Tulay Sagkal Midilli  ( Manisa Celal Bayar University, Faculty of Health Sciences, Department of Fundamental Nursing, Manisa, Turkey. )
Tulay Kirmizioglu  ( Hafsa Sultan Hospital of Celal Bayar University, Manisa, Turkey. )
Asli Kalkim  ( Ege University Nursing Faculty, Department of Public Health Nursing, Izmir, Turkey. )

Objective: To evaluate affecting factors and the relationship between patients\\\' attitudes towards the nursing profession and perceptions of nursing care.
Methods: This cross-sectional study was conducted at Hafsa Sultan Hospital of Celal Bayar University, Manisa, Turkey, from September to November 2014, and comprised inpatients. Data was collected by using a patient information form, the attitude scale for the nursing profession and the patient perception of hospital experience with nursing care scale. SPSS 21 was used for data analysis.
Results: Of the 604 participants, 320(53%) were female and 266(44%) were aged 60 years or above. Mean satisfaction level on the patient perception scale was 70.79±6.69, and on the attitude scale 176.77±11.63. A positive, statistically significant relationship was found between the two scores (p< 0.01). It was detected that the age for patient perception of nursing care, and gender and education level for patients\\\' attitudes towards the nursing profession were the affecting factors (p<0.05 each).
Conclusion: Nursing care satisfaction and positive attitudes towards the nursing profession increased while patients\\\' perceptions of nursing care improved.
Keywords: Nurse, Care, Attitude, Patient perception. (JPMA 67: 1059; 2017)


Introduction

Nursing care is one of the major health care services that contribute significantly to the patient healing process.¹ In addition, nursing care is the major determinant of patient satisfaction.^1-4 Nursing care depends on theoretical knowledge, systematic scientific methods, a dynamic relationship between nurse and patient, and interaction and participation aimed at satisfying the universal and individual needs of daily life.³
Assessing and addressing individual patient needs is fundamental to the nursing role, but patients and nurses have different priorities and expectations about care. Individual expectations may be difficult to elicit from patients in acute distress or during treatment. Low ratings for satisfaction with care may result from non-adherence of the nurse to a standard of care, inappropriate standards of care or unique patient expectations.² Nurses have 24-hour contact with patients and they are near to them. The way patients perceive nursing care largely depends on their social status, age, educational level, cultural background and previous hospital experiences. Support and respect from nurses, constant availability of nurses and appropriately given responses are the main indicators of satisfaction.¹
Patient satisfaction is defined as the patients\\\' subjective evaluation of their cognitive and emotional reactions as a result of the interaction between their expectations regarding ideal nursing care and their perceptions of the actual nursing care.^3,5,6 Patient satisfaction is the most important indicator of high-quality healthcare and is used for the general assessment and planning of health care. A patient\\\'s satisfaction from admission to the hospital to discharge is formed by his/her perception of nursing care.^6-8 In judging whether or not patients are satisfied, it is necessary to compare their expectations and experiences.²
The valid status of a profession is closely associated with the social image of the group forming that profession. Every profession is perceived by society in a particular way, and the society\\\'s opinion about nursing has either a positive or a negative effect on both the status of the nursing profession and the attitudes towards the members of this profession.⁹ It has been reported that the most important factors affecting a patient\\\'s satisfaction with hospital care is their satisfaction with nursing care. For this reason, it is advantageous and necessary to measure patient satisfaction constantly and to increase quality.^2,10
In the literature on the nursing profession, studies can be found on nursing students\\\' perceptions,^11,12 nursing students\\\' attitudes,^13-15 and nurses\\\' attitudes.^16,17 However, no studies were found on patients\\\' attitudes to the nursing profession other than studies of the perceptions of patients with various diagnoses to nursing care.^18-20 In Turkey, Coban and Yurdagul⁶ and Coban and Kasikci²¹ have carried out studies on the perception of nursing care and on attitudes to the nursing profession. It was suggested that the results of these studies could be applied to different populations. Starting from this suggestion and examining the literature, a study was performed examining the relationship between patients\\\' attitudes to the nursing profession and the perception of nursing care both in Turkey and in other countries.
The current study was planned to determine patients\\\' attitudes towards the nursing profession and perceptions of nursing care, and to determine the relationship between patients\\\' attitudes towards the nursing profession and perceptions of nursing care.


