Original Article

The nurse outcomes and patient outcomes following the

High-Quality Care Project
Q. Chen1 RN , L. Gottlieb2 RN, PhD, D. Liu1 RN, PhD, S. Tang1 PhD & Y. Bai1 MD
1 PhD candidate, Xiangya School of Nursing, Central South University, Hunan, China, 2 Professor, Ingram School of Nursing, McGill University, Quebec,
Canada

CHEN Q., GOTTLIEB L., LIU D., TANG S. & BAI Y. (2020) The nurse outcomes and patient outcomes following the
High-Quality Care Project. International Nursing Review 00, 1–10

Background: There have been many single cross-sectional studies on nurse or patient outcomes. However, long-term evidence on
improving nurse and patient outcomes is still limited. The High-Quality Care Project is a national project in China for improving
nurse and patient outcomes by implementing primary nursing.
Aim: (1) To assess the long-term changes in nurse and patient outcomes in the context of the High-Quality Care Project. (2) To
explore the potential influences of primary nursing on nurse and patient outcomes based on this study and broader existing evidence.
Methods: The data of two cross-sectional studies were used for analysis. The two cross-sectional studies were conducted before (2009)
and after (2016) the High-Quality Care Project. A total of 1376 nurses and 904 patients from 40 units of 10 tertiary hospitals were
surveyed. Reliable and validated instruments were used to measure nurse and patient outcomes. Multilevel modelling was the main
method for data analysis.
Results: Nurses in 2016 were more satisfied than nurses in 2009 with most dimensions of nurse work environment and job
satisfaction. However, they were not more satisfied with burnout, global job satisfaction or intention to leave their job. Nurses in 2016
also reported better quality of patient care and patient safety while their patients reported higher patient satisfaction.
Conclusion: The analysis of our results based on existing evidence indicates that primary nursing could be considered as a potentially
effective way to improve nurse work environment and patient outcomes. More studies with rigorous study design from micro
perspectives would be useful to further explore the direct effects of primary nursing on nurse or/and patient outcomes.
Implications for nursing and nursing policy: Policymakers, healthcare service leaders and nurse managers should make efforts to
provide multi-level supports to cultivate an encouraging environment for nurses to practice primary nursing, because the
implementation of primary nursing may improve the nurse work environment and patient outcomes. Furthermore, improving nurse
participation in hospital affairs and developing nursing discipline and education for increasing nursing staff resource and nurses’
capacity – which all need policy and management supports – are crucial to further improve nurse and patient outcomes.

Keywords: Burnout, Job Satisfaction, Nurse Work Environment, Nursing Policy, Patient Outcomes, Primary Nursing, Retention

Introduction worldwide. Improving nurse work environment to reduce

The combination of global ageing and nursing shortage has burnout and increase job satisfaction is an important strategy
posed significant challenges to the healthcare systems for improving the nursing workforce retention (Nantsupawat

Correspondence address: Dan Liu; Siyuan Tang, Xiangya School of Nursing, Central South University, 172 Tongzipo Road, Changsha, Hunan, 410013, China; Tex:
00867318265026; Fax: 008673182650266; E-mails: liudan@csu.edu.cn; tsycongcong@126.com

Conflict of Interest statement

None declared.
Funding Statement
This work was supported by Chinese Medical Board (No.740010006) and China Scholarship Council (No.201706370079).

