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document.docxDespite extensive research on defining and measuring health care quality, little attention has been given to consumers' perspectives of high-quality health care. The purposes of this study were to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of consumer perspectives to health status and selected demographic variables.
Exploratory. Consumers (N = 239) were recruited from waiting rooms of clinics and in neighborhoods of a large metropolitan area in the Midwestern United States that included both urban and suburban populations.
Participants completed the Quality Health Care Questionnaire (QHCQ) and the SF-36 Health Survey. On the QHCQ, they rated the importance of 27 attributes of health care and nursing care quality. The SF-36 is a 36-item instrument for measuring health status in eight general areas.
The most important indicators of high-quality nursing care to consumers were: being cared for by nurses who are up-to-date and well informed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; having a nurse teach about the illness, medications, treatments, and staying healthy; and being able to call a nurse with questions. The lowest-rated item was having an opportunity to be cared for by nurse practitioners. Ratings differed by race, age, years of education, income, and health status.
The importance that consumers place on teaching by the nurse was emphasized, particularly among people with less education, low income levels, and chronic illnesses.
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Headnote
Purpose: Despite extensive research on defining and measuring health care quality, little attention has been given to consumers' perspectives of high-quality health care. The purposes of this study were to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of consumer perspectives to health status and selected demographic variables.
Design: Exploratory Consumers (N = 239) were recruited from waiting rooms of clinics and in neighborhoods of a large metropolitan area in the Midwestern United States that included both urban and suburban populations.
Methods: Participants completed the Quality Health Care Questionnaire (QHCQ) and the SF-36 Health Survey On the QHCQ, they rated the importance of 27 attributes of health care and nursing care quality. The SF-36 is a 36-item instrument for measuring health status in eight general areas.
Findings: The most important indicators of high-quality nursing care to consumers were: being cared for by nurses who are up-to-date and well in formed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; having a nurse teach about the illness, medications, treatments, and staying healthy; and being able to call a nurse with questions. The lowest-rated item was having an opportunity to be cared for by nurse practitioners. Ratings differed by race, age, years of education, income, and health status.
Conclusions: The importance that consumers place on teaching by the nurse was emphasized, particularly among people with less education, low income levels, and chronic illnesses.
Headnote
(Key words: quality of nursing care, quality of health care, consumer health information, patient education)
Extensive research has been done to define and measure health care quality, yet less attention has been given to consumers' perspectives of high-quality health care. Many investigators have examined the type of information valuable to consumers in choosing among varied health plans, such as how a health plan works, its costs, benefits covered by the plan, quality of care, and patient satisfaction. Whether consumers understand this information and will actually use it to make health care decisions have not yet been established through research (Edgman-Levitan & Cleary, 1996; Longo et al., 1997; Oermann, 1999). Although research is available on patients' expectations of and satisfaction with nursing care in hospitals, less is known about their perspectives of care in ambulatory settings, where more care is being delivered.
Learning about what consumers want from their health care and what quality care means to them gives us a better understanding of their expectations. What people expect from their health plans and providers influences their satisfaction with care (Concato & Feinstein,1997; Conway & Willcocks, 1997; Kravitz, 1996; Pascoe, 1983; Sofaer 1997).
Kravitz (1996) developed a model to link expectations and patient satisfaction with a medical encounter. This model indicates that patients' expectations for care are formed before the encounter and include expectations for care in general and for the specific visit. These expectations are influenced by demographic characteristics, prior health care experiences, and concerns related to the patient's specific health problems. Patients evaluate their visit with the provider by comparing the events and their expectations. An understanding of these expectations is important because meeting them may lead to greater satisfaction with care (Kravitz, 1996).
Thus, this study was designed to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of quality of care importance ratings to health status and selected demographic variables.
Background
American consumers want information about the quality of their health plans and care in general. Isaacs (1996) reported on a survey of 1,081 adults from across the United States. Fifty percent of the subjects were enrolled in fee-for-service plans, 23% in health maintenance organizations (HMOs), 11% in preferred provider organizations (PPOs), and the remaining 16% were unsure how to characterize their coverage. Many (67%) people did not understand the differences between traditional fee-for-service and managed-care plans. Consumers were interested in information about specialists, the quality of physicians in the health plan, and certain illnesses and conditions.
