International Journal of Nursing Studies 50 (2013) 154–161

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Hospital nursing, care quality, and patient satisfaction: Cross-sectional

surveys of nurses and patients in hospitals in China and Europe
Li-ming You a, Linda H. Aiken b,*, Douglas M. Sloane b, Ke Liu a, Guo-ping He c, Yan Hu d,
Xiao-lian Jiang e, Xiao-han Li f, Xiao-mei Li g, Hua-ping Liu h, Shao-mei Shang i,
Ann Kutney-Lee b, Walter Sermeus j
a
Sun Yat-sen University, School of Nursing, Guangzhou, China
b
University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
c
Central South University, School of Nursing, Changsha, China
d
Fudan University, School of Nursing, Shanghai, China
e
Sichuan University, West China School of Nursing, Chengdu, China
f
China Medical University, School of Nursing, Shenyang, China
g
Xi’an Jiaotong University, Department of Nursing, Xi’an, China
h
Peking Union Medical College, School of Nursing, Beijing, China
i
Peking University, School of Nursing, Beijing, China
j
Catholic University of Leuven, Leuven, Belgium

A R T I C L E I N F O A B S T R A C T

Article history: Background: This study provides a comprehensive evaluation of nurse resources in Chinese
Received 6 March 2012 hospitals and the link between nurse resources and nurse and patient outcomes.
Received in revised form 16 April 2012 Methods: Survey data were used from 9688 nurses and 5786 patients in 181 Chinese
Accepted 5 May 2012 hospitals to estimate associations between nurse workforce characteristics and nurse and
patient outcomes in China. Nurse and patient assessments in China were compared with a
Keywords: similar study in Europe.
Nursing in China Results: Thirty-eight percent of nurses in China had high burnout and 45% were
Hospital nursing outcomes
dissatisfied with their jobs. Substantial percentages of nurses described their work
Patient satisfaction
environment and the quality of care on their unit as poor or fair (61% and 29%, respectively)
and graded their hospital low on patient safety (36%). These outcomes tend to be
somewhat poorer in China than in Europe, though fewer nurses in China gave their
hospitals poor safety grades.
Nurses in Chinese hospitals with better work environments and higher nurse-assessed
safety grades had lower odds of high burnout and job dissatisfaction (ORs ranged from
0.56 to 0.75) and of reporting poor or fair quality patient care (ORs ranged from 0.54 to
0.74), and patients in such hospitals were more likely to rate their hospital highly, to be
satisfied with nursing communications, and to recommend their hospitals (significant ORs
ranged from 1.24 to 1.40). Higher patient-to-nurse ratios were associated with poorer
nurse outcomes (each additional patient per nurse increases both burnout and
dissatisfaction by a factor of 1.04) and higher likelihoods of nurses reporting poor or
fair quality of care (OR = 1.05), but were unrelated to patient outcomes. Higher

* Corresponding author at: Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Blvd., Philadelphia,
PA 19104, USA. Tel.: +1 215 898 9759.
E-mail addresses: youlm@mail.sysu.edu.cn (L.-m. You), laiken@nursing.upenn.edu (L.H. Aiken), sloane@nursing.upenn.edu (D.M. Sloane),
liuke@mail.sysu.edu.cn (K. Liu), heguoping@mail.csu.edu.cn (G.-p. He), huyan@fudan.edu.cn (Y. Hu), jiang_xiaolian@126.com (X.-l. Jiang),
lixiaohan15@yahoo.com.cn (X.-h. Li), roselee@mail.xjtu.edu.cn (X.-m. Li), huapingliu@nursing.pumc.edu.cn (H.-p. Liu), hdzz@bjmu.edu.cn (S.-m. Shang),
akutney@nursing.upenn.edu (A. Kutney-Lee), walter.sermeus@med.kuleuven.ac.be (W. Sermeus).

