CLINICAL PERFORMANCE AND PATIENT SATISFACTION ON THE CARE RENDERED BY NURSING STUDENTS

Submitted to: Mr. George Vega

Submitted by: Charmagne Faye Miguel Chressie Anne Ortiz Dazel Villanueva Janine Cassandra Romero Joanna Carla Mei Pasiola Nikki Joy Dela Cruz Rowena Lonogan Ruby Joyce Martinez

ABSTRACT Clinical Performance and Patient Satisfaction are two components that are both vital in quality nursing care. The study was aimed at determining the relationship between clinical performance and patient satisfaction on the care rendered by nursing students. Using descriptive research design, the clinical performance of twenty five (25) level III nursing students were obtained using purposive-convenience sampling. Consents were obtained for disclosure of grades in a particular rotation. Meanwhile, patient respondents completed the Satisfaction Survey tool matched with the sample clinical performance rating of students. Then, the researchers retrieved the grades for comparison and analysis. Data showed that results were negligible on the relationship between the two variables yielding a Spearman Coefficient of 0.18. Thus, it is recommended to conduct the study in a bigger sample size using time-series design.

TABLE OF CONTENTS INTRODUCTION Background of the Study1 Statement of the Problem and Research Questions2 Significance of the Studies2 Review of Related Literature.3 Research paradigm7 Hypotheses..8 METHODS Research Design9 Population and Sample.9 Research Instruments...10 Data Collection and Procedure11 RESULTS. DISCUSSION ..... CONCLUSION. RECOMMENDATION.

1 INTRODUCTION Quality care of nurses is considered the hallmark of nursing responsibility. Different studies have proven the basis of quality nursing: some described patient satisfaction as the sole determinant of quality nursing care while others connote competence of nurses in terms of knowledge and skills as the source of this quality nursing care. Hence, nurses are expected to render quality care since patient satisfaction varies according to the perception of the patient and how the care is rendered by a nurse. Concomitantly, a nursing student who is as well exposed to the clinical setting is anticipated to give quality care. However, no studies have been made yet to prove if there exists a correlation between the clinical performance of a nursing student and patient satisfaction. Patient satisfaction with nursing services gains even more importance, since owing to the nature of nursing, patients may judge the overall quality of hospital services on the basis of their perceptions of the nursing care received (Scardina, 1994; Yellen et al., 2002); it establishes that patient satisfaction is subjective in nature and relies heavily on what the client perceives as a good nursing care. Aside from the patients perception of the care received, patient related factors like age and gender affects the patients satisfaction towards the care performed (Thiedke, 2007). Patient satisfaction with regards to nursing care are determined by these factors: a. when internal needs are met such as the need for interpersonal relations, recognition and participation in decision-making (Bond and Thomas, 1992); b. when adequate information/ health teachings are provided (Elder et al., 2005) and; c. when the nurses display good temperament, approachability and politeness (Cuevas, 2008). In fulfilling the goal of preparing nursing students as competent healthcare professionals, clinical preceptors have the responsibility of seeing to their performance in accordance to the standards of the profession. The Clinical Performance Evaluation Tool as a competency-based framework enables the institution and the nursing students to have a clear understanding of expectations in relation to their role performance which would in turn provide a basis for developing continuing educational improvement specifically training needs analysis that would meet the needs of the institution and the nursing students as future health care professionals. Based on the researchers own experiences in the clinical area and accounts from other nursing students, there have been instances wherein patients have expressed satisfaction with the care delivered with a poor outcome on the clinical performance grade. As a result, these sparked an interest in discovering whether patients are satisfied with the nursing care rendered and whether it affects the evaluation of the clinical performance of the nursing students. In this study, nursing care rendered by nursing students during their clinical exposure in a certain ward will be evaluated by the clinical performance and by the patient satisfaction. The researchers will build a bridge that will connect the existence of the correlation between clinical performance and patient satisfaction thus; the study is geared towards finding if a high clinical grade reflects a high rating of patient satisfaction or vice versa. These inquiries motivate the researchers to pursue the study so that improvement in certain aspect of nursing care such as nurse-patient-interaction will be attained.