Patients and Methods

This cross-sectional study was conducted at Hafsa Sultan Hospital of Celal Bayar University (CBU), Manisa, Turkey, from September to November 2014, and comprised inpatients. The cross-sectional survey design was used to evaluate affecting factors and the relationship between patients\\\' attitudes towards the nursing profession and perceptions of nursing care.
Patients who were aged 18 years above, hospitalised for two or more weeks, Turkish-speaking, , having no psychiatric history, having a self-reported absence of severe pain, willing to volunteer to complete the scales, and who completed the questionnaire after agreeing to give informed consent to be interviewed were included in this study. The participants had been under treatment for three months before the beginning of the study; this was ascertained by the examination of the hospital records. Non-probability sampling method was used. The sample size was calculated as 358 with a 95% confidence level.
A structured questionnaire was administered to patients by using the patient information form about their socio-demographic characteristics and hospitalisation, and two standardised scales: the patient perception of hospital experience with nursing care (PPHEN) and the attitude scale for the nursing profession (ASNP).
The patient information form included a 10-item self-reported form developed by the researchers after a review of the literature.^6,10 This form consisted of 10 questions to specify the patients\\\' socio-demographic and hospitalisation characteristics.
The PPHEN scale was developed by Dozier et al.² in 2001 in New York, and the validation and reliability studies of the scale for Turkish were carried out by Coban and Kasikci in 2006 in Turkey.⁵ This 15-item instrument, based on Swanson-Kauffman\\\'s framework, is able to detect changes in patients\\\' perceptions of the quality of nursing care when provided in different institutions and when care delivery varies within the same institution of caring. PPHEN has 15 items, a one-factor structure and is a five-point Likert scale Cronbach\\\'s alpha reliability coefficient was 0.92, and item-total item-point correlations were between 0.36 and 0.74. In addition, the test-retest correlation value was 0.90. Participants can score a minimum of 15 and a maximum of 75 points on the scale and the cut-off point is 45. A score of 45 or above shows positive perception of nursing care.⁵ In this research Cronbach\\\'s alpha was 0.92.
The ASNP scale was developed by Coban and Kasikci in 2010 in Turkey.²¹ ASNP consists of 40 items across the following three domains: properties of the nursing profession (18 items), preference for the nursing profession (13 items) and general position of the nursing profession (9 items). The ASNP is a five-point Likert scale and items 21, 23, 25, 26, 28, 30, 34 and 38 are reverse scored. Total score of the scale is 40-200. If the total score is high, the positive attitude is also high. Giving three points or above shows a positive attitude towards the nursing profession. The value of the Cronbach\\\'s alpha for the total scale was 0.91. The ASNP has been determined to be highly valid and reliable, and an adequate measuring instrument to determine attitudes towards the profession.²¹ In this research Cronbach\\\'s alpha for the total scale was 0.828.
Permission to use the PPHEN scale and ASNP in this study was obtained from the Turkish developers^5,21 before conducting the study.
After approval from the institutional review board, a registered nurse, one of the researchers, administered the patient information form and the two scales to the hospitalised patients meeting inclusion criteria. Data for the study was collected by her through face-to-face interview in the patients\\\' room.
SPSS 21 was used for data analysis. Descriptive statistics were used to describe patients\\\' socio-demographic characteristics. Independent t-test, one-way analysis of variance (ANOVA) and Pearson\\\'s product-moment correlation were used to assess associations between scores and socio-demographics variables. Multiple linear regression analysis was used to identify the impacts of variables between patients\\\' attitudes towards the nursing profession and perceptions of nursing care. P<0.05 was considered significant.


Results

Of the 5,275 patients, 604(11.5%) were selected. Of them, 320(53%) of the patients were female, and 266(44%) were aged 60 years or more with an overall mean age of 54.42±16.81 years, 477(79%) were married, 399(66.1%) were primary school graduate and 310(51.3%) were living in a small town. It was found that 474(78.5%) of them were not working and 362(59.9%) had low income. Besides, 477(79%) patients had been hospitalised before, 239(39.6%) three or more times, and 495(82%) were accompanied by a companion in the hospital.
Patients\\\' mean item scores on the PPHEN scale varied between 4.23±1.13 and 4.88±0.36, and the mean total score was 70.79±6.69. Patients\\\' mean total score on ASNP was 176.77±11.63. Mean ASNP subscale scores were 88.60±2.25 for characteristics of the nursing profession, 52.33±10.48 for preference for the nursing profession, and 35.83±1.98 for the general position of the nursing profession.
A significant positive correlation was found between patients\\\' PPHEN scale and ASNP (r= 0.226, p<0.01). There was a significant correlation between ASNP subscales and the PPHEN scale. This was between the PPHEN scale and characteristics of the nursing profession (r= 0.098, p<0.05), between the PPHEN scale and preference for the nursing profession (r= 0.187, p<0.01), and between the PPHEN scale and the general position of the nursing profession (r= 0.227, p<0.01) (Table-1).