© 2020 International Council of Nurses 1

2 Q. Chen et al.
et al. 2017). Nurse outcomes (such as nurse work environment,
burnout and job satisfaction) are closely related to better
patient outcomes (such as quality of care, patient safety and
patient satisfaction) (Nantsupawat et al. 2015; Copanitsanou
et al. 2017). Nurse and patient outcomes are both crucial indi-
cators for healthcare system and services evaluation (Aiken
et al. 2012).
In 2010, the Chinese Ministry of Health proposed a project
named the High-Quality Care Project (HQCP) to improve
nurse and patient outcomes in hospitals through the imple-
mentation of primary nursing (PN). PN was conceived by
Manthey and a group of nurses on Unit 32 at the University
of Minnesota Hospital in the 1970s. PN is a person-centred
nursing care delivery system based on a focus on the patient–
nurse relationship (Wessel & Manthey 2015). In PN, nurses
take responsibility for the total care of a patient and are
accountable for his/her care over a 24-hour period and from
admission to discharge. The primary nurse is responsible for
assessing the patient’s needs and then planning, organizing,
implementing, coordinating and evaluating the care (Wessel
& Manthey 2015). Although PN showed initial potential for
improving nurse outcomes and patient outcomes, its effects
are not established. In particular, PN’s long-term effects on
nurse and patient outcomes beyond western countries have
not been studied (Mattila et al. 2014; Kusk & Groenkjaer
2016).
Background
Studies on nurse outcomes and patient outcomes in hospitals
have received great attention worldwide during the past two
decades (Lu et al. 2019; Wei et al. 2018). RN4CAST was the
first multi-country, multilevel cross-sectional study focused
on nurse and patient outcomes such as the nurse work envi-
ronment, burnout, job satisfaction, intention to leave job,
quality of patient care, patient safety and patient satisfaction
(Sermeus et al. 2011). Twelve European countries were
included in that study (Sermeus et al. 2011). Meanwhile, a
similar survey was also conducted in other countries (e.g. the
United States, China, Thailand, Turkey and Omen) (Nantsu-
pawat et al. 2015; Topcu et al. 2016; Albashayreh et al. 2019;
Aiken et al. 2012; You et al. 2013). These studies indicated
that nurse and patient outcomes were not satisfactory in most
countries, and that these nurse and patient outcomes were
directly or/and indirectly related to each other.
The nurse work environment plays an important role in
the relationships between other nurse outcomes and patient
outcomes (Copanitsanou et al. 2017; Wei et al. 2018). Many
studies in different contexts have verified that a good nurse
work environment is critical for other positive nurse
© 2020 International Council of Nurses
outcomes (e.g. lower burnout, job satisfaction and retention)
(Albashayreh et al. 2019) and patient outcomes (e.g. quality
of care, patient safety and patient satisfaction) (Gaalan et al.
2019). Meanwhile, nurse outcomes are positively related to
patient outcomes (Nantsupawat et al. 2015). These interna-
tional surveys with large sample sizes have helped researchers,
nurse managers, and policymakers understand the status of
the nurse and patient outcomes worldwide and allowed the
exploration of the relationships among these outcome vari-
ables in different contexts. However, until now, most studies
on nurse and patient outcomes are still limited to the cross-
sectional design (Albashayreh et al. 2019; Nantsupawat et al.
2015; You et al. 2013). There is a lack of other types of stud-
ies to provide more long-term evidence on interventions
which simultaneously improve nurse outcomes and patient
outcomes.
In the Chinese national survey on nurse and patient out-
comes in 2009 (China Nursing Human Resource Study –
CNHRS), substantial percentages of nurses were not satisfied
with work environment, job, the quality of patient care and
patient safety. Meanwhile, most patients were not satisfied
with the communication with nurses and hospital services
(You et al. 2013). In order to respond to this dissatisfaction
situation, the Chinese Ministry of Health proposed the High-
Quality Care Project (HQCP) in 2010. The key aim of the
project was to improve nurse and patient outcomes through
the transformation of the nursing care delivery system in hos-
pitals from functional nursing (FN) to primary nursing (PN).
PN could promote continuity of care, enhanced accountabil-
ity for care, relationship-based and person-focused care, and
greater involvement of the patient and family (Tiedeman &
Lookinland 2004). This project was proposed based on aca-
demic literature, consultations with nursing experts and a
related pilot project. HQCP was initially just conducted in
some tertiary hospitals. Until now, it has been conducted in
all tertiary and secondary hospitals in the mainland of China.
FN involves reducing nursing to a set of defined tasks that
can then be assigned to different nurses according to the
nurses’ technical knowledge and skills (Koloroutis 2004). FN
was used in many countries in the context of nursing short-
ages (Tiedeman & Lookinland 2004). However, both patients
and nurses reported high levels of dissatisfaction with FN in
which nurses were unable to establish a good relationship
with a patient, nursing care became deprofessionalized, and
patients experienced a sense of fragmentation and depersonal-
ization in their care (Tiedeman & Lookinland 2004; Wessel &