0020-7489/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijnurstu.2012.05.003
 L.-m. You et al. / International Journal of Nursing Studies 50 (2013) 154–161
percentages of baccalaureate nurses were strongly related to better patient outcomes, with
each 10% increase in the percent of baccalaureate nurses increasing patient satisfaction,
high ratings, and willingness to recommend their hospital by factors ranging from 1.11 to
1.13.
Interpretation: Nursing is important in quality and safety of hospital care and in patients’
perceptions of their care. Improving quality of hospital work environments and expanding
the number of baccalaureate-prepared nurses hold promise for improving hospital
outcomes in China.
What is already known about the topic?
 Research in Western countries points to the importance
of nurse staffing adequacy and a work environment
supportive of professional nursing practice in nurse
recruitment and retention, but little is known about the
importance of these factors in countries with transitional
economies.
 Nursing in China has been understudied, particularly
with regard to the features of nursing that affect patient
satisfaction and quality and safety of care.
What this paper adds
 This is one of the first large studies of nurse and patient
outcomes associated with hospital nursing in mainland
China.
 Hospitals with better work environments and higher
nurse-assessed safety grades had lower odds of poor
outcomes for nurses (high burnout, job dissatisfaction,
and reports of poor or fair quality patient care) and
higher odds of good outcomes for patients (being more
likely to rate their hospital highly, satisfied with nursing
communications, and willing to recommend their
hospitals).
 Higher patient-to-nurse ratios are associated with
poorer nurse outcomes.
 Higher percentages of baccalaureate nurses are strongly
related to better patient outcomes.
1. Introduction
China is in the midst of reforming and modernizing its
health care system. Much has been written about market-
driven imbalances in financial incentives to doctors and
hospitals that may be at odds with achieving high quality,
affordable, and accessible care (Blumenthal and Hsiao,
2005; Hu et al., 2008; Yip and Hsiao, 2008). Ma (2011), Vice
Minister of Health, reported that new health reform
priorities include increasing patient satisfaction with
health care and improving quality and safety of care.
The Joint Learning Initiative concluded that effective
workforce strategies enhance health system performance
(Chen et al., 2004), but there is little published empirical
research to inform China’s nursing workforce and nursing
education policies. China has set as a goal of a hospital bed
to nurse ratio of 1:0.4 (Ministry of Health China, 2005) in
comparison to a median of 1:1 in OECD countries
(Anderson et al., 2005). China has more doctors than
nurses, contrary to global evidence that higher ratios of
nurses to doctors allow for efficiency gains (World Health
155
ß 2012 Elsevier Ltd. All rights reserved.
Organization, 2006). China also lags international norms
with the majority of nurses having completed their nursing
education in secondary schools (Kalisch and Liu, 2009; Xu
and Zhang, 2000).
Government-sponsored reforms are underway to
increase the number of nurses and improve their educa-
tion. In 2007, 71% of nursing students were enrolled in
secondary schools (Zhongzhuan), 22% in associate degree
programs (Dazhuan), and 7% in baccalaureate programs
(You et al., 2010). China’s current goal is 50% enrollment in
secondary schools, 30% in associate degree programs, and
20% in baccalaureate programs, demonstrating that nur-
sing education is on the national reform agenda (Ministry
of Health China, 2005). This is an improvement but still
lags industrialized countries where nursing education
takes place largely in post-secondary institutions.
This study provides one of the first comprehensive
evaluations of nurse resources in Chinese hospitals. We
examine the associations between hospital variation in
nurse staffing, educational qualifications, and work envir-
onments and patients’ assessments of their hospital care
experiences as well as nurse workforce outcomes.
2. Data and methods
Data reported here are from a multi-center collabora-
tive study by the China Medical Board China Nursing
Network, with comparisons drawn from RN4CAST, a
similar study of hospitals in Europe (Aiken et al., 2012;
Sermeus et al., 2011). The study comprises 181 Chinese
hospitals distributed nationally with surveys of 9688
nurses and 6494 patients. The purpose of the study was to
determine the extent to which variation in features of the
nurse workforce and the organizational context of nursing
practice are associated with quality and safety of care,
patients’ care experiences, and nurse workforce factors
such as job satisfaction and job-related burnout. We
discuss the findings in relation to China’s health reform
efforts.
2.1. Sample
There are 31 provinces/municipalities/autonomous
regions (PMAs) in Mainland China representing 8 eco-
nomic zones. One of the 9 Chinese universities participat-
ing in the study was located in each zone, and each
university collected data from hospitals in their region. A
purposive sample of Level 2 (300–500 beds) and Level 3
(over 500 beds) hospitals in each targeted region was
drawn. Within each region, hospitals were stratified by
location (capital cities vs. other areas); within each
156 L.-m. You et al. / International Journal of Nursing Studies 50 (2013) 154–161
location equal numbers of Level 2 and Level 3 hospitals
were recruited. A total sample of 20 hospitals from
each region was drawn, and sampled hospitals that
refused to participate were replaced by other hospitals
in the same level and location categories. The refusal rate
was roughly 4%.
Nurses served as informants about the care in their
hospitals. An extensive international literature demon-
strates that nurses’ reports of quality of care and
conditions of the work environment track closely with