In a telephone survey sponsored by the Kaiser Family Foundation (1996), 42% of the 2,006 adult participants rated quality of care as their major concern. Responses to the survey indicated that ease of access to specialists (68%) and range of benefits offered (66%) are major determinants of consumers' ratings of the quality of health plans. Other factors important to participants were percentage of physicians with complaints filed against them by patients (64%), percentage of plan members who get regular preventive screenings (62%), and patient satisfaction (57%).
Hibbard and Jewett ( 1996, 1997) examined how consumers viewed different quality indicators, the majority of which were taken from the Health Plan Employer Data and Information Set (HEDIS). Quality of physicians and hospitals were more important to consumers than was information about the health plan itself. Indicators of preventive care were the most important factors to consumers, followed by patients' ratings of quality and satisfaction.
Although consumers reported high interest in having information about the quality of health plans, their stated preferences for this information were inconsistent with actual choices (Hibbard & Jewett, 1996). Participants were given a sample report card comparing two plans with hypothetical data about their quality. When asked to choose between the plans, participants did not select the plan that was consistent with their earlier ratings of quality indicators. For example, they chose the plan with more favorable ratings for events such as hospital death rates after a heart attack, instead of choosing preventive care. Consumers reported that they could provide their own preventive care, but undesirable events, such as those following surgery or a heart attack, were not under their personal control.
Many of the published report cards contain information not readily understood by consumers. To provide more meaningful information to consumers, researchers at the Foundation for Accountability (FACCT) developed and tested a model for reporting quality information derived from FACCT, HEDIS, and Consumer Assessment of Health Plans (CAHPS). Twelve focus groups (n = 112) and eight interviews were held with Medicare beneficiaries (FACCT, 1997). The researchers identified these five categories for reporting information to consumers: (a) basics of good care, such as access and communication with providers, (b) staying healthy, such as reduction of health risks and early detection, (c) getting better, including appropriate treatment and follow-up, (d) living with illness, such as receiving needed assistance with an ongoing illness, and (e) changing needs, including support and care when health needs change (FACCT, 1997, 1999; Lansky, 1998). In an extension of the research, federal employees and retirees confirmed that FACCT's five performance categories were wellsuited for providing information about quality to them (Bethell & Read, 1998).
Oermann (1999) interviewed consumers in the community about their perspectives of quality health care and quality nursing care. Consumers were asked four open-ended questions about their definitions of health care and nursing care quality and were asked to describe experiences that they felt represented high-quality care. These interview questions were consistent with the methodology used by FACCT researchers who began by asking consumers to define quality health care and identify characteristics of health care experiences that represented quality care.
Consumers described high-quality health care as having access to care (n = 143), having competent and skilled providers (n = 104), and receiving the proper treatment (n = 100). Consumers defined high-quality nursing care as having nurses who were concerned about them and demonstrated caring behaviors (n = 148), were competent and skilled (n = 115), communicated effectively with them (n = 99), and taught them about their care (n = 97). Consumers in both fee-for-service plans and HMOs reported that access to care was the most important indicator of good health care. They defined high-quality nursing care similarly, although 10.8 % of people in HMOs added that an important role of nurses was to be liaisons for them concerning their physicians and other care providers.
Other research in nursing related to consumer assessment of health care quality has been focused predominantly on patient satisfaction with care, particularly nursing care in hospitals (Chang, 1997; Hinshaw & Atwood, 1992; Jacox, Bausell, & Mahrenholz, 1997; Minnick & Young, 1999) and outpatient care settings (Ketefian, Redman, Nash, & Bogue,1997). Patient satisfaction is influenced by patients' expectations and how they define quality of care. Providers' perceptions of quality, however may differ from patients' perceptions (Larrabee,1995; Lynn & McMillen, 1999; Lynn & Moore, 1997).