Manthey 2015).
In contrast to FN, nurses in PN take responsibility for the
total care of a patient and are accountable for his/her care
Nurse and Patient Outcomes in HQCP
over 24 h a day from the patient’s admission to discharge
(Wessel & Manthey 2015). In a before and after study con-
ducted in Italy, PN showed positive effects on diagnostic
thinking and nursing competencies of nurses and patient sat-
isfaction on nursing care (Dal Molin et al. 2018). In a cross-
sectional study in Switzerland, nurses thought PN could pro-
vide patient-centred care while patients receiving PN reported
the nursing care were individualized, responsive and high-
quality (Naef et al. 2019). PN also showed the potential to
reduce missing nursing care (Moura et al. 2019).
Although PN has been proposed for several decades and
gradually conducted and explored in many countries (Wan
et al. 2011; Dal Molin et al. 2018; Naef et al. 2019), the evi-
dence on PN is still limited, especially beyond western coun-
tries (Kusk & Groenkjaer 2016; Mattila et al. 2014).
Furthermore, no study was found to assess the long-term
changes of nurse and patient outcomes from a macro per-
spective (i.e. a sample of participants from many hospitals, a
long-term study period) after the implementation of PN.
Therefore, the objectives of this study are, from a macro per-
spective, to detect any changes in nurse and patient outcomes
between 2009 and 2016 in the context of HQCP, and to
explore the possible effects of PN on nurse outcomes and
patient outcomes based on this study’s results and broad
existing evidence.
Methods
Design
The data of two cross-sectional studies were used. The first
cross-sectional study (one part of CNHRS) was conducted
between 1 January 2009 and 30 March 2009, before the
HQCP was implemented in Hunan, China. In order to
explore the influences of HQCP, the second cross-sectional
study was designed and conducted between 1 July 2016 and
30 August 2016, after the HQCP was implemented in Hunan,
China. These two cross-sectional studies were conducted by
the same research group and used the same instruments. Just
one part of the data (nurse job satisfaction and nurse burn-
out) from the first cross-sectional study was used to explore
the related factors of nurse job satisfaction and nurse burnout
and the relationship between these two variables. The corre-
sponding findings had been published (Zhou et al. 2015).
Participants and settings
Multi-stage sampling was used in the first study in 2009
(Zhou et al. 2015). Twenty hospitals (ten tertiary hospitals
and ten secondary hospitals) in Hunan province were selected
by purposive sampling to ensure that the hospitals selected
© 2020 International Council of Nurses
3
were equally representative of various categories considering
the hospital level, location and affiliation. Four units (includ-
ing at least one medical unit, surgical unit and intensive care
unit) were selected in each hospital by systematic sampling.
All eligible nurses and patients on these units were surveyed.
Eligibility criteria for nurses included the following: providing
direct care for patients; registered in the selected units; and
not on sick leave, maternity leave or on a holiday. Eligibility
criteria for patients included the following: 18 years old or
above; hospitalized for three days or more as an in-patient in
medical and surgical units; available during the survey period
of the unit; and able to understand and respond to questions.
The HQCP was only implemented in tertiary hospitals in
2010, so this study just used the data from the 10 tertiary
hospitals selected in the first study in 2009. In the second
study in 2016, the same 40 units of the same 10 tertiary hos-
pitals were selected to ensure the comparability of the set-
tings. FN was practiced as the nursing care delivery system on
these units before the HQCP implementation, but it gradually
transformed into PN thereafter (after the implementation of
HQCP). All eligible nurses and patients on these units were
surveyed in 2016.
The introduction of a new nursing care delivery system is a
complex undertaking. Any transformation involves changes at
many organizational levels with its many interacting compo-
nents. In order to support the change toward PN, the Chinese
Ministry of Health proposed the HQCP, including a set of
supportive measures for the introduction and implementation
of PN (See more details in Appendix S1 in the online ver-
sion).
Measures
The data of the hospital’s level, location, affiliation, number
of beds, number of nurses, unit type, bed-to-nurse ratio, and
actual working hours per shift were collected in 2009 and
2016, respectively. The data about general information and
nurse and patient outcomes were collected by a nurse ques-
tionnaire and a patient questionnaire in 2009 and 2016,
respectively. The questionnaires (English version) were ini-
tially used in RN4CAST (Aiken et al. 2012), then were trans-
lated to many versions of different languages and used in
many international surveys. The Chinese version question-
naires showed good psychometric properties which were
reported as follows (You et al. 2012).
General information
Nurse demographics included gender, age, type of contract,
highest education level in nursing and career experience as a
registered nurse. Patient demographics included gender, age,
4 Q. Chen et al.
highest education level, length of hospital stay and self-rated