independent data on patient outcomes (Aiken et al.,
2011a,b, 2012; Kutney-Lee et al., 2009) and nurse
outcomes (Liu et al., in press). Within each hospital,
nurses were sampled from at least four inpatient units
including medical, post-operative surgical, and intensive
care. All bedside care nurses, excluding nurse managers,
from all shifts were invited to participate with a target
sample of at least 50 nurses per hospital. Surveys were
delivered to all nurses by the research nurse designated by
the nursing department in each hospital. The nurses
completed the questionnaires and returned them in a
sealed envelope to a sealed box on the unit within one
week. No incentives were offered for participation. A
research nurse in every hospital communicated directly to
the targeted populations that the survey was voluntary.
The voluntary nature of the survey was repeated in
writing on each survey instrument along with a descrip-
tion of provisions to ensure the confidentiality of
responses including no access of hospital personnel to
any of the surveys. A total of 10,221 nurse questionnaires
were delivered yielding 9688 (95%) completed surveys.
Fifty or more nurses responded in 145 (80%) of the
hospitals and at least 30 nurses responded in all hospitals,
a number our previous research suggests yields good
reliability of nurse-assessed variables (Aiken et al.,
2011a).
Patients from the same units were sampled, with a
target of 5 patients per unit and 30 patients per hospital.
Eligible patients had been hospitalized for a minimum of 3
days. Of 7295 questionnaires delivered, 6494 (89%) were
completed, including 5786 patients from medical and
surgical units, which we used in these analyses. In 166
hospitals (92%), we obtained 30 or more patient surveys
and all study hospitals had at least 19 patients surveyed.
The nurse survey instrument was the Multi-State
Nursing Care and Patient Safety Study (Aiken et al.,
2011a) which was translated from English to Mandarin
and validated through back-translation and content
validity testing (Sermeus et al., 2011). The patient survey
was adapted from AHRQ’s Consumer Assessment of
Healthcare Providers and Systems (CAHPS1) Hospital
Survey (Giordano et al., 2010). Translation and validation
of the CAHPS Hospital Survey included rigorous translation
procedures and content validity testing with bilingual
nurses and Chinese-speaking patients in one hospital (Liu
et al., 2011). The only modifications were deletion of
personal information questions to conform with Chinese
cultural norms and deletion of content about discharge
because the survey was administered during the hospital
stay. Ethical approval was obtained by each participating
university school of nursing.
2.2. Measures
The nurse work environment is measured by a
composite of 4 of the five subscales of the Practice
Environment Scale of Nursing Work Index (PES-NWI):
Nurse Participation in Hospital Affairs; Nursing Founda-
tions for Quality of Care; Nurse Manager Ability, Leader-
ship, and Support of Nurses; and Collegial Nurse–Physician
Relations (Aiken et al., 2011a). In creating this composite
measure we deleted the fifth subscale, which measures
Staffing and Resource Adequacy, since it is very highly
correlated with the patient-to-nurse ratio which we
include separately in the analyses. The PES-NWI is a
validated instrument used extensively in international
research (Aiken et al., 2011a,b; Lake, 2007; Warshawsky
and Havens, 2011). In regression models, hospitals with
the best (top quartile) environments are contrasted with
the rest, since preliminary analyses revealed that the
associations between hospital practice environments and
the outcomes considered in this sample of hospitals were
non-linear. That is, hospitals in the top quartile were found
to be markedly different from hospitals in the other three
quartiles, but hospitals in the other three quartiles were
not found to be very different from one another.
Nurses were classified according to their initial and
current nursing education referencing three types: sec-
ondary-level diploma, post-secondary associate degree,
and baccalaureate degree. In regression models we coded
the proportion of nurses with baccalaureate degrees as
highest educational attainment in each hospital.
Patient-to-nurse staffing ratios were estimated using
nurse reports about how many patients and nurses were
present on their unit on their last shift. These reports were
for all shifts for the study units aggregated to the hospital
level, so our staffing measure captures the average number
of patients per nurse for each hospital.
Nurses assigned their unit an overall grade on patient
safety using an item from the AHRQ Hospital Survey on
Patient Safety Culture (Sorra and Nieva, 2004). Our
measure of nurse rating of patient safety contrasts ‘‘poor,’’
‘‘fair,’’ or ‘‘acceptable’’ with ‘‘good’’ or ‘‘very good.’’ For
regression models, this measure was aggregated to the
hospital level and reflects the percentage of nurses in each
hospital that graded safety as ‘‘good’’ or ‘‘very good.’’
Nurse burnout was measured by the emotional
exhaustion subscale of the internationally validated
Maslach Burnout Inventory (Poghosyan et al., 2009). High
burnout exceeded 27, the threshold for health care
workers documented by Maslach and Jackson (1986).
Nurses were also classified as satisfied or dissatisfied with
their job, salary and wages, and opportunities for
advancement. Proxy measures for quality of care included
nurses’ assessments of how confident they were that
‘‘patients can manage their own care upon discharge’’ and
that ‘‘management will act to resolve problems in patient
care. ‘‘We also contrasted nurses who reported quality of
care on their unit to be ‘‘poor’’ or ‘‘fair’’ vs. ‘‘good’’ or ‘‘very
good.’’
Patients’ experience with care was measured with an
adapted version of the CAHPS Hospital Survey (Giordano
et al., 2010) which asks patients whether communications
 L.-m. You et al. / International Journal of Nursing Studies 50 (2013) 154–161 157