Patients\\\' attitudes towards the nursing profession and perceptions of nursing care were compared with affecting factors. A significant relationship was found between patients\\\' age groups, gender, education level, place of residence, income, working status, and number of hospitalisations and the PPHEN scale and/or ASNP and its subscales (p <0.05). No significant relationship was found between patients\\\' marital status, previous hospitalisation experience and whether they had a companion and the PPHEN scale and ASNP and its subscales (p>0.05). Multiple regression analyses were calculated in order to explore the relationships between patients\\\' the PPHEN scale, ASNP and variables. Assumptions of homogeneity of variance, linearity, normality, singularity, multicollinearity and heteroscedasticity were all tested and were found to be valid. Multiple regression showed that the combination of variables was significantly related to the PPHEN scale (F=9.677, p<0.001, R2 =0.08). Significant predictors of patients\\\' perceptions of nursing care included patients\\\' age and ASNP (Table-2).

Multiple regression showed that the combination of variables was significantly related to ASNP (F=24.905, p<0.001, R2 =0.20). Significant predictors of patients\\\' attitudes towards the nursing profession included patients\\\' gender, education level and PPHEN (Table-3).




Discussion

An investigation was made of the perceptions of hospitalised patients of nursing care. The level of perception with nursing care of patients in the study was found to be high. Patient satisfaction is the most important indicator of quality health care, and provides very important feedback for the evaluation of nursing care and its quality.⁷ In a study performed in Turkey as in our study, patients\\\' perception of nursing care was high.⁸ However, in some studies,^6,10 patients\\\' mean PPHEN scores were found to be low and their levels of satisfaction were also evaluated as low. In studies performed in other countries, similar to our study, patients\\\' opinion of nursing care was high.^1,22,23 These differences in patient perception of care may arise for a number of reasons, including population difference, differences in the evaluation scales of perception of nursing care, and differences in patients\\\' expectations of care.
An investigation was made in this study of patients\\\' attitudes to the nursing profession. In Turkey, studies have generally been carried out on views and attitudes towards the nursing profession in nurses^17,21 and in nursing students.^24,25 In other countries, studies^13,14 have studied the attitudes of nursing students to the nursing profession. In Turkey, however, no studies of patients\\\' attitudes to the nursing profession were encountered. Since the ASNP which we used in this study was a scale which could be used with either patients or nurses, it was possible to investigate the attitude of patients to the nursing profession, and it was found to be very positive. When ASNP subscales were examined, it was found that attitudes to characteristics of the nursing profession, preference for the nursing profession and general position of the nursing profession were also positive. That is, patients in this study displayed positive attitudes to the nursing profession. Nursing is a professional occupation which can protect and raise the level of human rights. The importance of a profession is evaluated by the importance accorded by society to that profession. As professions affect social development, social dynamics are also a factor in the positive development of professions. The value of a profession is measured by the effectiveness of the services which it provides to society. The provision of services is closely linked to the level of knowledge, views and expectations of society in relation to these services. It is felt that a positive attitude on the part of patients towards the nursing profession springs from a positive nurse-patient relationship, a positive image of nursing, and from patients\\\' positive expectations of nurses.
As the perception of patients in this study became more positive, so did their attitudes towards the nursing profession. Similarly, a positive relationship was found between patients\\\' perception of nursing and their attitudes to nursing in a study.⁶ The negative attitude towards the nursing profession increases as patients\\\' negative perceptions increase. For patients in our study, the more they showed a positive attitude to the nursing profession and the more positive their perception of nursing care, the more their patient satisfaction increased. Thus, a satisfied patient tends to return more frequently when in need of health care. Moreover, a satisfied patient is more willing to recommend to others the hospital that provided his or her care.³
The support which a patient receives from a nurse, the respect shown to patients by nurses, positive behaviour towards patients, giving clear answers to questions, always being accessible, in short professional behaviour, are all important factors in patient satisfaction. At the same time, patients\\\' levels of perception of nursing care are also closely linked to factors such as their social position, age, education level and cultural background. Aged 40 and over of patients in our study was a factor affected PPHEN. In other studies, the level of satisfaction with services given was found to increase with patients\\\' age.^8,10 Patient satisfaction may be lower in young patients because their expectations of nursing care are higher and their conformity to nursing and medical recommendations is lower. In addition, older patients may have previously had worse experiences, and therefore they are more satisfied with the services which they are currently receiving.