overall health.
Nurse outcomes
• Nurse work environment: The Nurse Work Index – Practice
Environment Scale (NWI-PES) (Lake 2002) consisted of 31
items divided among five subscales: (1) Nurse participation in
organization affairs, (2) Nursing foundation for quality care,
(3) Nurse manager ability, leadership and support, (4) Staff
and resource adequacy, and (5) Collegial nurse–physician
relations. Nurses rated their agreement on a 4-point Likert
scale. A higher score means a better nurse work environment.
Cronbach’s a of the total scale is 0.97. For subscales, the coef-
ficients are from 0.84 to 0.95 (You et al. 2012).
• Burnout: Maslach Burnout Inventory (MBI) (Poghosyan
et al. 2009) consisted 22 items divided among three subscales:
(1) Emotional Exhaustion (EE), (2) Depersonalization (DP)
and (3) Personal Accomplishment (PA). Each item uses a 6-
point Likert scale for rating. A EE score of ≥27 indicates a
high level of burnout (Zhou et al. 2015; Aiken et al. 2002).
Cronbach’s a of MBI was 0.79, and the coefficients of all
three subscales varied from 0.77 to 0.85. Item-subscale corre-
lation coefficients of EE were greater than 0.5 (You et al.
2012).
• Job satisfaction: It was measured by an overall job satis-
faction item and eight individual items of different aspects of
job satisfaction including: work schedule flexibility, opportu-
nities for advancement, independence at work, professional
status, salary, healthcare benefits, retirement benefits and tui-
tion benefits. Each item was scored from 0 ‘Very dissatisfied’
to 3 ‘Very satisfied’. Cronbach’s a of the total scale in the
Chinese version is 0.87. Item-total correlation coefficients vary
from 0.30 to 0.69 (You et al. 2012).
• Intention to leave job: It was measured with a dichoto-
mous item of ‘yes’ or ‘no’ that asked about their intentions
or plans to leave their job in the next year.
Patient outcomes
• Quality of patient care and Patient safety: Quality of patient
care was evaluated by one item of the nurse questionnaire
which asked the nurse to give an overall grade from 0 ‘poor’
to 3 ‘excellent’ on the quality of patient care. The grade 3 ‘ex-
cellent’ was regarded as the best rating. Patient safety was
measured by five items scoring from 0 ‘never’ to 6 ‘every day’
which required nurses to estimate nurse-sensitive adverse
events frequency involving their own patients (such as medi-
cation administration errors, pressure ulcers, falls, urinary
tract infections and venous catheter-related infections) (Butler
et al. 2011). The possible scores ranged from 0 to 30. A
© 2020 International Council of Nurses
higher total score on these five items meant that the patient
adverse events frequency was higher.
• Patient satisfaction was measured with one global item
and one composite measure from the adapted version of the
Consumer Assessment of Healthcare Providers and Systems
(CAHPS) Hospital Survey to evaluate patient healthcare expe-
riences and communication with nurses, respectively (Gior-
dano et al. 2010). The global item represents the overall
hospital rating ranging from 0 to 10 given by the patient. The
scores 9 and 10 were regarded as the best rating. The com-
posite measure of communication with nurses includes three
items asking patients about their communication with nurses
(Aiken et al. 2012). The S-CVI (content validity index) of
CAHPS is 0.95. The Cronbach’s a of the composite measure
‘communication with nurses’ is 0.69, and its item-composite
correlation coefficients are greater than 0.5 (You et al., 2012).
Ethical approval
Ethical approval was provided by the Institutional Review
Board of Behavioural and Nursing Research in the School of
Nursing of Central South University (No. 2015050). All study
settings approved the surveys. All participants provided the
written consent after being given the full information of the
study, which was on the first page of the questionnaires.
Data analysis
The data were analysed using IBM SPSS 22.0, and statistical
significance was determined at P < 0.05. Descriptive statistics
were used to describe all variables’ data collected from the
2009 and 2016 groups.
This study used multilevel models (Level 1 = nurse/patient
and Level 2 = unit) to analyse the nested data. For the sample
size in multilevel modelling, it was suggested that researchers
should strive for at least 30 Level 2 groups (Hox et al. 2010).
The sample size of Level 2 groups (40 units) met this crite-
rion. Multilevel modelling requires the assessment of signifi-
cant variability in outcomes between units (Level 2) and
intra-class correlation (ICC). In this study, 5% was selected as
the ICC cut-off point (Hox et al. 2010). In the case of little
or no variation in outcomes between units, it is recom-
mended that a simple ordinary least squares (OLS) regression
analysis at the individual level should be used (Hox et al.
2010).
The multilevel models were built with outcome variables as
dependent variables and the Group (1 = 2009, before HQCP;
0 = 2016, after HQCP) as the independent variable control-
ling corresponding covariates. The covariates in this study
were those individual level (nurse or patient) characteristic
variables related to nurse or patient outcomes of which the
Nurse and Patient Outcomes in HQCP
data’s differences between the 2009 group and 2016 group are
significant (P < 0.05). This analysis process aimed to show
the differences between the two groups (2009 and 2016) and