2 Statement of the Problem The study sought to determine the relationship between clinical performance and patient satisfaction on the care rendered by Level III USL nursing students. Specifically, it aims to answer the following questions: 1. What are the demographic characteristics of the patients in Cagayan Valley Medical Center? 2. What is the average clinical performance of students rotating in Cagayan Valley Medical Center when grouped according to four areas of nursing core competencies? 3. What is the patient satisfaction rating when grouped according to three domains of nursing care? 4. What is the patient satisfaction rating when grouped according to age and gender? 5. What is the relationship between clinical performance and patient satisfaction of clients cared by the nursing students? Significance of the Study The study was of particular importance to the nursing profession and society for reasons that it sought to understand the relationship between clinical performance of the students and patients satisfaction. It also sought to determine if the patients demographic characteristics influenced their satisfaction. Specifically, the study was essential for reasons that it: Patient. Since the researchers valued patient satisfaction, this study was geared towards optimal patient-centered health promotion that would endeavor to uphold patient satisfaction and to the care rendered by the nursing students. Nursing Practice. Through this study, nursing students were made aware of their contribution to their patients by means of measures undertaken to aid their recovery. Nursing Administration. The study aimed to provide significant contributions toward improvement of the overall health care delivery system in carrying out nursing care for hospitalized patients. In the long run, this would be beneficial to the entire health institution, for the patients trust and satisfaction in the capabilities of the care service would be improved. Nursing Education. In clinical education, assessment of students in clinical practice was imperative in order to ensure that those who become registered nurses are safe and competent practitioners. The study could contribute to the improvement of the way nursing students deliver care thus contributing to the development of nursing education and enrichment of nursing research pertinent in patients satisfaction. A significant relationship between the clinical performance of nursing students and patient satisfaction would provide another dimension by which the nursing students clinical performance would be evaluated. Nursing Research. The study could supplement and support the previous research study done by Cuevas (2004) and could be used in correlation with other studies and reviews like that of Thiedke (2007) about the effects of profile variables on patient satisfaction, so that the researchers would be able to have comprehensive reviews reevaluation. It could also be used as a framework or basis for the establishment of future studies for those who wish to pursue the research study.

3 Review of Related Literature Nursing students and Clinical Performance Evaluation Patients provided data from the product consumer viewpoint. Patient satisfaction was considered an important marker in quality health care and can be considered as part of student evaluation. Judgment about nursing students performance was made from patients personal experiences and data should be weighted for its value. Patients often have positive comments to make about their students which can be positive for the students to hear. The goal of evaluation was an objective report about the quality of the clinical performance. Faculty needs to be aware of the potential for evaluation of students clinical performance to be subjective and inconsistent. Even with objective instruments based on measurable and observable behavior, subjectivity can still be introduced into a tool that is viewed as objective. Billings and Halstead encouraged faculty to be sensitive to the forces that contribute to the subjective side of evaluation as faculty strives for fairness and consistency (as cited by Reilly and Oerman, 1992). However, clinical evaluations based on direct observation are inherently biased, and subjective evaluations lack generalized reliability (Vannata et al., 1996). Billings and Halstead argued also that educators cannot ignore the social connotations of grading including the impact evaluation has on the learning process and motivation (as cited by Wiles and Bishop, 2001). Literature also suggests that nursing education is often far removed from the realities in which students experience during clinical practice. This study suggests that students have difficulty in transferring the principles of 'good' communication from the classroom into their own interactions with patients (Duffy et al., 2007). Fair and reasonable evaluation of students in clinical settings requires use of appropriate evaluation tools that are effective and ideally efficient for faculty to use. Instrument content can vary according to the academic level of a student and can also relate to the teaching institutions purpose and philosophy. Any evaluation instrument used to measure clinical learning and performance should have criteria that are consistent to the course objectives. A faculty groups decisions about the tools to be used for the data collection are typically indicated. Many clinical evaluation tools have been developed and implemented within clinical settings. Faculty must make decisions about using these instruments according to their purpose for clinical evaluation. Primary strategies for the evaluation of clinical practice include (1) observation, (2) written communication, (3) oral communication, (4) simulation, and (5) selfevaluation. Because clinical practice is complex, a combination of method is indicated and helps support a fair reasonable evaluation (Billings & Halstead, 2004). According to the theory proposed by Patricia Benner (1984) students nurses still belong to the novice level with limited background experiences and will only acquire skills such as management of resources, increase level of efficiency, clinical grasp and resource based practice by reaching a higher level of expertise such as advance beginner, competent, proficient and expert levels. However according to Bramble (1994) nursing students plays a pivotal role in the care of patients though difficulty is inevitable. Nursing students' synthesis of didactic information and abilities to apply knowledge in the clinical setting can be compromised. Competence is the knowledge, skills, abilities and behaviors that a nurse needs to perform their work to a professional standard, and is key lever for achieving results that will enable the organization to achieve its health care objectives (Ryan, 2001). The competencies needed to undertake a given role in nursing and health care should prepare practitioners who are fit for purpose and fit to practice. Competencies are needed to provide recognition of learning, wherever it takes place, and provide links between individual and organizational requirements,