On the other hand, female patients and patients educated to university level were factors affected ASNP. It is thought that the reasons for this conclusion of our study may be that until ten years ago nursing in Turkey was a profession reserved for women, there is greater interest in the nursing profession among women, and it is easier for women to communicate with nurses. This finding was consistent with a study²² which reported that gender seemed to be unimportant in patient satisfaction. However, other studies^1,8,10 reported higher satisfaction among females than males. The different results between the studies may be related to the different populations in the studies, or to patients\\\' expectations. Also, similarly, it was found in many other studies that university educated patients were not satisfied with nursing care.^1,5 One study²² reported that the education level of patients did not affect their satisfaction with nursing care. Another study³ explained that patients with higher levels of education probably made greater demands on nursing care, which may lead to expectations of more information and education. Different results between studies can be related to the conditions of the application environments and whether patient expectations were met or not. Also, it is thought that patients with a high education level have access to information on the duties of nurses and are therefore not satisfied with the way nurses carry out their own care in the light of this knowledge, and thus do not display a positive attitude to the nursing profession in general.
The mean PPHEN scores of patients living in small towns were higher than those of patients living in the provincial capital. Similarly, it was found in studies^26,27 that there was a significant correlation between patients\\\' place of residence and their satisfaction with nursing care. In contrast to the results of these studies, it was found in certain studies^8,28 that patients\\\' place of residence did not affect their satisfaction with nursing care. One study²⁸ explained that no matter where the individuals lived, whether it was rural or urban, their evaluations of nursing care were similar to each other because human necessities were universal. It was found in our study that the patient satisfaction levels of those coming from rural areas were higher than those of patients who came from the provincial capital or small towns. It is thought that this may be because the study was carried out in a university hospital in the provincial capital where nursing care services were good, and the patients were comparing this with the care given in rural hospitals and basing their expectations on this.
It was seen that patients whose income levels were low displayed a positive attitude to the nursing profession. It is thought that the reason for this may be that people living in difficult economic conditions may prefer the nursing profession as one which has an important place in society. However, no significant difference was found in our study between patients\\\' PPHEN scales and their income levels. Similarly, it was found in studies^27,28 that income and expenditure levels did not affect satisfaction with care. However, it was established in some studies^5,8,26 that levels of satisfaction with nursing care in patients whose income was equal to or greater than their expenditure was greater than that of patients whose income was low. Thus, different studies have arrived at different conclusions regarding patients\\\' income and expenditure status. Normally, it would be expected that patients with low incomes would be more satisfied with the services provided. It may be that this is because those whose income status is equal can more easily meet their needs and so their expectations are low.
The mean scores on ASNP and preference for the nursing profession of patients who were not working were higher than those of working patients, and the difference was found to be significant. The reason for this is thought to be that most patients who were not working were retirees, and old people had a more sympathetic view of the nursing profession.
The mean scores for PPHEN, ASNP and preference for the nursing profession of patients who had been hospitalised three or more times were higher than those of patients who had been hospitalised once or twice. According to this, it was concluded that as the number of stays in hospital increased, satisfaction with nursing care increased and expectations lowered. In contrast to our study, it was concluded in other studies^26,27 that the number of stays in hospital did not affect satisfaction with nursing care.
The current study was not without its limitations. It was conducted at only one university hospital, therefore its results cannot be generalised to all university hospitals. In the future, it would be interesting to compare private with public sectors including more than one hospital in each sector. Data for the study was collected during face-to-face interviews from patients, which might have affected the reliability of answers.
The results suggest that a further study should be carried out to determine patients\\\' perception with nursing care and their attitudes to the nursing profession at different hospitals and in different population groups.


