Relationship between inpatient satisfaction and nurse absenteeism: an exploratory study using WHO-PATH performance indicators in France

Improving the performance of healthcare facilities is a central theme for hospitals, whether for professionals or for users of the healthcare system. Performance is by essence multidimensional, since objectives and expectations are numerous and varied [1]. The conceptual models developed thus far, such as the PATH (Performance Assessment Tool for Hospitals) of the World Health Organization (WHO) [2], or the EFQM (European Foundation for Quality Management) health model [1, 3], converge as to the main dimensions that should be taken into account, such as efficiency, clinical efficacy, safety, human resources and the patient-centered approach. The value of these models also resides in their integrated approach, arising from the interdependence among the different dimensions [2]. Among all these dimensions, interrelations between human resources and patient-centered approach dimensions are interesting to focus on. First of all, indicators of patient-centeredness dimension are usually characterized by patient satisfaction surveys, considered to be global outcome indicators in the evaluation of quality of care and hospital performance [4]. Most health care organizations are able to regularly collect user experiences and numerous studies exploring patient needs and expectations and determinants of patient satisfaction have been conducted. Most of this work has explored clinical characteristics and demographic factors, but findings on the impact of these factors on satisfaction scores are inconsistent and diverge from one study to another. According to the literature, patient age, subjective health status and satisfaction with life in general are the main predictors of satisfaction results [5–11].

Moreover, while two major dimensions are generally seen as to conditioning the quality of patient-caregiver interaction--the medical information delivered by caregivers and relationships with caregivers--only a few studies have explored relationships between patient satisfaction and atmosphere in the workplace or job satisfaction among healthcare professionals [12, 13]. Vahey showed that burnout among nurses affects patient satisfaction with their care [13]. Several studies [14–16] have suggested that "magnet" hospitals have lower staff turnover and greater job satisfaction. Patient satisfaction seems to be greater when units have adequate staff and good administrative support for nursing care.

To our knowledge, no research work has set out to explore the effect of absenteeism among nurses on patient satisfaction scores. The aim of this study was to explore interactions between two performance dimensions of the OMS-PATH model: human resources and patient-centered approach. The objective was to explore relationships between rates of absenteeism among nurses and patient satisfaction results using a large sample of hospitals taking part in the OMS-PATH performance assessment project in France [17].

The results obtained from this work suggest that short-term absenteeism among nurses is significantly correlated with quality of care in terms of patient satisfaction, and in a negative manner, in particular in relation to MI and RS. These exploratory results involve a large sample from 25 hospital facilities, both public and private, and differing in size, in several French regions.

These results are interesting for several reasons. Firstly they enable confirmation of the hypothesis of interdependence between dimensions of performance underpinning the WHO-PATH model, at least for the "patient centeredness" and "human resources" dimensions. Secondly, they consolidate and widen the scope of previously published work exploring relationships between quality of care provided and the satisfaction of professionals in the workplace. Finally, these results reemphasize the need to explore human resource indicators as explicative factors for satisfaction data, in the French context too.

Factors known to affect job satisfaction are burnout, stress, lack of autonomy, or poor cohesion in the team [20–22] and these factors are linked to inadequate organisational and managerial support [23]. This has been shown in studies on "magnet hospitals", where it is good to work and good to be cared for [15]. Aiken showed a link between job satisfaction on the one hand and quality of care or patient safety on the other [24], as did Clarke [25]. The direct relationship between absenteeism and care quality was explored by Unruh [26]: this author shows that absenteeism in conjunction with a heavy workload leads to a significant increase in incidents reported. Workload does not on its own affect patient safety, but appears liable to do so when in conjunction with staff burnout [27, 28]. Overworked nurses are more tired and find it harder to cope with pressures when there are extra efforts to be made. Another study was conducted by Aiken to determine the association between increased workload and care safety. Beyond a certain patient to nurse ratio, the increase of a single patient is associated with a 7% increase in the likelihood of dying within 30 days of admission [29]. Several authors have shown the existence of a relationship between burnout among nurses and patient satisfaction [12, 13, 24]. Thus the results of a survey among patients and nurses indicated that, in facilities that were described by professionals as having sufficient staff and in which relationships between doctors and nurses was good, patients were more inclined to report that they were satisfied with their care [13, 30]. The key role of nurses in patient satisfaction appears to be more relational than technical [12, 13]. Indeed, it is nurses who connect most to patients, because they take charge of day-to-day needs. They give physical care and emotional support to both patients and families.

The present study presents numerous limitations. The study protocol was not designed in order to verify the particular hypothesis explored. This possible relationship was studied because the literature contained work on the subject, and because a large number of the hospital facilities had exhaustive data available for the indicators analysed. The PATH Project didn't include a lot a adjustment variables concerning type of professionals, hospitals or patients, and adjustment has been only based on few variables. Results have to be interpreted cautiously.

Concerning satisfaction data, the mean response rate was about 40% as expected for a postal survey [9]. However, the risk of a selection bias exists due to the relatively low number of responding patient per hospital.

Further to this, indicators' definitions for absenteeism are still the subject of debate. Short-term absenteeism as studied here takes account of WHO-PATH specifications, and concerns medically motivated absences of 2-7 days. This measure of absenteeism is assumed to reflect the social atmosphere in the workplace and the implication of staff, while long-term absenteeism is more likely to be an indicator of health status and the effects of conditions in the workplace on health. It would nevertheless be interesting to take account of non-justified or motivated absences of one day, which could reflect poor atmosphere in the workplace. According to [31], short-term absenteeism is an absence of less than three days. Certain publications distinguish between "approved and non-approved" absenteeism [32]. Some calculate the days, others the hours of unplanned absence [33]. A national working group coordinated by our team is to be set up in 2011 to define a consensus on data collection for absenteeism. A further limitation in the present study is that the data collected concerned average figures for absenteeism over one semester, and they are set against patient data from a study over 2 months, for reasons of feasibility and in compliance with WHO requirements. Future studies should integrate patient and staff data over the same period. Finally, the indicators of the WHO-PATH project ultimately aim to be used by all member countries: they therefore need, beyond their necessary validity, to be simple to handle.

Despite these limitations, our results constitute a starting-point for other studies, in particular in the context of growing demographic and financial pressures [29].

Future research, for which funding has been obtained by our team, will set out to study, specifically and conjointly, the link between patient satisfaction and staff absenteeism, in particular short-term absences, which could reflect atmosphere in the workplace and burnout, adjusting on more precise data such as the circumstances of the absence from work, the workload in the unit, or the characteristics of the team.