4 which should enable cost effective education and training programs to be delivered. Competencies of nurse practitioners are dependent upon development and application of a strong fund of knowledge in the specialty area and demonstration of technical, interpersonal, and critical thinking skills, attitudes, and ethics. Contexts change, new knowledge emerges, and practice develops therefore competence to practice needs to be redefined on a regular basis if the practitioner is to ensure that they are meeting the needs of their patients and the organization. The Clinical Performance Evaluation Tool as a competency-based framework enables the institution and the nursing students to have a clear understanding of expectations in relation to their role performance which would in turn provide a basis for developing continuing educational improvement specifically training needs analysis that would meet the needs of the institution and the nursing students as future health care professionals. Evaluations conducted by clinical preceptors and direct observation by faculty are the most frequent methods used for the evaluation of nursing students in the clinical area. Patient and Patient Satisfaction Patient satisfaction has become an established outcome indicator of the quality and the efficiency of the health care systems (Johansson et al., 2002; Mahon, 1996; OConnell et al., 1999). According to Merkouris et al. (1999a), patient satisfaction measurement can also be seen as a therapeutic intervention, an important criterion for making and evaluating organizational and administrative decisions, a tool for patient client marketing or as an ethical obligation which has the potential to humanize care by bringing forth patients views. Patient satisfaction with nursing services gains even more importance, since owing to the nature of nursing, patients may judge the overall quality of hospital services on the basis of their perceptions of the nursing care received (Scardina, 1994; Yellen et al., 2002). Patient related factors like age, gender, and economic status affects the patients satisfaction towards the care performed. In terms of the patients age, Woods (1990) has classified the population into: (a) Veterans; (b) Baby boomers; (c) Generation X and; (d) Generation Net. The Veterans include those who are 65 years old and above. Next are Baby Boomers which are composed of people who belong to the 45-64 age range. The Generation X are those whose ages are 30-44 years old. Last is the Generation Net whose age range is from 18-29 years old. It is difficult to keep up with generational labels these days Veterans, Baby Boomers, Generation X and Generation Y. But regardless of what they are called, generation designations have one thing in common: they assume that people in different age groups have certain characteristic values, perceptions, and expectations that set them apart from those who came before and after (Blizzard 2004). However, in the study made by Blizzard (2004), inpatient satisfaction rating is higher among patients between the ages of 18-35 years old. Studies on the effect of gender are contradictory. In the study made by Blizzard (2002), he found out that males were also less satisfied than females. Staff members should be sensitive to the fact that males tended to be more impatient and concerned with the speed of the process. On the other hand, some studies showed that women tend to be less satisfied and other studies showing the opposite (Thiedke, 2007). According Risser (1975), patient satisfaction with nursing care is the degree of convergence between the expectations patients have of ideal care and their perception of the care they really get. A consensus on a common conceptual definition of patient satisfaction is still lacking (Bond and Thomas, 1992; Fitzpatrick, 1991; Williams et al., 1998). Satisfaction with care is a composite and subjective concept with still undefined boundaries and multiple interacting variables (Walsh and Walsh, 1999). These, coupled with the knowledge and information they receive, enable them to define the situation and their needs. Thus, a set of expectations about care is formed and it provides a subjective standard against which the quality of care received is