prevent the observed differences between the two groups was
from being caused by the differences in individual characteris-
tics of participants. The complete results of all models are
shown in the Appendices S3-S7 in the online version.
Results
A total of 580 eligible nurses and 796 eligible nurses com-
pleted the questionnaire in 2009 and 2016, respectively. The
response rates of nurses were 84% in 2009 and 83% in 2016.
A total of 354 eligible patients and 550 eligible patients com-
pleted the questionnaire in 2009 and 2016, respectively. The
response rates of patients were 85% in 2009 and 89% in
2016.
The descriptive findings are shown in Table 1. In unit char-
acteristics, the bed-to-nurse ratio decreased but actual work-
ing hours per shift increased in 2016. Nurse characteristics
showed statistically significant differences across all variables.
The length of stay of the patient group in 2016 was shorter
than that of the patient group in 2009. The descriptive results
and comparison of nurse and patient outcome variables
between the 2009 group and the 2016 group are shown in
Appendix S2 in the online version.
All null models and multilevel models with the nurse out-
comes as dependent variables are shown in Appendices S3-S5
in the online version. The fixed effect results of the indepen-
dent variable Group in multilevel models were extracted and
are shown in Table 2. After controlling covariates on the
nurse level (i.e. nurse gender, type of contract, highest educa-
tion level in nursing and career experience as a registered
nurse), the results suggested nurses in 2016 perceived better
foundation for quality care (b = 2.016, P < 0.001), nurse
manager ability, leadership and support (b = 0.794,
P = 0.007), and collegial nurse–physician relations
(b = 0.776, P < 0.001). For nurses in 2016, the odds of rating
opportunities for advancement, independence at work, profes-
sional status, salary, healthcare benefits, retirement benefits
and tuition benefits as ‘very satisfied’ were increased by 1.978,
1.879, 1.578, 2.133, 1.816, 2.058 and 2.468 times, respectively,
compared with nurses in 2009, controlling for covariates on
the nurse level. However, there were no differences between
the two nurse groups (i.e. 2009 versus 2016) on nurse partici-
pation in hospital affairs, staff and resource adequacy, burn-
out, work schedule flexibility satisfaction, overall job
satisfaction, and intention to leave job.
All null models and final models with the patient outcomes
as dependent variables are shown in Appendices S6-S7 in the
© 2020 International Council of Nurses
5
online version. The fixed effect results of the independent
variable Group in multilevel models were extracted and shown
in Table 3. The odds ratio of 1.718 (P = 0.005) suggested that
the odds of nurses in 2016 rating quality of patient care ‘ex-
cellent’ had increased by 1.718 times compared with nurses in
2009, controlling the covariates on the nurse level. Mean-
while, the result of b = －0.894 (P < 0.001) showed nurses in
2016 reported fewer patient adverse events, compared to
nurses in 2009, controlling the covariates on the nurse level.
Moreover, for patients in 2016, the odds of rating a hospital
with a score of ‘9’ or ‘10’ had increased by 1.705 (P = 0.01)
times compared with patients in 2009, controlling the covari-
ate on the patient level (i.e. length of hospital stay). The odds
ratio of 4.718 (P < 0.001) revealed that the odds of rating the
communication with nurses ‘always (good)’ were 4.718 times
higher for patients in 2016 than patients in 2009, holding the
effect of length of hospital stay constant.
Discussion
In our research, the data collected from two cross-sectional
studies were used to detect the changes in nurse outcomes
and patient outcomes between 2009 and 2016 in the context
of HQCP (i.e. the implementation of PN). However, it is
noted that, because of the limitations of the study design, this
study cannot – and does not – aim to draw a conclusion that
PN is the only reason for the changes or no changes in nurse
and patient outcomes in this study. This study has demon-
strated a positive correlation between PN implementation and
nurse/patient outcomes, not causality. Still, this study has
implications for future studies and policymaking. In this dis-
cussion, we will explore the potential effects of PN that may
account for the changes observed in nurse and patient out-
comes based on this study and the broader existing evidence.
In this study, nurses in 2016 were more satisfied than
nurses in 2009 with most dimensions of nurse work environ-
ment (i.e. nursing foundation of quality care, nurse manager
ability, leadership and support, and collegial nurse–physician
relations) and job satisfaction (i.e. opportunities for advance-
ment, independence at work, professional status). Nurses in
2016 also reported better quality of patient care and patient
safety while their patients reported higher patient satisfaction.
Therefore, PN showed the potential for improving nurse work
environment, some aspects of job satisfaction and patient
outcomes (i.e. quality of care, patient safety and patient satis-
faction). The positive effects of PN on patient outcomes have
been shown in some studies (Wan et al. 2011; Moura et al.
2019; Nadeau et al. 2017). That PN may improve patient out-
comes is not surprising, as PN care is relationship-based and
patient-centred, in which nurses are more familiar with their
6 Q. Chen et al.

