Nursing Care

Hospitals were recruited from nine Chinese provinces/municipalities/autonomous regions which spanned all eight economic zones in mainland China. The survey method, which has been described in detail previously
[14 (link)], involves a stratified and purposive sample that recruited 20 hospitals from each of eight geographic areas, except for one research site where 21 hospitals were recruited. Equal numbers of level 2 hospitals (300 to 500 beds) and level 3 hospitals (over 500 beds) were drawn. In addition to the differences in bed size, level 3 hospitals, unlike level 2 hospitals, are usually major hospitals with high technology capacity and resources to care for more complex patients. The hospital sample was stratified to represent different urban community contexts (municipality, capital cities, and non-capital cities) and different sponsorship (provincial hospitals, municipal hospitals, and university hospitals). The response rate (agreement to participate) at the hospital level was 96%, and the few hospitals that refused to participate among the hospitals that were initially sampled were replaced by hospitals at the same level and in the same location categories. Thus while China is a very large country, the systematic sampling of hospitals is believed to have resulted in a hospital study population reasonably representative of level 2 and level 3 hospitals that care for patients with complex medical conditions.
After hospital selection, at least four units were randomly chosen from all the medical, post-operative surgical, and ICUs in each hospital. All registered nurses from the selected units, excluding nurse managers, were informed of the purpose of the study and its voluntary nature, and were invited to participate by a designated research nurse in each hospital. Ninety-five percent of sampled registered nurses (RNs) completed the confidential surveys which were sent unopened to the research team at Sun Yat-sen University (SYSU) for analysis
[14 (link)].
In each selected unit patients with at least 3-day inpatient stays were also sampled on a designated day with a minimum target of 5 patients per unit, and 30 patients from each hospital. A 3-day stay has been established by previous research to result in patient satisfaction assessments with predictive validity
[17 (link),18 (link)]. The overall response rate for the patient survey was 89%, with a total of 6,494 patients from 181 hospitals, and an average of 36 patients per hospital.
The China nurse survey was based on the well-designed and rigorously vetted University of Pennsylvania Multi-State Nursing Care and Patient Safety Study
[19 (link)]. The patient survey instrument was the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey
[20 (link)]. Both survey questionnaires were translated to Mandarin and back-translated to English by two bilingual nursing researchers independently. Items that were not culturally relevant to Chinese nurses were removed or revised. Before utilization, both questionnaires were pilot tested in one Chinese hospital with high content validity
[21 (link)-23 ].
A hospital survey was also sent to the department of nursing in each participating hospital to collect information on hospital characteristics such as teaching status, hospital level designation, number of inpatient beds, and number of medical and surgical units and ICUs. The three surveys were linked by unique hospital identification numbers prior to the data analyses.

The questionnaire included basic demographic information (e.g., sex, age, profession, education level, marital status, and economic condition) and relevant clinical characteristics (e.g., diagnosis, chemotherapy session, number of hospitalizations, satisfaction with medical and nursing care).