5 measured up. Many researchers have focused on the relationship between patients expectations and satisfaction (Staniszewska and Ahmed, 1999) but there is no concurrence, as to the degree and the way in which unmet expectations affect overall satisfaction (Williams et al., 1998). Patient satisfaction is a persons feeling of pleasure or disappointment resulting for comparing product/services perceived performance or outcome in relation to his or her expectations. As this definition makes clear, satisfaction is a function of perceived performance and expectations. If the performance falls short of expectations, the patient is dissatisfied. If the performance matches the expectations, the customer is satisfied. If the performance exceeds expectations, the customer is highly satisfied or delighted. Recently, providers of medical and nursing services have awakened to consumer challenges, competition, quality, and the realities of marketing. With these changes, a related and equally important issue has emerged, the patient-provider relationship on the overall medical and nursing services quality evaluation. Patients are increasingly frustrated with the commercialization of medical and nursing service, proliferated bureaucratic health care system and weakened client-provider relationship (Sinay, 2002). To achieve patient satisfaction, medical and nursing service providers should realize the importance of healthcare marketing. Therefore, hospitals, clinics and medical service providers should make effort to develop therapeutic relationships with their patients, determining their needs, and tailoring their services to meet those needs (Habbal, 2006). Vuori (1987) investigated the reasons that have led to a questioning of the validity of the measurements of patient satisfaction and concluded that: (a) patients do not have the scientific or technical knowledge to assess the quality of care, (b) patients can be in such a physical and psychological state that they are unable to express objective opinions, (c) the most rapid succession of interventions, diagnostic tests and measuring does not allow the patients to have a complete and objective picture of what is happening, (d )the professionals and the patients can have different goals, and (e) the notion of quality depends on the cultural habits and varies from country to country. It also depends on the patients characteristics such as their age, educational background, social class and their state of health. Hospital nurses need to take into consideration the way nursing is defined and organized in our days so that these instruments can be used to evaluate the needs of their patients and their interventions to meet these needs. Evaluating care provision in this regard involves both patients and nurses (Merkouris, et al. 1999). Patient Satisfaction and Nursing Care Nurses are not limited as a caregiver; they can also be counselor and teacher when the need arise. Studies also showed that providing patients with information increase their satisfaction with the health institution. Marchal, et al. (2005) found out that information provided by the nurse was rated a mean of 9.33 (with 10 as the most satisfied) in a study about post-operative care and patient satisfaction after ambulatory surgery for breast cancer patients. Another study by Elder et al. (2005), found out that the more information provided for the patient the more the satisfaction. The study concludes that patient satisfaction is an important health outcome and is necessary to improve the overall quality of patient care. The nurse patient relationship, according to research by Press Ganey Associates Inc., sets the tone of the care experience and has a powerful impact on patient satisfaction. Nurses spend the most time with patients. Patients see nurses interactions with others on the care team and draw conclusions about the hospital based on their observations. Also, nurses attitudes toward their work, their coworkers and the organization affect patient and family judgments of all the things they dont see behind

6 the scenes. Without a positive nurse patient relationship, there cannot be patient and family satisfaction. And there cannot be an environment that supports anxiety reduction and healing (Leebov, 2009). Patient satisfaction with nursing services gains even more importance because nursing staff comprises the majority of the health staff (McDonnel and Nash, 1990) and are constantly found at the side of the patient to satisfy their needs comprising the main component in the maintenance and rehabilitation of the patients health. There seems to be a concurrence among researchers regarding the importance of nursing interventions in the molding of over-all patient satisfaction with hospital services (Abramowitz, Cote & Berry 1987). Bond and Thomas (1992) explain patient satisfaction with nursing services, contended that patients are satisfied when internal needs, such as the need for interpersonal relations, recognition and participation in decision-making, while they become dissatisfied when the environmental factors and amenities which are provided are not the right ones. Risser Scale (1975) identified a dissatisfaction factor and drew the conclusion that satisfaction and dissatisfaction are not the exact opposites of the same straight line. La Monica and associates (1986), making a factor analysis with one of the classic patient satisfaction instruments. Recent studies suggest that triangulation provides a fairly accurate description of patient satisfaction (Hyrkas et al, 2000), an effective design and method of data synthesis remains to be determined. Patients and Nursing students The study entitled The Patients' Satisfaction with AU Nursing Students' Performance of Jittakoat, Y. revealed that most patients were very satisfied with AU nursing students' performance in providing health-care services. There was no statistical correlation between socio-demographic factors and satisfaction with AU nursing students' performance in all categories, except for the quality of nursing care and age which have statistically significant correlation. An evaluation of the performance of the nursing students in the Philippines is essential both for the national and foreign health institutions and for the nursing students themselves. Filipino nurses still rule when it comes to patient satisfaction as compared to their other foreign co workers (Katigbak, 2008). Synthesis Patient satisfaction is considered as an important measure of quality care services. It is influenced by the different internal and external needs of the patient. These include the sociodemographic factors such as age, gender, economic status and educational attainment. Other than these, environmental factors and expected outcomes are also taken into consideration in assessing and evaluating the nursing care received. Nurses, comprising majority of the health care team, are considered as the best determinants in patient satisfaction since they are often at the patients side to render care. Their professional skills, technical knowledge, interpersonal capabilities are viewed as the basis of evaluation of care from patient to patient. Today, nursing students also play a great role in patient care. With this in mind, nursing students are able to put into practice their knowledge instilled from the academe. To effectively evaluate their skills and abilities, the clinical performance evaluation tool is designed as a guide for clinical preceptors and serves as the basis for nursing students grades. The clinical performance tool aims to grade nursing students in an objective manner however it is still subject to the perception of the faculty assigned. Clinical instructors perceptions for evaluating nursing students differ from patients perception because of the formers professional competencies. Some studies such as those conducted by, French Meterko and Merkouris pointed out that evaluation of care provision involves both patients and nurses, whereas Vuori questions the ability of patients in evaluating the quality of nursing care rendered. In addition there was no relationship established between