Table 1 Characteristics of the hospitals, units, nurses and patients

Characteristic 2009 group 2016 group t/x2/Z P-value

Hospital
Location of the hospital, n (%)
Capital city 5 (50) 5 (50)
Other cities 5 (50) 5 (50)
Affiliation, n (%)
Non-affiliated 5 (50) 5 (50)
University-affiliated 5 (50) 5 (50)
Total number of beds, Median (Q25, Q75) 1068 (909, 1257) 1837 (1317, 2068) 2.805 0.005
Total number of nurses, Median (Q25, Q75) 590 (445, 729) 1307 (944, 1405) 2.803 0.005
Unit
Unit type, n (%)
Medical 15 (37.5) 15 (37.5)
Surgical 16 (40.0) 16 (40.0)
ICU† 9 (22.5) 9 (22.5)
Bed-to-nurse ratio, Mean (SD) 3.01 (1.39) 2.45 (1.21) 5.569 0.000
Medical and Surgical 3.65 (0.76) 3.01 (0.67)
ICU 0.79 (0.26) 0.51 (0.20)
Actual working hours per shift‡, Mean (SD) 8.05 (0.64) 8.51 (0.90) -2.903 0.006
Nurse
Gender, n (%)
Female 573 (98.8) 751 (94.3) 18.242 0.000
Male 7 (1.2) 45 (5.7)
Age, Mean (SD) 26.83 (5.52) 27.94 (4.75) 3.907 0.000
Type of contract, n (%)
Permanent employment contracts 200 (34.7) 208 (26.2) 11.457 0.001
Non-permanent employment contracts 377 (65.3) 586 (73.8)
Highest education level in nursing, n (%)
Diploma§ 27 (4.7) 2 (0.3) 13.425 0.000
Advanced diploma¶ 324 (56.2) 201 (25.4)
Baccalaureate 221 (38.4) 570 (72.0)
Master or above 4 (0.7) 19 (2.4)
Career experience as RN (year), Median (Q25, Q75) 4 (2, 9) 5 (3, 8) 2.984 0.003
Patient
Gender, n (%)
Female 153 (43.2) 225 (40.9) 0.473 0.492
Male 201 (56.8) 325 (59.1)
Age, Mean (SD) 54.45 (17.63) 56.48 (17.47) 1.698 0.090
Highest education level, n (%)
No schooling/Primary school 113 (31.9) 171 (31.1) 0.635 0.525
Middle school/High school 171 (48.3) 294 (53.5)
Associate degree/Bachelor degree or above 70 (19.8) 85 (15.5)
Length of hospital stay (day), Median (Q25, Q75) 10 (6, 18) 8 (5, 12) 5.223 0.000
Self-rated overall health, n (%)
Excellent/Very good 34 (9.7) 85 (15.5) 0.544 0.587
Good 131 (37.2) 168 (30.5)
Fair/Poor 187 (53.1) 297 (54.0)

†
There was no ICU in one of the ten hospitals in 2009, so only nine ICUs were included.
‡
The required working hour per shift is 8 h.
§
The Diploma consists of a three-year nursing program designed to teach clinical skills.
¶
The Advanced diploma consists of a three-year associate nursing degree program offering general clinical training alongside nursing theory and skills.