with nurses and physicians, responsiveness of nurses when Table 1

Characteristics of the nurses (n = 9688) and patients (n = 5786) in the
help is needed, pain management, and communication
Chinese samples.
about medications were always, often, sometimes or never
satisfactory. We created composite measures indicating the Nurse characteristics Mean (SD) Median
percentage of respondents that said communications with Age 29.1 (6.8) 27
nurses, with physicians, and about medications were always Total years experience working in nursing 8.3 (7.4) 6
satisfactory, and that pain was always well controlled (CMS, Workload (patients per nurse) – all nurses 6.8 (9.0) 4
Medical surgical nurses 7.9 (9.7) 5
2011). We also report two single-item measures that
ICU nurses 2.5 (2.9) 1.9
represent patients’ global hospital ratings (scale 0–10)
and whether the patient would ‘‘definitely recommend’’ the Nurse characteristics N Percent

hospital to family or friends. Female 9405 98.9

European data from RN4CAST, a study of 14,639 nurses Highest degree
Secondary diploma 1702 17.8
in 300 hospitals and 11,336 patients in a subset of 211 of
Associate degree 5816 60.8
the same hospitals in eight countries (Belgium, Finland, Baccalaureate degree 2022 21.2
Germany, Greece, Ireland, Poland, Spain, and Switzerland) Master’s degree 22 0.2
using the same research protocol and instruments and Initial degree
collected in the same time frame, are provided as a point of Secondary diploma 5992 62.6
Associate degree 3030 31.6
reference. RN4CAST is described in detail elsewhere (Aiken Baccalaureate degree 558 5.8
et al., 2012; Sermeus et al., 2011). Master’s degree 0 0.0