7 patient satisfaction and clinical performance of the nursing students in all of the studies reviewed thus the study aims to evaluate clinical performance grades through a qualitativequantitative combination of the subjective perceptions of the patient and the objective use of the clinical performance tool. Research Paradigm The theory involved in the study is Duffy and Hoskins Quality-Caring Model. Caring relationship is its core concept. While caring exists in a generic sense in all cultures and between relatives and friends, the caring that exists in nursing practice is integrated in the daily work of nursing and has as its aim of health and healing (Leininger, 1988; Duffy & Hoskins, 2003). In 1971, Mayerhoff wrote that knowledge is required for caring to occur. Gordon (2002) agreed with Mayerhoff and labeled caring that is embedded in nursing practice as educated caring. This theory is guided by the following assumptions: (1) caring must be done in relationship; (2) caring is submerged in the daily work of nursing; (3) caring relationships are tangible and can be measured; (4) knowledge of caring is a significant issue for nursing education, nursing practice, and nursing administration and; (5) increased use and study of nurse caring will determine nursing contribution to health care. The first major component of this theory is "Structure". Originally, structure was defined by Donabedian (Donabedian, 1988) and relates to components of a system such as the resources, equipment, and providers. Dr. Duffy's definition of structure blends the causal past of the participants and takes into account characteristics of the provider and the system. Within each of the participants (provider and patient), there are unique attributes and knowledge that characterizes their previous life's experiences, demographics, physiological, psycho-socio-cultural, biomedical, and spiritual factors. Structural characteristics influence the processes and outcomes of health care. Within the structure component, Person is defined as a multidimensional interdependent participant who is connected to the larger diverse world. Participants include the provider and patient. Each participant has a phenomenal field that has a unique frame of meaning. Unique experiences, demographics, attitudes, and behaviors comprise the participant's phenomenal field. The second major component is "Process" which is located in the center column. Processes, according to Duffy, are the real focus of the model since the caring practices of nursing professionals assist patients and other health care providers to meet health outcomes. Necessary human connection is created by Clinical Caring Processes (Watson, 1979; 1985). The roles of the nurse are "initiating, cultivating and sustaining caring relationships." (Duffy & Hoskins, 2003, p 79-80) Donabedian defined "Outcomes" as the consequences or the end point of a process (Donabedian, 1988). These are high priority indicators for quality. Intermediate outcomes are the end results of the individual and collaborative relationships that produced feelings of being "cared-for," necessary to the attainment of terminal outcomes. Terminal outcomes are depicted not only for the patient, but for providers and the health care system. Examples of terminal outcomes include quality of life, costs, disease-specific outcomes, and satisfaction with care. The Quality-Caring Model provides a continuous, dynamic framework to practice professional nursing and assess health care outcomes. Evaluating care provision in this regard involves both patients and nurses (Merkouris, et al. 1999). The theory above supports this study in terms of delineating the variables and components involved. Structure, which includes the provider and patients (Person), was reflected in the study by the nursing students and patients respectively. Moreover, the Person also encompasses the socio-demographics of both the provider and patients; however, in this study, only the patients demographics were considered. Furthermore, attributes and knowledge of the

