Cheng-Shung Wng,Mei-Zhen Zho,Tie-Ying Zeng,*

aSchool of Nursing,Huazhong University of Science and Technology,Wuhan,Hubei 430030,China

bNursing Department,Tongji Hospital Af fi liated to Tongji Medical College of Huazhong University of Science and Technology,Wuhan,Hubei 430030,China

Review article

Progress in applying patient experience in nursing quality improvement*

Cheng-Shuang Wanga,Mei-Zhen Zhaob,Tie-Ying Zengb,*

aSchool of Nursing,Huazhong University of Science and Technology,Wuhan,Hubei 430030,China

bNursing Department,Tongji Hospital Af fi liated to Tongji Medical College of Huazhong University of Science and Technology,Wuhan,Hubei 430030,China

a r t i c l e i n f o

Article history:

Patient experience

Service quality

Quality improvement

Quality standards

Precautions

Background:Improving and sustaining the quality of nursing care is an intractable and persistent challenge.The patient experience of nursing care can give a different perspective on nursing quality and help clinicalnursing staff to direct quality improvement.Attempts to identify what is patient experience, the relationship with nursing care,and the application of patient experience in nursing quality improvement practice,in order to provide advices for constructing the quality standards and quality improvement strategies of nursing care.

Methods:We conducted a literature review of original research publications.The database platforms Pubmed,Web of Science,China National Knowledge Infrastructure(CNKI)and Wanfang were searched from inception until end of August 2015.After screening retrieved articles,40 sources(articles and organizational websites)were selected for analysis for the connotation,development and application of patient experience in nursing quality researches.

Results:Our study identi fi ed several concepts about patient experience,roughly sorted out the development path of patient experience in worldwide and the application of patient experience in nursing quality improvement.It points out four precautions when applying patient experience in nursing quality improvement,which are differentiating patient satisfaction and patient experience,choosing appropriate data collection method and appropriate feedback time,and the last but the most important,applying theories to actual clinical practice.

Conclusions:Professional indexes are important to maintain the care quality,but it cannot fully re flect quality of nursing care,which needs patient experience as the supplement.Nursing staffs need to make more efforts to enhance patient's nursing care experience,and apply the research results to clinical practice,and fi nally make patient-centered care come true.For future study,the evaluation system and management strategies about patient experience need to be developed to guide nursing quality improvement.

©2017 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction

Patient experience,one theme of the quality of care,1is consistent with the idea of“patient-centered care”,and it has been considered an important indicator of medical service quality.In recent years,it has been playing an increasingly signi fi cant role in the quality assessment and quality improvement of medical care and has been increasingly used worldwide.The International Joint Commission includes patient experience as an evaluation criterion in the accreditation of healthcare organizations.2The National Health and Family Planning Commission and State Administration of Traditional Chinese Medicine is implementing a plan called“To further improve the medicalservice action”to improve the patient experience in China.However,there is limited research on predicting and improving the nursing quality and patientexperience in China.This article reviews the progress and application of the patient experience in nursing quality improvement in recent years to provide suggestions for developing nursing quality standards and strategies for nursing quality improvement.

2.Connotation and development of patient experience

2.1.Connotation of patient experience

The concept of patient experience was proposed in the 1980s.3The National Health Service Constitution(NHS)for England considers a good patient experience as the basic element of good quality of care.4Shale et al5asserted that the patient experience included the physicalillness experience,service experience and life experience with the disease.Additionally,the Beryl institute defi nes the patient experience as“the sum of allinteractions,shaped by an organization's culture,that in fluence patient perceptions across the continuum of care”,which includes four key elements: interaction,culture,perceptions and continuum of care.6To date, there is no uniform de fi nition ofthe patientexperience because itis multi-structured and multi-dimensioned.3Most researchers tend to agree that the patient experience has the following characteristics:occurs throughout the process of care,is aligned with patient-centered care principles,emphasizes the patient and their families'expectations,focuses on individualized care,and incorporates more than patient satisfaction.7

2.2.Development of the patient experience

In the last two decades,the patient experience has received special attention in medical care.Substantial research on quality evaluation and improvement of medicalcare based on the patient experience has been performed.The framework,quality standards and clinical guidelines8of nursing care were established by the Institute of Medicine(IOM),9Picker Institute,10Picker Institute Europe,11and National Quality Board(NQB)of England.12They are also applied in clinical practice to improve the quality of clinical care.13,14

Since the 1980s,China's healthcare institutions and related researchers have mainly performed studies on patient satisfaction to improve the quality of care,but there have been few reports on the patient experience.Tian et al15used the SERVQUAL model and the concept of patient experience to establish medical services,such as quality key indicator systems,and formulated the patient experience questionnaire,which includes six dimensions, namely,tangibles,reliability,responsiveness,assurance,empathy and continuity,and 50 items with factual options.In 2015,the implementation of the“To further improve the medical service action”plan placed the patient experience improvement project on the health care reform agenda.Patient experience has become increasingly prominent in healthcare quality improvement efforts.