Studies of consumer perspectives of health care quality have shown limited information about how consumers define quality nursing care. Because the predominant focus of studies has been on choosing a health plan, few studies have addressed consumer views of quality nursing care.
Methods
This exploratory study included a convenience sample of 239 consumers recruited from waiting rooms of clinics and from neighborhoods of a large metropolitan area in the Midwest, with both urban and suburban populations. Participants were over 18 years of age and were able to write and speak English. None of the consumers had been hospitalized within the last 6 months.
The Quality Health Care Questionnaire (QHCQ), developed by the investigators, included demographic and background information and 27 attributes of health care and nursing care quality. Consumers rated the importance of each of these attributes in their views of quality care. A Likert scale of 1 (not at all important) to 5 (very important) was used. The attributes were identified from the literature on health care quality, research on consumers' perspectives of quality care, and research on patient satisfaction with nursing care.
Factor analysis was done using principal component analysis. All factors with Eigenvalues greater than 1 were retained, resulting in six factors that accounted for 64% of the variance: medical care, teaching by the nurse, provider competence, choice of provider, nurse-patient interaction, and convenience of appointments. Medical care included nine items, such as getting the information needed about treatments, being included in decisions about care, and having access to specialists. The factor teaching by the nurse included five items, such as having a nurse teach about the illness, medications, and treatments. The provider competence factor included three items relating to physicians and nurses being up-to-date and competent to provide care. Choice of provider included four items, such as choosing my own physicians and having an opportunity to be cared for by nurse practitioners. The factor nurse-patient interaction included three items on communicating with the nurse. The factor convenience of appointments included two items related to getting appointments easily and not waiting too long past the appointment time. These factor scores were standardized to a mean of 50 and a standard deviation of 10.
Because previous research has shown differences in definitions of quality care for people with chronic conditions, health status was measured using the SF-36 Health Survey. The SF-36 is a 36-item instrument for measuring health status in eight general areas: physical functioning, role limitations because of physical-health problems, bodily pain, general health, vitality (energy or fatigue), social functioning, role limitations because of emotional problems, and mental health. Another concept measured is health transition, whether general health is reported as better or worse than for the previous year. For norm-based scoring of the SF-36 each scale was standardized to a mean of 50 and standard deviation of 10 in the general population (Ware, 1997). In this study the alpha coefficients for the scales ranged from .84 to .90.
Neighborhoods within census tracts in a large metropolitan area were selected to include a broad spectrum of consumers, including both African Americans and Caucasians and varied socioeconomic levels. The first half of the sample was obtained by surveying individual households, door-to-door; this group of consumers (n = 117, 49%) completed the instruments in their own homes. The second half of the surveys were completed by consumers (n = 122, 51%) recruited from the waiting rooms of clinics in these same neighborhoods.
Findings
The sample included 149 women (63.1%) and 87 men (36.9%). The ages of the consumers varied widely, from 18 to 92 years; the mean age was 50.8 (SD = 15.05) years. One-half of the subjects (n = 120, 50.2%) were married. About half (49.4%) of the consumers had a high school education; level of education ranged from less than highschool (n = 17, 7.1%) through post-graduate (n = 49, 20.5 % ).
Slightly over half of the participants (n = 134, 56.1%) were currently employed. Most consumers had private health insurance through an employer (n = 140); some had Medicare (n = 68), were covered as veterans (n = 39), had Medicaid (n = 18), or a combination of coverage. Participants had been seen by a physician in the last year (M = 6.68 times), a nurse practitioner (M = 1.14 times), or an RN in a physician's office or clinic (M = 1.95 times).
Consumers rated the importance of 27 attributes of health care and nursing care quality to them personally. Ratings ranged from a low of 3.43 (SD = 1.16) for having an opportunity to be cared for by nurse practitioners to the most important indicators of quality health care: getting better (M = 4.92, SD = 0.34) and being cared for by physicians who are up-to-date and well informed (M = 4.92, SD = 0.32).