8 provider influenced the quality of nursing care given. The second component, Process, as it was applied to the study, was the nursing care rendered by the nursing students. Nursing care is governed by four competencies namely: Patient Care, Enabling, Enhancing, and Empowering competencies. The produced feelings of patient satisfaction illustrated the end-point termed as the Outcome. Therefore, the three components of the theory discussed represented the variables adequately in this study. The theory shows that the Person is composed of the provider and patient. In this study, the student nurse acts as the provider wherein his/her clinical performance grade is the independent variable. In addition, patients attributes such as age and gender are the moderating variables which could influence the patient satisfaction rating. The Outcome or the end point of the process yields the feeling of being cared for as manifested by the patient satisfaction (DV). Patient satisfaction encompasses three domains of nursing care namely: Technical Professional, Interpersonal Educational and Interpersonal Trusting. Furthermore, the center of the relationship termed as the Process was reflected in the study as the Nursing Care rendered by the students. Below is the schematic diagram that shows the interrelationship between the variables. Hypotheses 1. Differences in patient satisfaction are influenced by the patients demographic characteristics. 2. Patient satisfaction is associated with the clinical performance of nursing students. 3. Patient satisfaction decreases with age. 4. Female patients are more satisfied than male patients in terms of overall care rendered by the nursing students. Definition of Terms Clinical Performance (CPET Grade) It is the rating given by the clinical instructor based on the student nurses performance on bedside care measured by the Clinical Performance Evaluation Tool. In this study, clinical performance will be evaluated using the following nursing care areas: (i) Patient Care Competencies includes Safe and Quality Nursing Care, Health Education, Communication and Collaboration and Teamwork. (ii) Enabling Competencies includes Management of Resources and Environment and Records Management. (iii) Enhancing Competencies includes Quality Improvement and Research (iv) Empowering Competencies includes Legal Responsibility and Personal and Professional Development Patient Satisfaction it is the degree of congruency between a patients expectations of ideal nursing care and his perception of the real nursing care that he receives. In this study, patient satisfaction is measured using the following domains: (i) Technical- professional behavior - includes nurses knowledge, physical care for the patient and expertise in implementing medical care. (ii) Interpersonal- educational- it deals with the social aspects of nursing care as well as the information exchange between patient and nurse which includes answering questions, explaining and demonstrating. (iii) Interpersonal- trusting- this includes sensitivity to people and their feelings, and listening t/o patient problems.

9. Nursing student Students under the nursing curriculum and exposed with the clinical situations in their related learning experiences. In the study, this will be composed of USL nursing students at 3th year level that are exposed to any wards. This term is synonymous to student nurse. Nursing Care Actions of the nursing student concerned with or involved in providing physical and mental services, preventive medicine, and treatment to individuals or the public. In this study, it is the one that affects the satisfaction of the patients. Care rendered is geared towards improving the health status of the client measured in terms of satisfaction as perceived by the patient in the context of caring, continuity of care, competence of nurses, and education of patient and significant others. METHOD Research Design The researchers used the descriptive correlational design as it is a more useful tool in finding out the relationship between clinical performance and patient satisfaction on the nursing care rendered by nursing students. No interventions were introduced & performed during the course of this study. In addition, causal relationship between clinical performance & patient satisfaction was not established. Consequently, data gathering efforts were aimed at grouping & ranking patient satisfaction ratings as well as clinical performance grades. Determining the relationship between the two variables is possible only with the use of Spearmans rho, specific for comparison of non-parametric measures (ordinal system). Population and Sample The study was conducted in Cagayan Valley Medical Center. Inclusion criteria for the patient respondents were (1) either male or female; (2) 18 years old and above; (3) under the care of the same assigned nursing student for at least two consecutive days; (4) conscious and coherent; (5) willed to participate; (6) and were able to answer questions indicated; (7) able to read and write. Characteristics of the study participants that deterred the respondents from participating in the study included: (1) were those not under the care of FEU-IN senior nursing students; (2) were under the care of more than one assigned nursing students; (3) were under the care of nursing students from 11 P.M. to 6 A.M.; (4) suffered from severe mental or cognitive disorders; (5)were unable to read and write. On the other hand, the nursing students that were subjected to the study were (1)Level III USL nursing students, (2) had their duty in the said affiliated hospital,(3) solely rendered care to the client, (4) were under the same clinical instructor as with the other nursing students that were involved in the study, (5) and willed to give his/ her consent for the CPET grade released by the clinical instructor that handles the said students on the said hospital. Students who did not meet the above inclusion criteria were not qualified as subjects for the study. The researchers used non-probability purposive sampling design in sample selection. In this design, the researchers decided who will be included in the study. The researchers hand-picked the sample because they knew who among the population was qualified and also this type of sampling design was the most applicable to the study. After the implementation, the researchers had consented 25 nursing students assigned in Cagayan Valley Medical Center that participated in the study. A total of 25 patient satisfaction tools were accomplished and 25 CPET tools were collected from their respective clinical instructor. Table1 showed the demographic characteristics of the patient respondents. Majority of the respondents belonged to Baby Boomers or those who were 45-64 years old which comprised 48% of the