Conclusion

Patients\\\' perception of nursing care and attitudes towards the nursing profession were positive. As patient perception of nursing care became more positive, so did their attitudes to the nursing profession. In addition, this study also demonstrated that the age for patient perception of nursing care, and the gender and education level for patients\\\' attitudes towards the nursing profession were the affecting factors.

Disclaimer: The study was presented as an oral presentation in Celal Bayar University Graduate School of Health Sciences, International Graduate Education Congress, held from May 12 to 14 2016 in Manisa, Turkey.
Conflict of Interest: None.
Source of Funding: None.


References

1. Dzomeku VM, Ba-Etilayoo A, Perekuu T, Mantey RE. In-patient satisfaction with nursing care: a case study at Kwame Nkrumah University of Science and Technology Hospital. Inter J Res Med Health Sci. 2013; 2:19-24.
2. Dozier AM, Kitzman HJ, Ingersoll GL, Holmberg S, Schultz AW. Development of an instrument to measure patient perception of the quality of nursing care. Res Nurs Health. 2001; 24:506-17.
3. Johansson P, Oleni M, Fridlund B. Patient satisfaction with nursing care in the context of health care: A literature study. Scand J Caring Sci. 2002; 16:337-44.
4. Agosta LJ. Patient satisfaction with nurse practitioner-delivered primary healthcare services. J Amer Assoc Nurse Pract. 2009; 21:610-17.
5. Coban IG, Kasikci M. Reliability and validity of the scale of patient perception of hospital experience with nursing care in a Turkish population. J Clin Nurs. 2010; 19:1929-34.
6. Coban IG, Yurdagul G. The Relationship between Cancer Patients\\\' Perception of Nursing Care and Nursing Attitudes towards Nursing Profession. APJON. 2014; 1:16-21.
7. Chan JN, Chau J. Patient satisfaction with triage nursing care in Hong Kong. J Adv Nurs. 2005; 50:498-507.
8. Icyeroglu G, Karabulutlu E. Determining the level of satisfaction of patients in terms of nursing. Firat Saglik Hizmetleri Dergisi. 2011; 6:67-81.
9. Eser I, Khorshid L, Denat Y. Perception of nursing profession. Cinar Dergisi. 2004; 10:31-9.
10. Akgün SZ, Kardas ÖF. The levels of satisfaction of patients in terms of nursing. Izm Univ Med J. 2014; 2:1-10.
11. Zhang MF, Petrini MA. Factors influencing Chinese undergraduate nursing students\\\' perceptions of the nursing profession. Int Nurs Rev. 2008; 55:274-80.
12. Sand-Jecklin KI, Schaffer AJ. Nursing students\\\' perceptions of their chosen profession. Nurs Educa Persp. 2006; 27:130-6.
13. Al-Omar BA. Knowledge, attitudes and intention of high school students towards the nursing profession in Riyadh city, Saudi Arabia. Saudi Med J. 2004; 25:150-5.
14. Poreddi V, Ramachandra, Konduru R, Swamy P, Math SB. A study to assess attitudes and perceptions of nursing profession among undergraduate nursing students. Nurs J India. 2012; 103:6-8.
15. Shukri RK, Bakar BS, El-Damen MA, Ahmed SM. Attitudes of students at Sultan Qaboos University towards the nursing profession. Sultan Qaboos Univ Med J. 2013; 13:539-44.
16. Coverston CR, Harmon KR, Keller ER, Malner AA. A comparison of Guatemalan and USA nurses\\\' attitudes towards nursing. Int Nurs Rev. 2004; 51:94-103.
17. Altuntas S, Baykal U. Factors influencing Turkish hospital nurses\\\' attitudes towards their profession: A descriptive survey. Contemp Nurse. 2010; 35:114-27.
18. Verhaeghe N, Maeseneer JD, Maes L, Heeringen CV, Annemans L. Health promotion in mental health care: perceptions from patients and mental health nurses. J Clin Nurs. 2013; 22:1569-78.
19. Rchaidia L, Casterle BD, Verbeke G, Gastmans C. Oncology patients perceptions of the good nurse: an explorative study on the psychometric properties of the Flemish adaptation of the Care-Q instrument. J Clin Nurs. 2012; 21:1387-400.
20. Garrino L, Curto N, Decorte R, Felisi N, Matta E, Gregorino S, et al. Towards personalized care for persons with spinal cord injury: a study on patients perceptions. J Spinal Cord Med. 2011; 34:67-75.
21. Coban IG, Kasikci M. Development of the attitude scale for nursing profession. Int J Nurs Pract. 2011; 17:518-24.
22. Abdel Maqsood AS, Oweis AI, Hasna FS. Differences between patients\\\' expectations and satisfaction with nursing care in a private hospital in Jordan. Int J Nurs Pract. 2012; 18:140-6.
23. Zhao SH, Akkadechanunt T. Patients\\\' perceptions of quality nursing care in a Chinese hospital. Int J Nurs Midwifery. 2011; 3:145-9.
24. Tan M, Yuncu S, Sentürk Ö, Yildiz Ö. Point of view on nursing of university students. J Anatolia Nurs Health Sci. 2007; 10:22-9.
25. Dinc S, Kaya Ö, Simsek Z. Knowledge, opinion and expectations of students in Harran University School of Nursing. J Anatolia Nurs Health Sci. 2007; 10:1-9.
26. Arslan S, Nazik E, Tanriverdi D, Gürdil S. Determining the level of satisfaction of patients in nursing care and health services. TAF Prev Med Bull. 2012; 11:717-24.
27. Sise S. Satisfaction of patients with nursing care. Kocatepe Med J. 2013; 14:69-75.
28. Kaya F, Ozcan A, Yaz M. Comparing communication and empathic ability levels of nurses with patients\\\' perception of nursing care. PJPHM. 2013; 1:1-8.