQQ were

highly skewed (range was 0.447 to 1.29).
The majority of patients rated their satisfaction as either very good or excellent. Although PSNCQQ mean scores were similar
across hospital types, patients in large community hospitals were significantly less satisfied than patients in smaller hospitals on the
total PSNCQQ scale and overall satisfaction
with hospital care. Teaching and large community hospitals did not differ on any satisfaction measures.
To ascertain the source of hospital-type
differences in patient satisfaction, we used
ANOVA to examine group differences on
PSNCQQ item means (see Table 1). Patients
in small hospitals were significantly more satisfied than those in large community hospitals
on 5 of the 19 PSNCQQ items: willingness of
nurses to answer their questions, the extent to
which nurses kept them informed about their
condition, nurses willingness to be flexible
in meeting their needs, and provisions for a
restful environment (P < .05). They also were
more satisfied than patients in teaching hospitals on the following items: how well nurses
kept them informed, how flexible the nurses
were in providing care, and the promptness
of nurses responses to their calls for help.
Although all patient satisfaction item means
were highest in small hospitals, most were not
significantly higher (P > .05), and the actual
differences among groups were not large. This



suggests that the PSNCQQ is tapping relatively

consistent levels of patient satisfaction regardless of hospital type.
Reliability analyses
The Cronbach reliability estimates for the
PSNCQQ were excellent (.97). Item total correlations were high, ranging from 0.61 to 0.89.
Reliability estimates were similar across hospital categories (Table 4). This suggests that
patients in different types of hospital systems
were interpreting the items on the PSNCQQ
in a consistent manner.
Construct validity was established through
exploratory factor analysis and confirmatory
factor analyses. The results of the EFA revealed
Table 4. PSNCQQ Cronbach reliability estimates by hospital type



Item total



PSNCQQ indicates Patient Satisfaction with Nursing

Care Quality Questionnaire.

Psychometric Analysis of the Patient Satisfaction Questionnaire

a 1-factor solution with factor loadings greater
than 0.70 (range was 0.753 to 0.890). A confirmatory factor analysis confirmed the 1factor model. Various fit indices demonstrated
a good fit of this model to the data ( 2 =
14.36, GFI = 0.944, IFI = 0.958, CFI = 0.958,
RMSEA = 0.091) according to standards recommended by Bentler and Bonett.50
The predictive validity of the PSNCQQ was
examined by testing its ability to predict expected outcomes frequently used for validation purposes in health services research. After adjusting for length of stay, gender, age,
and self-rated health, the PSNCQQ explained
significant amounts of the variance in the
overall quality of care and services (64%),
overall quality of nursing care (73%), and intent to recommend the hospital to family and
friends, in the combined sample of hospitals (55%) (Table 5). These results provide
strong support for the predictive validity of
To measure the sensitivity of the PSNCQQ,
the overall satisfaction with care measure was
dichotomized into 2 groups: excellent/very
good and poor/fair responses. The excellent/very good group had significantly higher
scores on the PSNCQQ than had the poor/fair


group (M = 3.18, SD = 0.59, and M = 1.17,

SD = 0.71, for the high and low groups, respectively). These results demonstrated the
ability of the PSNCQQ to discriminate between high and low levels of overall patient
satisfaction with the care they received during
their hospital stay and added further support
for the construct validity of the instrument.
Owing to funding constraints, we were not
able to conduct a second wave of the study
to obtain test-retest reliability data, which
would have strengthened these study results.
Although these studies are often plagued with
methodological problems, such as poor return rates and the failure to obtain follow-up
data for all subjects, particularly with patient
satisfaction surveys, it would have been desirable to have a measure of stability for the
PSNCQQ. This should be addressed in future
The results of the study provide encouraging support for the PSNCQQ. The PSNCQQ

Table 5. Risk-adjusted final multiple regression models

Overall quality of care and services
Age, sex, LOS, health at admission
Final model
Overall quality of nursing care
Age, sex, LOS, health at admission
Final model
Intent to recommend the hospital
Age, sex, LOS, health at admission
Final model

at P < .001.
indicates length of stay.




All hospitals















showed excellent psychometric properties

and a strong relationship with overall satisfaction with the quality of care received during
hospitalization. This is consistent with findings in previous research.1,2 The PSNCQQ
was also strongly related to the likelihood
of recommending the hospital to friends
and family. This is particularly important in
market-driven healthcare systems, such as
that in the United States. Patient satisfaction
with care is a key component of hospital report cards that are shared with both accreditation agencies and the public. Most hospitals
use this information as part of their marketing strategy. In socialized healthcare systems,
the results are often reported in yearly systemwide report cards and shared with both
government and the public as part of the public accountability process.
The results of this study yielded actionable,
patient-focused results that can be used by
managers to address areas requiring improvement. The specific nature of the items in the
new instrument make it possible for managers to identify strengths and weaknesses of
their nursing care delivery processes. Since
the items are based on factors identified by
patients as important elements of satisfaction
with nursing care, actions to address areas of
improvement are more likely to be appropriate to patients. In our study, each hospital was
provided with a summary report of the hospital means and standard deviations for each
item on the questionnaire, as well as the percentage of patients rating each item as excellent. For comparative purposes, we provided
the combined data for all other hospitals of
similar type (ie, small, community, and teach-

ing). Thus, hospitals could compare their results to the average scores across other similar hospitals in the sample. This feedback was
received very favorably by the nurse administrators in our sample.
The PSNCQQ can be incorporated into an
existing hospital quality monitoring system to
monitor patient satisfaction over time. It is a
feasible instrument for use at the unit level
owing to its short length and the specificity
of each item to a broad range of nursing care
activities. The instrument could be used on
an ongoing basis to track variability in patient
satisfaction with nursing care comparatively
between units and organizations. Finally, the
PSNCQQ could also be used as an outcome
variable to evaluate the impact of unit or organizational change on patient satisfaction (ie,
changes in staff mix, nurse-patient ratios, and
other organizational changes). This information could be used by nursing management
as one evidence-based indicator of nursings
contribution to the patient care process.
The PSNCQQ appears to have very good
psychometric properties, is of reasonable
length, is easy to administer, and yields data
that can be used by management in quality
improvement efforts. Further testing must be
done to validate the results of this study and
add to the database of psychometric properties for the new instrument. However, the
results of this study provide encouraging support for the reliability, validity, and clinical utility of the PSNCQQ as a measure of patient satisfaction that is patient-centered.

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