3.Application of patient experience in nursing quality improvement

3.1.Relationship between patient experience and nursing quality

IOM considered good care quality as care in which healthcare institutions made use of existing expertise to provide continuous service for individuals or groups as well as improve patients' health outcomes.16Chinese nursing researchers generally believe that quality of care is the synthesis of the effect of nursing care technology and the extent of the satisfaction of patients'needs.In 2012,the good quality of nursing service action advocated by the Ministry of Health of China stressed that all nursing activities should be performed with the patient-centered principle.Nursing care activities are centered on patient,and the above de fi nitions and policies re flect that quality improvement should be based on patient needs and expectations.However,the demands and expectations directly expressed by patients are not always reasonable,which may interfere with nursing care content,and quality improvement is dif fi cult to achieve.However,the patient experience is evaluated with a post-event survey that re flects whether patients'expectations are satis fi ed after nursing services are completed,which can make the patient's needs and expectations be described as more reasonable.Patient experience not only re flects the patient's perception and concerns with nursing care but can also expose the inadequacies in both the process of nursing activities and the construction of the medical environment.In care quality assurance,patient experience is necessary to the supervision and evaluation of current quality improvement projects.

3.2.Research status on patient experience in nursing quality improvement

When the patient experience was applied to guide health care quality reform,studies on re fi ning the content of the patient's nursing experience gradually emerged,which covered a number of speci fi c nursing care areas.The factors in fluencing the patient experience were expanded and induced by collecting patient's opinions on nursing care related activities in hospitals.Environment,staff characteristics,direct nursing hours,patient involvement,information,communication skills,response time,empathy, respect for family members and awareness of patient needs were considered as predictors of a good patient experience.17e21Meanwhile,Rantz et al22,23designed the Observable Indicators of Nursing Home Care Instrument(OIQ)based on the elderly resident perceptions.The instrument contains multidimensional aspects of nursing home care quality,such as the staff,care,family involvement,communication,homelike feeling and environment.Additionally,the conclusions of Rantz'study were supplemented with the nurse e patient interaction by Nakrem et al.24Trust,being treated as a person and self-esteem were emphasized in home care as well.25All efforts have been made to improve the patient experience in clinical practice,and Pemberton et al26successfully improved the patient experience and quality of care through establishing a quality improvement modelbased on prior scienti fi c studies.

Researchers in China have also made unremitting efforts to improve the quality ofnursing care.Yang et al27combined nursing home care quality indicators with the environment,nursing professional competence,quality management,basic human rights, caregivers'attitudes,social interaction and resident's needs being met based on the views of residents.In recent years,mainland scholars have mainly explored the feasibility of using patient expectations and perceptions to guide nursing quality improvement in generalhospitals.The perceived nursing service instrument was formulated based on the Two-factor Theory and SERVQAUL models to compare the patient expectations and patient perceptions.28Studies on constructing theoretical nursing care quality evaluation systems29,30and describing current nursing care quality31were widely conducted.Chang et al32used the nursing quality criteria proposed by IOM as a framework and built an inpatient satisfaction scale that contains 11 dimensions and 47 items.Additionally,4 Likert-type factual questions were used in the investigation,and respondents were asked to answer questions about the nursing activities they experienced.Compared with other countries,China rarely explores themes related to a patient's nursing care experience,and the experiences in nursing homes and community nursing care also require further study.In addition,the effect of applying research results to clinical nursing quality improvement is rarely reported.We need to pay close attention to these features in the future.

4.Precautions for applying patient experience in nursing quality improvement

4.1.Patient experience vs.patient satisfaction

For a long time,the concepts ofpatient experience and satisfaction were dif fi cultto distinguish,and some researchers thoughtthat patientsatisfaction is equivalentto the patientexperience.However, the meaning of the patient experience goes far beyond patient satisfaction.33Patient satisfaction describes the patient feelings about nursing issues.The results ofpatient satisfaction surveys can indicate whetherpatients are satis fi ed with nursing issues,butwhat patients are actually concerned about has been ignored.For this reason,satisfaction reports do not imply the causes of unsatis fi ed conditions,and they cannot direct what we can do to improve patientsatisfaction.By contrast,the patientexperience is the patient's perception aboutcaring behavior based on the statementoffacts,34which can demonstrate de fi ciencies in the process of nursing care. We can clarify factors that in fluence the patient experience and determine nursing service quality defects according to the realexperiences and feelings provided by patients.21Patient experience surveys can do better than patient satisfaction in helping nursing managers improve the nursing quality.