© 2020 International Council of Nurses

Nurse and Patient Outcomes in HQCP
patients. Through this care delivery system, patients would
likely feel less objectified, more appreciated and more satisfied
with their care and hospital experiences (Wessel & Manthey
2015; Mattila et al. 2014). For nurse outcomes, PN could cre-
ate a healthy and professional nursing practice environment
in which nurses could expand their scope of practice, make
deeper use of their education, expand their knowledge, and
broaden their repertoire of skills and competencies for pro-
viding patient-centred care (Estabrooks et al. 2002). Some lit-
erature suggests that PN could increase nurses’ sense of job
autonomy and control (Mattila et al. 2014). PN has also
demonstrated positive effects on head nurse leadership and
team climate (Dal Molin et al. 2018). These conclusions cor-
respond with this study’s results which showed that the PN
was correlated with increased nurse’s satisfaction on the work
environment, independence at work, opportunity for personal
advancement and professional status.
Although positive changes were shown in this study on cer-
tain dimensions of the nurse work environment and on some
aspects of job satisfaction, no changes were found on nurse
burnout, global job satisfaction and intention to leave job.
These maintained perceptions of burnout, job satisfaction and
intention to leave may be related to nurses’ perceptions of the
lack of improvement in staff and resource adequacy, nurse
participation in organization affairs, and work schedule flexi-
bility satisfaction.
In 2016, the bed-to-nurse ratio indeed decreased, but
nurses did not report better staff and resource adequacy. This
may be related to the implementation of PN. In PN, the
change in the nurse’s role – including increased expectations
and responsibilities – required nurses to get to know their
own patients better in order to not only meet patients’ physi-
cal needs, but also their psychosocial and spiritual needs
(Wessel & Manthey 2015). Compared to FN, the greater psy-
chosocial demands required by PN might have increased
nurses’ workload. This conclusion is also consistent with the
result of increased actual working hours per shift in 2016 in
this study (see more details in Table 1). Nurse’s satisfaction
involving work schedule flexibility also did not change in this
study. This may be due to staff and resource inadequacy, as
well as due to the continuity of care required by PN which
may have limited nurse managers’ abilities to plan work
schedules that provided greater flexibility for frontline nurses.
Therefore, adequate nursing staff and resources may be
important for implementing PN (Payne & Steakley 2015;
Wessel & Manthey 2015). Some studies have found that ade-
quate nursing staff resource and higher education level are
critical for enhancing the quality of patient care, decreasing
job dissatisfaction and burnout of nurses to improve
© 2020 International Council of Nurses
7
retention (Aiken et al. 2002; Zhou et al. 2015). Furthermore,
improving nurse participation in organizational affairs should
also be addressed to positively influence nurse outcomes and
broader system change (Goedhart et al. 2017; Lu et al. 2019).
When employees are permitted and engaged in organizational
affairs, it has a positive influence not only on the employee’s
perceptions of self-accomplishment and self-efficacy (Yang
2011; Zhou et al. 2015); it is also reflected in the employee’s
greater commitment to the institution and profession (Heinen
et al. 2013).
Therefore, in order to practice PN to provide better nurse
work environment and improve patient outcomes, managers
must employ a sufficient number of nurses with excellent
nursing skills and expertise (Naef et al. 2019). Adequate nurse
staffing, resources and nurse participation in organizational
affairs are all critical for improving nurse outcomes (lower
burnout, global job satisfaction and retention), and are likely
necessary for PN to succeed in improving all – not just some
– of the nurse outcomes assessed in this study.
Limitations
Considering that all of the study sites in this research were
tertiary hospitals in the Hunan province, we caution about
generalizing the findings to other settings (e.g. smaller hospi-
tals, more specialized medical facilities, other countries). We
also recognize that the comparison of two cross-sectional
studies cannot lead to conclusions of causal relationships
(although it does provide some implications for causality,
which should be further explored). Therefore, we analysed the
results cautiously, and we discussed the results in relation to
other existing international evidence on nurse and patient
outcomes. We controlled individual-level variables in data
analysis to help prevent the observed differences between the
two groups (2009 and 2016) from actually being caused by
the differences in individual characteristics of participants.
The same research group and same instruments were used for
the data collection, and the same units of the same hospitals
were surveyed in two cross-sectional studies. These were all
the practical methods we used for reducing potential biases in
the comparison. Considering that an experimental study
design would have been impractical, given the context and
decisions of the Chinese Ministry of Health independently
pursuing HQCP in tertiary hospitals nationwide, a long-term
comparison of two cross-sectional studies was our best option
for learning about the effectiveness of the PN intervention on
nurse and patient outcomes. Furthermore, nurse outcomes
and patient outcomes were investigated simultaneously in this
study, lending more plausible interpretations of the findings.
Nevertheless, more studies with strong methodology and in
8 Q. Chen et al.

Table 2 Fixed effects of Group on nurse outcomes in multilevel models

Outcome Group‡

Coefficient (95% CI) Std. error t P-value OR† (95% CI)

Nurse participation in hospital affairs (A) 0.191 ( 1.317, 0.936) 0.574 0.332 0.740 —
Nursing foundation for quality of care (B) 2.016 (1.125, 2.906) 0.454 4.442 0.000 —
Nurse manager ability, leadership, and support (C) 0.794 (0.214, 1.374) 0.296 2.687 0.007 —
Staff and resource adequacy (D) 0.417 ( 0.929, 0.096) 0.261 1.595 0.111 —
Collegial nurse–physician relations (E) 0.776 (0.446, 1.105) 0.168 4.623 0.000 —
Burnout (F) 0.099 ( 0.245, 0.442) 0.175 0.562 0.574 1.104 (0.782, 1.557)
Job satisfaction global rating (G) 0.152 ( 0.197, 0.501) 0.178 0.856 0.392 1.164 (0.822, 1.651)
Work schedule flexibility (H) 0.133 ( 0.604, 0.339) 0.240 -0.552 0.581 0.876 (0.546, 1.404)
Opportunities for advancement (I) 0.682 (0.262, 1.102) 0.214 3.185 0.001 1.978 (1.300, 3.011)
Independence at work (J) 0.631 (0.258, 1.004) 0.190 3.316 0.001 1.879 (1.294, 2.729)
Professional status (K) 0.456 (0.113, 0.800) 0.175 2.608 0.009 1.578 (1.120, 2.225)
Salary (L) 0.758 (0.247, 1.268) 0.260 2.910 0.004 2.133 (1.280, 3.555)
Healthcare benefits (M) 0.597 (0.104, 1.089) 0.251 2.376 0.018 1.816 (1.110, 2.972)
Retirement benefits (N) 0.722 (0.297, 1.147) 0.217 3.332 0.001 2.058 (1.346, 3.148)
Tuition benefits (O) 0.904 (0.484, 1.323) 0.214 4.223 0.000 2.468 (1.622, 3.756)
Intention to leave (P)§ 0.390 0.268 — 0.145 1.477 (0.874, 2.497)
—