Patient characteristics Mean (SD) Median

2.3. Data analysis
We first provide descriptive information about nurses
and patients, using means for continuous measures and
percentages for categorical ones. We then show descrip-
tive information related to nurse outcomes and quality
assessments and patient ratings, and we compare these
results with those from Europe. We also show in
histograms the distribution of hospitals according to work
environments and educational composition of nurses.
Finally, we use multi-level models to estimate how nursing
work environments, patient-to-nurse ratios, nurse educa-
tional attainment, and nurse-assessed hospital safety
grade are related to select outcomes after differences
across hospitals in the characteristics of nurses and
patients are controlled for. In the multi-level models
related to nurse outcomes, we controlled for nurse
experience, unit type, hospital size, province, and whether
the hospital was located in a capital city. In the multi-level
models related to patient outcomes, we controlled for
length of stay, age, sex, health status, unit type, hospital
size, province, and whether the hospital was located in
capital city. Robust procedures were used to adjust
standard errors by taking account of the clustering of
nurses and patients within hospitals. Analyses were
performed using STATA 11.
3. Results
As shown in Table 1, the average age of nurses was 29
years and, on average, they had been working as nurses for
8 years. The average (mean) workload was 6.8 patients per
nurse per shift overall, though it was decidedly (and quite
expectedly) higher for medical and surgical nurses (7.9)
than for ICU nurses (2.5). Nearly all (99%) of the nurses
were female. Initially, 6% received a baccalaureate degree
in nursing and 32% an associate degree; at the time of the
survey 21% had obtained baccalaureate qualifications and
61% had an associate degree.
The average patient age was 54 years and, on average,
they were surveyed on day 15 of their hospital stay,
Age 54.3 (17.6) 55
Day of stay at time of survey 14.9 (18.6) 10
Patient characteristics N Percent
Female 3107 54.5
Self rated health
Excellent/very good 1119 19.6
Good 1890 33.2
Fair/poor 2691 47.2
Note: The percent of missing data ranged across characteristics from 1.1%
to 4.1%.
although the distribution on this variable shows that half
the patients were interviewed on day 10 or earlier. This is
not a measure of length of stay. Nearly half the patients
(47%) reported that their health was fair or poor, 33%
reported good health, and 20% reported very good or
excellent health.
As noted in Table 2, 38% of nurses had scores on the
Maslach Burnout Inventory indicating high burnout, and
45% were dissatisfied with their jobs. Salaries were a
source of dissatisfaction for 76% of the nurses, nearly 50%
were dissatisfied with their choice of nursing as a career,
and 44% were dissatisfied with their opportunities for
advancement. 61% described their work environment as
poor or fair, 36% gave their hospital a low grade on patient
safety, and 29% described the quality of care on their unit
as fair or poor. Nearly half lacked confidence that
management would act to resolve patient care problems
or that their patients could manage their own care when
discharged. Nurse-reported outcomes tend to be some-
what poorer for Chinese nurses than European nurses, with
exceptions being that fewer nurses in China give their
hospitals poor safety grades, and fewer lack confidence
that management will resolve patient care problems and
that patients can manage their own care upon discharge. In
both regions the variability in these percentages across
hospitals is quite marked.
Table 3 shows that only just over half of patients in
Chinese hospitals gave their hospital high ratings (54%)
and indicated that they would recommend their hospital to
158 L.-m. You et al. / International Journal of Nursing Studies 50 (2013) 154–161

Table 2
Percentages of Chinese and European nurses reporting various outcomes and quality assessments overall, and the range in those percentages across
hospitals.

Nurse outcomes China Europe

Percentage Inter-hospital Percentage Inter-hospital

range range

High burnout (emotional exhaustion score > 27) 38.1  1.00 8.3–73.3 30.3  0.77 0.0–100.0
Dissatisfied with current job 45.2  1.00 3.9–87.8 30.2  0.75 0.0–85.7
Dissatisfied with salary/wages 75.6  0.86 33.3–100.0 65.4  0.78 0.0–100.0
Dissatisfied with nursing as a career 49.5  1.00 3.1–79.5 17.4  0.62 0.0–71.4
Dissatisfied with opportunities for advancement 43.6  0.99 9.8–82.4 49.8  0.82 5.4–100.0
Nurse quality assessments
Low grade on patient safety 36.3  0.98 5.8–76.1 58.0  0.80 9.1–100.0
Quality of care on unit poor or fair 29.0  0.91 1.9–66.7 26.1  0.71 0.0–76.9
Describe the work environment as poor or fair 61.0  0.97 14.3–93.8 54.9  0.81 0.0–100.0
Not confident management will act to resolve problems in patient care 45.7  1.00 9.4–79.6 78.0  0.68 9.1–100.0
Not confident that patients could manage their care upon discharge 46.3  1.00 10.4–76.0 53.0  0.81 0.0–100.0

Note: ‘‘Dissatisfied’’ is a combination of survey answers ‘‘somewhat dissatisfied’’ and ‘‘very dissatisfied’’ (‘‘satisfied’’ is a combination of ‘‘very satisfied’’ and
‘‘satisfied.’’). Similarly, ‘‘not confident’’ combined survey answers ‘‘not at all confident’’ and ‘‘somewhat confident’’ versus ‘‘confident’’ which combined
answers ‘‘confident’’ and ‘‘very confident.’’
The European sample includes 14,639 nurses in 300 hospitals in Belgium, Finland, Germany, Greece, Ireland, Poland, Spain, and Switzerland.
Overall percentage differences between the Chinese and European samples are significant in all cases, at P < .001.