Other important indicators of quality health care to consumers were: understanding my physicians' explanations of my illness, treatments, and options (M = 4.91, SD = 0.36), having access to specialists when needed (M = 4.89, SD = 0.41 ), being able to communicate with the physician (M = 4.89, SD = 0.36), being included in decisions about my care (M = 4.88, SD = 0.42), and getting the tests I need to find diseases early (M = 4.88, SD = 0.42).
The most important indicators of quality nursing care to consumers were: being cared for by nurses who are up-todate and well informed (M = 4.84, SD = 0.50); being able to communicate with the nurse (M = 4.70, SD = 0.55); spending enough time with the nurse and not feeling rushed during the visit (M = 4.51, SD = 0.71); having a nurse teach me about my illness, medications, and treatments (M = 4.43, SD = 0.86); having the nurse help me cope with my illness and maintain my usual activities (M = 4.31, SD = 0.88); being able to call a nurse with questions (M = 4.23, SD = 0.94); and having a nurse teach me how to avoid illness and stay healthy (M = 4.15, SD = 1.04).
Some differences were found in importance ratings based on race, age, years of education, income, and health status. Participants included 163 (68.2%) Caucasians and 66 (27.6%) African Americans. As shown in Table 1, the factor medical care was reported a's less important to African Americans than to Caucasians (F [1,229] = 9.95, p < .01), but teaching by the nurse was significantly more important (F [1,229] = 6.77, p < .01). Convenience of appointment also was more important as reported by African Americans in their view of quality health care than by Caucasians (F [1,229] = 12.24, p = .001). The African Americans in this study reported significantly lower scores than did Caucasians on every SF-36 scale (Oermann, 1999), and they reported more chronic illnesses (F [1, 229] = 7.26, p = .008).
Age was negatively correlated with choice of care provider (r = -.33, p < .0001), see Table 2. The opportunity to choose a care provider was reported as more important to younger subjects than to older people.
Years of education was positively related to the medical care factor (r = .22, p < .001) and negatively correlated with teaching by the nurse (r = -.19, p = .004 ). Consumers with less education rated teaching by the nurse as more important than did people with more education. Participants with lower income levels also rated teaching by the nurse as more important in their care (r = -.25, p < .001 ).
Participants reported various chronic health problems, predominantly visual problems, arthritis, hypertension, and low back pain. The mean number of chronic illnesses was two. Number of chronic illnesses was significantly related to the importance of teaching by the nurse (r = .25, p < .001 ), choice of provider (r = .24, p < .001 ), and convenience of appointments (r = .14, p = .03 ), Table 2.
The mean scores on all the SF-36 scales were below the norms for the general population (Ware, 1993) except the mental health scale which was at the mean. The Pearson r formula was used to calculate relationships between healthstatus scores and importance factors. Participants with low scores on emotional health, indicating problems with work and other daily activities as a result of emotional problems, rated teaching by the nurse as more important than did people with good emotional health (r = -.161, p = .015). Similarly, a negative correlation was found between the mental health scale and importance of teaching by the nurse (r = -.16, p < .05), Table 2.
Although general health was not found to be related to medical care quality, a statistically significant negative correlation was found between the general health scores and importance of teaching by the nurse (r = -.27, p < .001). Consumers with poorer health rated teaching by the nurse as more important than did people with better general health. Teaching by the nurse also was related to consumers' ratings of the quality of nursing care they received in the last 6 months in ambulatory care settings (r = .16, p = .03).
Convenience of appointments was inversely related to physical function (r = -.15, p = .02) and general health (r = .16, p = .016) scores. People with limited physical functioning and poor general health rated the ease of getting appointments and not waiting too long past their appointment times as important indicators of quality care.
For consumers who had health coverage programs, 97 (49.5%) were in fee-for-service programs and 99 (50.5%) were in an HMO or PPO. No statistically significant differences were found in any of the importance factors between these groups.
Participants were asked if they read any information about health care quality in the last 6 months. Most consumers (n = 139, 81.8%) had read something about health care quality in the newspaper. People had also read information about health plans from their employers (n = 35, 20.6%) and advertisements (n = 34, 20.0%). Although the majority had recently read information about health care quality, few (n = 64, 26.8 % ) reported using this information when making health care decisions, such as changing health plans or deciding on a hospital or clinic. A related finding was that nearly half of the consumers in this study (n = 117, 49.0%) had a choice of different health plans.