10 respondents. 30% of the respondents were from Generation Net or those that are 18-29 y/o while the remaining 22% of them were from Generation X or those 30-44 y/o. It also showed that 74% of the respondents were females while the remaining 26% were males. TABLE 1 Demographic Characteristics of the Patient Respondents Demographic Profile Age Generation net Generation X Baby Boomers Sex Male Female N= Percentage

Research Instruments The instrument used by the researchers measures the patients satisfaction and the clinical performance of the students. Data on patient satisfaction was gathered through a checklist. The study developed by Risser, consisted a 28- item statements which evaluated the effectiveness of nursing care provided in a hospital ward. The three domains used to evaluate student nursing care were: Technical Professional, Interpersonal Educational and Interpersonal Trusting. Content validity and test retest reliability had been established. The instruments original Cronbach score is 0.912; while on the pilot study done among 5 patients under USL level III student on Cagayan Valley Medical Center., the Cronbach score is 0.54. Patients found a specific item as inapplicable (i.e. The nurse gives good advice over the telephone) and were confused on items having similar thought (i.e. The nurse gives directions at just the right speed and The nurse gives direction too fast wherein the former was retained and the latter was omitted). After revising the tool, the researcher came up with the 26 item checklist from which the contents were approved by the head of the training office in Cagayan Valley Medical Center. Retesting was done on the same hospital and it came up with the Cronbach score of 0.81. The instrument that was developed by the researchers was modified; the term nurse was replaced to nursing student. Demographic data such as name (optional), age and sex were asked in the instrument. In order to measure the patient satisfaction and the domain of nursing care, Likert 5 point scale wherein 1- Strongly agree, and 5- Strongly disagree was used as the basis. The study participants chose the most appropriate rating for each query by putting a check on the box corresponding to the degree of satisfaction felt and nursing care performed. Prior to dissemination, the instrument was translated into Filipino language to break the language barrier among the study participants. The translation done by the researchers was approved by a Filipino professor with a Doctorate degree in Filipino language that ensured the reliability of the content of the translation. The applicability of the statements to student nursing care was assured because the researchers sought the approval of one of the staff nurses and clinical preceptor in an affiliating hospital of USL, in this case, USL-NRMF. Prior to answering the questionnaire, instructions were given to the patients. Entries such as name, age and gender were filled-up. Also, Likert scale was clarified to the patients: 5 strongly agree and 1 as strongly disagree. In terms of measuring the clinical performance of the nursing students, the researchers relied on the Clinical Performance Evaluation Tool (CPET) used by the clinical

11 instructors to grade the students including the four domains (Patient Care Competencies, Enabling Competencies, Enhancing Competencies and Empowering Competencies). The grading system also utilized the Likert scale: 4 Competent and 1 Progress Unacceptable. Validity of this tool had been established since it is being used by the Institute of Nursing in the RLE exposure of the nursing students. Data Collection Procedure Beforehand, the researchers wrote a letter of request to the Dean of CHAS asking for permission for data collection on Cagayan Valley Medical Center. The researchers also asked the level III USL coordinators about the RLE rotation plan, so that the researchers will be able to locate the group of BSN Level III assigned to the said hospital. Also, a letter was made to the hospital administrator through the training officer to inform them of the purpose of the study and be able to gain entry to the health institution and to make the data gathering possible, ensuring mutual agreement and understanding on both the researchers and the hospital administrator. The researchers also requested the hospital administrator that for a particular period of time, only USL level III nursing students will be assigned to handle patients in a particular ward. After the approval, the researchers obtained the names of nursing students and their clinical instructor. The researchers coordinated with the clinical instructor regarding patient assignment to satisfy the inclusion criteria. The schedule of activities of the nursing students was also communicated. In relation to the clinical grades, the researchers sought the consent of level III nursing students on the disclosure of their CPET grades for a particular rotation. Then the researchers wrote a letter of request to the Dean of CHAS asking for permission for gaining access to the grades of the students. Explanation about the purpose of the study was given and assurance of the confidentiality of their grades was made. Afterwards, the researchers coordinated with the Level III BSN coordinators for the RLE grades. Clinical performance grades were obtained from the clinical instructor after the students clinical rotation for processing and analysis purposes. The researcher collected data after gaining entry. Purposive, non-probability design to obtain subjects was used, of which there was no randomization done; homogeneity in terms of the availability of patients whom the nursing student rendering bedside care was utilized by the researchers to control confounding/ extraneous variables. This design was utilized to confirm specific targets that qualified in the inclusion criteria. The primary data gathering was done once for each client. The researchers conducted the survey guided by the checklist they have on hand. Introduction with the client about the purpose of the survey was made. Clients were not forced to participate because they were consented verbally. Then, the researcher proceeded with explaining the instruction in answering each question. Terms that the client understands was used; the researcher assured the client about the confidentiality of the results at the end of the interaction. Statistical Treatment 1. The clinical performance of nursing students in relation to their instructors evaluation of care rendered to the patient respondent was grouped into four domains (Patient Care Competencies, Enabling Competencies, Enhancing Competencies and Empowering Competencies). The mean of clinical performance were assigned according to the four domains. The total mean for each domain of clinical performance was used to derive the general average of patient satisfaction. Mean was used to identify the average of clinical performance from 25 nursing students.