family or friends (53%). Less than half thought that nurse
communications (38%) and doctor communications (46%)
were always satisfactory, and fewer than a third thought
that pain management (31%) and communications about
medications (23%) were always satisfactory. While patient
ratings of hospitals differed little between China and
Europe, smaller percentages of Chinese patients would
recommend their hospital and smaller percentages por-
trayed positive experiences with doctor and nurse com-
munications, pain management and explanations about
medications.
Data from the nurse surveys allow us to characterize
hospitals along several dimensions including quality of the
work environment, educational qualifications of nurses,
patient-to-nurse ratios, and nurse ratings of patient safety.
We show in Fig. 1 the distribution of PES-NWI scores
distinguishing the top quartile of hospitals with the most
favorable work environments. Fig. 1 also illustrates the
significant variation in percent baccalaureate nurses across
hospitals.
Table 4 suggests that nursing is important in quality of
care and patients’ experiences with care, and that features
of the work environment are highly related to levels of
nurse dissatisfaction and burnout. The work environment
is strongly related to the nurse outcomes and all but one of
the patient outcomes. In the quartile of hospitals with the
best work environments, nurses are less likely to be burned
out or dissatisfied with their jobs and less likely to report
only poor or fair patient care quality, by factors ranging
from 0.56 to 0.74. In those same hospitals, patients are
more likely to be satisfied with nursing communications
and to rate their hospital highly. Hospitals in the top
quartile of nurse-rated patient safety also show lower
burnout, dissatisfaction, and likelihood of nurses to report
poor or fair quality of care. High patient safety grades are
also related to patients’ increased satisfaction with nursing
(OR = 1.24), willingness to recommend the hospital
(OR = 1.31) and likelihood of rating it highly (OR = 1.40).
Additionally, higher patient-to-nurse ratios are associated
with poorer nurse outcomes (each additional patient per

Table 3
Patient ratings of their hospital, willingness to recommend hospital, and patient experiences with nurse and doctor communications, pain management,
and medication, in China and Europe.

China Europe

Percentage Inter-hospital Percentage Inter-hospital

range range

Hospital ratings Hospital rating 9 or 10 (best rating) 54.4  1.29 4.2–96.4 53.0  0.94 0.0–100.0
Would definitely recommend hospital 53.2  1.29 4.4–97.6 61.6  0.91 17.6–100.0
to friends and family

Composite measures Nurses always communicated well 37.7  1.26 4.3–96.4 47.6  0.93 10.0–91.4
Doctors always communicated well 46.2  1.29 2.2–92.9 50.6  0.93 10.3–94.1
Pain management was always well 31.2  2.40 0.0–100.0 47.8  1.14 0.0–81.0
controlled (if applicable)
Staff always explained medications 23.1  1.39 0.0–100.0 27.1  1.07 0.0–62.5
(if applicable)
Note: The European sample includes 11,336 patients in 211 hospitals in Belgium, Finland, Germany, Greece, Ireland, Poland, Spain, and Switzerland.
Overall percentage differences between the Chinese and European samples are significant in all cases except for patient ratings of their hospital, at P < .001.
For patient ratings the difference (54.4 vs. 53.0) is not significant (P = .08).
 L.-m. You et al. / International Journal of Nursing Studies 50 (2013) 154–161 159

Lower 3/4s Top Quarle

30

25

Number of Hospitals
20 Mean=3.3
SD=.20
15

10

2.8
2.85
2.9
2.95

3.05
3.1
3.15
3.2
3.25
3.3
3.35
3.4
3.45
3.5
3.55
3.6
3.65
3.7
3.75
3.8
3
Work Environment Scores

35

30
Number of Hospitals

25
Mean=21.1
20 SD=14.5

15

10

0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
Percent Baccalaureate Nurses

Fig. 1. Distributions of the numbers of hospitals by work environment and nurse education.