4.2.Data collection method

To fi nd the direction of nursing quality improvement,quantitative and qualitative research methods are used.The questionnaires were nearly self-designed in quantitative surveys,which contained factualoptions(yes/no/no need,or fact statement),and they were analyzed using relevant statistical methods.35The analyzing processes of quantitative studies are simple,and the results can be replicated.However,the limitation of quantitative studies is that they can rarely explore new themes of patient experience because most items in the questionnaires were derived from prior studies and the researchers'work experiences. Qualitative studies were conducted through focus groups and personal interviews,17,19and patient interview data can be analyzed in more depth,helping us comprehensively understand the connotation of patient experience.However,the results of qualitative studies are regional and are therefore dif fi cult to replicate,and the research process is relatively cumbersome.36Therefore,if we want to improve nursing quality,we need to describe the patient experience through qualitative with quantitative research methods.To obtain the connotation themes of patient experience through qualitative interviews,nursing quality defects were searched and the effect of nursing quality improvement measures was evaluated by questionnaire-based quantitative investigations.

4.3.Experience feedback time

There is no de fi nite conclusion about the best feedback time to obtain the patient experience.In general,feedback is preferably collected immediately aftera patienthas experienced a certain type ofcare.However,we recommend caution for temporary emotional fluctuations generated from other reasons that may confuse the patient experience.Feedback time delays can make patients calm down to think aboutwhetherthe nursing care they received is good or bad.However,ifthe data collection time is delayed too long,it is likely to cause recall bias,and the patients'perceptions of their experiences will be slowly forgotten.37Considering the above factors,the data collection time needs to be appropriately extended; however,“appropriately”,it is not easy to grasp.Edwards et al38chose to collect the patient experience within 2 weeks after the patient was discharged from the hospital.Additionally,the data of the Hospital Consumer Assessment of Healthcare Providers and Systems(HCAHPS)were collected in a range oftime from 48 h after admission to 42 days after discharge.39To improve the credibility of the research results and obtain more reliable patient experiences, the feedback time must be considered.

4.4.Directions for nursing quality supervision

Many studies focus on the development of patient satisfaction, nursing behavior perception and patient experience assessment tools.15,28However,in the complex work of improving quality of care,we also need to create suitable quality improvement strategies to enhance the patient experience.Focusing on the patient experience throughout the whole process of care and creating management strategies are the concrete implementations of patient-centered principles in nursing care.Scienti fi cally and practically applying theories to actualwork rather than floating on the surface seems to be more meaningful to nursing quality improvement.At the same time,we need to realize that the action for improving the patient experience not only requires patient involvement,it requires the active participation of nursing staff members26who are an integral part in the process of nursing quality reforms.

5.Conclusions

In conclusion,nursing staff have been striving for nursing quality improvement for a long time,and they have produced a series of nursing quality sensitive indexes.40However,these professional indexes do not fully re flect the quality of care,which requires patient experience as a supplement.However,studies on patient nursing care experiences are rare in China,and the nature and connotation of the patient's nursing care experience has not previously been reported.Therefore,to further improve the quality ofnursing care,nursing staffneed to make more efforts to enhance patients'nursing care experiences and apply the research results to clinical practice,which will eventually make patient-centered care possible.

Conflicts of interest

Allcontributing authors declare no con flicts of interest.

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How to cite this article:Wang C-S,Zhao M-Z,Zeng T-Y.Progress in applying patient experience in nursing quality improvement. Chin Nurs Res. 2017;4:1e4. http://dx.doi.org/10.1016/ j.cnre.2017.03.001

20 June 2016

*This project was supported by General Project of the National Natural Science Foundation of China(No.71573097).

*Corresponding author.

E-mail address:984451641@qq.com(T.-Y.Zeng).

Peer review under responsibility of Shanxi Medical Periodical Press.

http://dx.doi.org/10.1016/j.cnre.2017.03.001

2095-7718/©2017 Shanxi MedicalPeriodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons. org/licenses/by-nc-nd/4.0/).

Received in revised form 14 August 2016

Accepted 5 December 2016

Available online 30 March 2017