†
Odds ratio (OR) value was calculated using the formula: OR = Exp (Coefficient).
‡
Nurse’s gender, type of contract, highest education level in nursing and career experience as a Registered Nurse were all included in the multilevel mod-
els. (The rationale for excluding Nurse’s age from the multilevel models was because it is highly correlated with career experience as an RN.) Only the
fixed effect results of the independent variable Group in multilevel models were shown in table above.
§
Binary logistic regression analysis was used to evaluate the effect of the independent variable Group on the Intention to leave.

Table 3 Fixed effects of Group on patient outcomes in multilevel models

Outcome Group‡

Coefficient (95% CI) Std. error t P-value OR† (95% CI)

Quality of patient care (Q) 0.541 (0.160, 0.922) 0.194 2.787 0.005 1.718 (1.174, 2.515)
Patient adverse events frequency (R) 0.894 ( 1.348, 0.441) 0.231 3.866 0.000 —
Overall hospital rating (S) 0.533 (0.127, 0.940) 0.207 2.576 0.010 1.705 (1.135, 2.560)
Communication with nurses (T) 1.551 (0.939, 2.164) 0.312 4.973 0.000 4.718 (2.558, 8.702)

†
Odds ratio (OR) value was calculated using the formula: OR = Exp (Coefficient).
‡
Nurse’s gender, type of contract, highest education level in nursing and career experience as RN were all included in the multilevel models of Quality of
patient care and Patient adverse events frequency. (The rationale for excluding Nurse’s age from the multilevel models was because it is highly correlated
with career experience as an RN.) Length of hospital stay was included in the multilevel models of Overall hospital rating and Communication with
nurses. Only the fixed effect results of the independent variable Group in multilevel models were shown in table above.

other settings are needed to further explore the PN’s direct nurse outcomes and patient outcomes. Meanwhile, cost-bene-
effects on nurse outcomes and patient outcomes. In the fit analysis is important for implementing a new nursing
future, mixed methods research could be considered for deep- model and should be included in future research on nursing
ening our understanding and explaining the effects of PN on models.

© 2020 International Council of Nurses

Nurse and Patient Outcomes in HQCP
Conclusion and implications for nursing policy
PN could be considered as a potentially effective way to
improve nurse work environment and patient outcomes.
However, to successfully implement PN in hospitals, nurs-
ing staff and resource adequacy is precondition. Further-
more, policymakers, healthcare service leaders and nurse
managers should consider making a practical plan with
multi-level supports to provide an encouraging work envi-
ronment for nurses to provide PN with their patients. On
this basis, greater attention should be paid to changes in
the organizational culture of the hospital level to improve
nursing participation in hospital affairs and focus on the
development of the nursing discipline and education to
increase nursing staff resource and nurses’ capacity, which
are crucial for better implementing PN and further improv-
ing nurse outcomes and patient outcomes.
Acknowledgements
We would like to sincerely thank the participants and those
who facilitated the research in the study hospitals. Special
thanks go to Dr. Melanie Lavoie-Tremblay, Dr. Genevieve
Lavigne and Ms. Aimee R. Castro, who provided support for
statistical analysis and paper review.
Author contributions
Study design: QC, LG, DL, ST and YB
Data collection: QC, DL, ST and YB
Data analysis: QC, LG, DL and ST
Manuscript writing: QC, LG, DL, ST and YB
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Supporting information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1. The supportive main measures proposed by
the Chinese Ministry of Health for implementing PN
included in HQCP.
Appendix S2. Comparison of nurse and patient outcomes
between the 2009 group and the 2016 group.
Appendix S3. Multilevel models with nursing work envi-
ronment and burnout as outcome variables.
Appendix S4. Multilevel models with Job satisfaction (glo-
bal rating and eight aspects) as outcome variables.
Appendix S5. Logistic regression with intent to leave as the
outcome variable (n = 1311) (P).
Appendix S6. Multilevel models with quality of nursing care
and patient adverse events frequency as outcome variables.
Appendix S7. Multilevel models with overall hospital rating
score and communication with nurses as outcome variables.