nurse increases both burnout and dissatisfaction by a 4. Discussion

factor of 1.04) and higher likelihoods of nurses reporting
poor or fair quality of care (OR = 1.05), but are unrelated to
patient outcomes. Finally, higher percentages of bacca-
laureate nurses are strongly related to better patient
outcomes, with each 10% increase in the percent of
baccalaureate nurses increasing patient satisfaction, high
ratings, and willingness to recommend their hospital by
factors ranging from 1.11 to 1.13.
Our results suggest that in China the quality of the
hospital work environment is associated with nurse
satisfaction and more positive patient experiences. Sub-
stantial proportions of nurses experience high job-related
burnout (38%) and dissatisfaction (45%). While perceptions
of low salaries (76%) are part of the picture, over 60% of
nurses rate the overall quality of their work environments

Table 4
Effects of hospital factors on nurse and patient outcomes.

Outcomes Work environment Patient-to-nurse ratio Percent baccalaureate Nurse assessed hospital
nurses safety grade

Odds ratio P-Value Odds ratio P-Value Odds ratio P-Value Odds ratio P-Value

Nurse burnout 0.66 (0.53–0.82) <.001 1.04 (1.01–1.08) .020 1.03 (0.96–1.11) .382 0.75 (0.62–0.90) .002
Nurse job dissatisfaction 0.56 (0.46–0.68) <.001 1.04 (1.01–1.07) .020 0.99 (0.92–1.06) .718 0.59 (0.49–0.70) <.001
Nurses report poor/fair 0.74 (0.59–0.92) .008 1.05 (1.02–1.09) .005 0.95 (0.88–1.04) .264 0.54 (0.44–0.66) <.001
quality of patient care
Nurses always 1.30 (1.02–1.67) .035 0.94 (0.85–1.04) .242 1.12 (1.03–1.21) .008 1.24 (1.00–1.53) .048
communicated well
Patient willingness to 1.01 (0.75–1.37) .945 0.98 (0.88–1.08) .642 1.13 (1.01–1.25) .028 1.31 (1.03–1.68) .030
recommend hospital
Patient rates hospital 1.29 (1.00–1.67) .048 1.07 (0.97–1.18) .187 1.11 (1.02–1.21) .021 1.40 (1.14–1.71) .002
highly (9 or 10)
Note: The estimated effects of the organizational characteristics on the nurse outcomes and nurse reports of poor/fair quality of care are from models which
control for nurse experience, unit type, hospital size, province, and whether the hospital was located in a capital city. The estimated effects of the
organizational characteristics on the patient outcomes are from models which control for length of stay, age, sex, health status, unit type, hospital size,
province, and whether the hospital was located in capital city.
160 L.-m. You et al. / International Journal of Nursing Studies 50 (2013) 154–161
as only fair or poor and a third give their hospital an
inadequate grade on patient safety. Our measure of work
environment taps such dimensions as adequate staffing to
support safe care, nurse involvement in hospital affairs,
doctor–nurse relationships, and managerial commitment
to professional nursing and quality of care. Higher patient-
to-nurse ratios are associated with more dissatisfied and
burned out nurses. We did not find, as in other research
(Aiken et al., 2012), that better nurse staffing was
associated with higher patient satisfaction. This may be
due to the task oriented delivery of nursing care in Chinese
hospitals and involvement of family members in care
giving.
Only 54% of patients gave their hospitals high overall
ratings and only 53% would recommend their hospital.
Patients in hospitals with the best work environments
were almost 30% more likely to rate their hospitals highly
and nearly 30% more likely to be satisfied with nursing, a
link that has also been found in other research (Jha et al.,
2008; Kutney-Lee et al., 2009). The World Health Report
2000 by the World Health Organization (2000) and the
Institute of Medicine’s Crossing the Quality Chasm (2001)
landmark reports on healthcare quality improvement,
concluded that responsiveness to citizens’ expectations
was a desired outcome of health system performance. The
Joint Learning Initiative (Chen et al., 2004) and the World
Health Report of 2006 by the World Health Organization
(2006) both concluded that poor work environments were
endemic in health services and responsible for problems
retaining qualified workers and achieving high quality
care. While there is little mention of work environments in
published papers on health reform in China, our results
suggest that both nurses and patients might benefit from
targeted attention to improving hospital work environ-
ments.
National statistics suggest that China’s nurse to bed
ratio is significantly lower than OECD countries. We
confirm that nurses in hospitals with higher patient to
nurse ratios are less satisfied with their jobs and more
likely to be burned out – a patient safety hazard. While we
do not find an association between higher patient to nurse
ratios and more negative patient perceptions of care, this
may reflect the task-oriented nature of hospital nurses’