2. The satisfaction ratings of patient respondents were grouped into three domains (Technical Professional, Interpersonal Educational, Interpersonal- Trusting). The mean of the satisfaction rating were assigned according to the three domains. The total mean for each domain of patient satisfaction was used to derive the general average of patient satisfaction. Mean was used to identify the average of the patient satisfaction from the 25 patient respondents. 3. The profile variable of the patient respondents were age and sex. Age was grouped into Baby Boomers, Generation X, and Generation Net. The sex was grouped into Male and Female. The mean score of patient satisfaction were grouped according to what was stated above. 4. The relation between each of the four domains of clinical performance and the three domains of patient satisfaction were treated using the Spearmans Rho to indicate the magnitude of the relationship between the patient satisfaction and clinical performance. 5. The relation between the general average of clinical performance and the general average of patient satisfaction were treated using Spearmans Rho to identify the degree of the relationship between patient satisfaction and clinical performance. Spearmans rho is a non-parametric test that was used because ordinal and nominal numbers were utilized in the study. 6. The relation between the general average of clinical performance and the general average of patient satisfaction was treated using t-test to determine the level of significance between the two variables. In addition, it was used to validate the statistical difference between clinical performance and patient satisfaction. Results and Discussion This chapter presented the findings of the study, their analyses and interpretations. For better understanding, the results were presented in three parts. Part I focused on the Clinical Performance of the nursing students. Part II focused on the Patient Satisfaction rating and its score according to age and gender. Part III discussed the relationship between clinical performance score and patient satisfaction rating. Part I. Clinical Performance Table 2 Clinical Performance of Nursing Students Based on the Four Areas of Competencies Areas of Competency I. II. III. IV. Patient care competencies Enabling Competencies Enhancing competencies Empowering Competencies Mean Interpretation*

Mean Clinical Performance Rating:

Reference Value: Competent= Progress Acceptable= Needs improvement= Progress Unacceptable=

Part II. Patient Satisfaction Table 3 Patient Satisfaction on the Care Rendered by Nursing Students Domains of Nursing Care Technical performance (TP) Interpersonal education (IE) Interpersonal trusting (IT) Mean Patient Satisfaction Rating: Reference Value: Strongly Satisfied= Satisfied= Neutral= Table 4 Mean Difference in Patient Satisfaction according to Demographic Characteristics DOMAIN OF AGE Nursing care TP IE IT Total *Reference Value: 4.51-5.00=Strongly Satisfied 3.51-4.50=Satisfied 2.51-3.50=Neutral 1.51-2.50=Unsatisfied 1.00-1.50=Strongly Unsatisfied Generation net Generation x Baby boomers Male GENDER Female Unsatisfied= Strongly Unsatisfied= Mean Interpretation*

Part III. Relationship between Clinical Performance and Patient Satisfaction TABLE 5 Relationship between the Clinical Performance Rating and Patient Satisfaction Rating Clinical performance x= x= Patient Satisfaction Spearmans Rho Result/ Interpretation p=

*0.05 Level of Significance: Table Value = 0.41