Consumers recruited from clinics had less education (t = 3.35, p = .001 ), lower incomes (t = 3.23, p = .001 ), and were in poorer health (t = 4.16, p = .001 ) than were participants who completed the surveys in their homes. Most notably, the views of these two groups did not differ except concerning the' two factors on nursing care. Consumers recruited from clinics placed more importance on teaching by the nurse (t = 3.48, p = .001 ) and interacting with the nurse (t = 2.12, p = .03) than did the consumers surveyed in their homes.
Discussion
The attributes of health care important to consumers in this study are consistent with findings from other research in ambulatory care. Edgman-Levitan and Cleary (1996) reported patients receiving care in physicians' offices, outpatients clinics, community health centers, and other ambulatory settings are concerned about access to care, coordination of services, education, being treated with respect, and processes of care such as waiting times for appointments.
What has not been reported in other studies, however, is the importance consumers place on teaching by the nurse. Because most of the research is in the context of choosing a health plan, few investigators have asked consumers about the importance of nursing care in their views of quality. Teaching about illness and management of care at home, teaching about preventive care, having a nurse help patients cope at home with their health problems, and being able to call a nurse with questions were important to consumers. Although understanding the physician's explanation of the illness and treatment options was important, consumers looked to the nurse for their health education.
Effective teaching requires knowledge and expertise, ability to communicate with patients and families, and ability to assess learning needs, plan and deliver the instruction, and evaluate its outcomes (Oermann, 1997; Oermann & Gaberson,1998). Being cared for by nurses who were up-todate and well informed, being able to communicate with them, and not feeling rushed during their visit were important to consumers and relate to effective teaching.
For consumers with limited education and income levels, teaching by the nurse was more important than to other consumers. Patients who were not well educated placed greater importance on the nurse providing information about their health problems. This view was true particularly for African Americans for whom health education by the nurse was central to their view of quality nursing care.
People with limited physical functioning, relatively poor general health, and more chronic illnesses rated the ease of getting appointments and not waiting too long past their appointment times as important indicators of quality care, consistent with results from other studies (Concato & Feinstein, 1997; Edgman-Levitan & Cleary, 1996).
When asked about selecting a new health plan, participants indicated that they would ask for recommendations from their regular physician or other physicians (n = 107, 47.3%) or from family and friends (n = 65, 28.8%). Few reported that they would rely on quality information provided by their employers (n = 11, 4.6%). These findings are consistent with the Kaiser Family Foundation ( 1996) survey in which people reported that they relied on personal recommendations from their physicians (59%) and from family and friends (57%) for making health care choices. In the Kaiser survey, 6 out of 10 people said that employers were not good resources because they could not be trusted to provide reliable information about the quality of different health plans. While consumers might read about health care quality, they might not always use this information in making health related decisions (Chernew & Scanlon, 1998; Hibbard & Jewett, 1996). The information available might be too complex and detailed for many people to understand (Oermann & Huber, 1999).
Conclusions
Nurses have important responsibilities for teaching patients about health problems, self-care, and prevention. Nurses also have a role in helping people understand quality information, how they might use it in their decisions, and how to determine if they are receiving high-quality care from their providers. The tradition of educating patients about their health care, combined with the importance consumers attribute to teaching by nurses, make nurses key people for carrying out patient education as an important component of quality of care.
References
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AuthorAffiliation
Marilyn H. Oermann, RN, PhD, FAAN, Lambda, Professor; Thomas Templin, PhD, Statistician; both at the College of Nursing, Wayne State University, Detroit, MI. This study was funded by Wayne State University Faculty Research Grant, Detroit, MI. Correspondence to Dr. Oermann, 168 North Cranbrook Cross, Bloomfield Hills, MI 48301-2508. E-mail: [email protected]
Accepted far publication November 18, 1999.
Copyright Sigma Theta Tau International, Inc., Honor Society of Nursing Second Quarter 2000