roles in China as compared to a patient population nurse
assignment model in many other countries where a strong
association between nurse staffing and patient satisfaction
has been found.
We document for the first time in China that a more
educated nurse workforce is associated with more positive
patient perceptions of their hospitals and care. In other
countries where computerized patient records are avail-
able for study, more baccalaureate nurses have also been
associated with lower mortality (Aiken et al., 2011a; Van
den Heede et al., 2009). Current China policy recommen-
dations include increasing the number of baccalaureate-
prepared nurses. Our findings, if replicated in subsequent
research, provide empirical support for this direction. Our
data also show the importance of ongoing access to higher
education since many nurses attained more education over
time (Table 1). Most of the gain was from initial secondary
education to highest education as associate degree. While a
more detailed cohort study is necessary to confirm this in
China, continuing to graduate 50% of new nurses from
secondary school programs is not an efficient way to
achieve more baccalaureate-prepared nurses (Aiken et al.,
2009). Rather, moving basic nursing education to post-
secondary levels would allow more nurses to achieve
baccalaureate qualifications over time. As the complexity
of hospital care continues to increase and nurses’ roles in
community care expand, a more educated nurse workforce
will become even more crucial.
Our study is cross-sectional and we cannot confirm
causality. Establishing causality would require, optimally,
manipulating the nursing characteristics of interest (i.e.,
increasing staffing or improving work environments) and
measuring resultant changes in outcomes or, minimally,
observing hospitals over time and seeing whether natu-
rally occurring changes in the nurse characteristics
correspond to changes in outcomes. Neither is likely to
be tractable any time soon in the study of nursing in
Chinese hospitals, which is still in its infancy. Also, the
sampling of hospitals in China was purposive, and while
the sample consists of a diverse set of larger hospitals in all
geographic regions, it is not a probability sample.
Potentially important variables were omitted from our
models as we lacked comparable data on doctors’
qualifications and patient to doctor ratios. Lacking
administrative data on mortality, patient falls, infections,
and adverse events, we had to rely on nurse and patient
reports and assessments to derive our primary indicators
of quality of care and patient safety.
5. Conclusions and policy recommendations
In this first comprehensive assessment of nursing and
patient outcomes in hospitals in China, we conclude that
nursing contributes importantly to better quality of care
and more positive patient reports. Three policy recom-
mendations emerge from the study that can inform
discussions in China about how to maximize nurses’
contributions to improved hospital care. Improving patient
to nurse ratios, and moving to more patient-centered
organization of nursing care, may hold promise for
reducing the patient safety hazard of nurse burnout and
improving patients’ satisfaction with care. Our findings
also suggest a focus on improving hospital work environ-
ments including introducing evidence-based best practices
in human resource management including greater parti-
cipation of nurses in decision-making, greater responsive-
ness of management to correct system problems in patient
care, and good working relationships among health
professionals. Patients in Level 2 and Level 3 hospitals
may also benefit from having a larger proportion of their
care from baccalaureate-qualified nurses, raising the
challenge for China of how to feasibly transition to a more
educated nurse workforce.
Authors’ contributions: All authors contributed to study
design and implementation, data collection, and inter-
pretation of findings for this report. You, Aiken, and Sloane
are responsible for the data analysis and interpretation,
and the finalization of this manuscript. All authors have
approved this manuscript.
 L.-m. You et al. / International Journal of Nursing Studies 50 (2013) 154–161
Conflict of interest: We have no conflicts of interest.
Funding: The study was funded by the China Medical
Board (CMB) and the European Union’s Seventh Frame-
work Programme FP7/2007–2013 under grant agreement
no. 223468 provided support for RN4CAST. The sponsors
had no role in study design, implementation, manuscript
development, or decision to publish.
Ethical approval: Each of the 9 participating schools of
nursing obtained ethical approval (p6).
Acknowledgments
The authors acknowledge the contributions of Timothy
Cheney, Jing Zheng, Xiao-wen Zhu, Li-feng Zhang.
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