A comparison study of nursing care quality in different working status nursing staffs: An example of one local hospital.

Abstract

To reduce costs, many hospitals are trying to adopt strategies to contract out their nursing workforce. The purpose of this study is to compare the quality of health care among the following three categories of nursing workforces in public hospitals: outsourced nurses, permanently employed nurses and contracted nurses compensated based on hours worked. The research sample included 300 patients cared for by 78 nurses in insurance wards in a local public hospital. Four methods were used to evaluate care quality. They included examining medical records, interviewing nurses, observing, and interviewing patients. The study found the best care quality was delivered by permanently employed nurses followed by that delivered by contracted nurses. The worst care quality was delivered by outsourced nurses employed by agency companies contracted to the public hospital. Care quality dimensions that were statistically significant among three categories of nurses included total quality of nursing care, nursing care planning, nursing instruction, and nursing evaluation.

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A Comparison Study of Nursing Care Quality in
Different Working Status Nursing Staffs:
An Example of One Local Hospital
Shiou-Hua Wu ? Jwo-Leun Lee*
ABSTRACT: To reduce costs, many hospitals are trying to adopt strategies to contract out their nursing workforce.
The purpose of this study is to compare the quality of health care among the following three
categories of nursing workforces in public hospitals: outsourced nurses, permanently employed
nurses and contracted nurses compensated based on hours worked. The research sample included
300 patients cared for by 78 nurses in insurance wards in a local public hospital. Four methods were
used to evaluate care quality. They included examining medical records, interviewing nurses,
observing, and interviewing patients. The study found the best care quality was delivered by
permanently employed nurses followed by that delivered by contracted nurses. The worst care
quality was delivered by outsourced nurses employed by agency companies contracted to the public
hospital. Care quality dimensions that were statistically significant among three categories of nurses
included total quality of nursing care, nursing care planning, nursing instruction, and nursing
evaluation.
Key Words: outsourced nurses, contracted nurses, permanently employed nurses, quality of nursing care.
Introduction
The Taiwan government has encouraged competition
in the health care market for over a decade and imple-
mented the National Health Insurance (NHI) scheme in
March 1995. The national medical expenditure has been
gradually increasing for years and has become a heavy
financial burden on the government. In order to contain
medicalexpenditures,theBureauofNationalHealthInsur-
ance (BNHI) aggressively promoted fixing the budget of
every single hospital since 2000, and subsequently intro-
duced many other financial deflation strategies. Financial
liabilities were therefore gradually transferred from the
BNHI to each individual hospital.
Government-owned public hospitals, as well as pri-
vatefor-profitandnon-for-profithospitals,werefacingthe
changing context of the medical industry and the impact of
NHI financial deflation strategies. Although public hospi-
talsarepartlysupportedbygovernmentbudgets,privatiza-
tion and self-sustaining policies have led to gradual reduc-
tion of government budgets. Thus, organizational reen-
gineering, corporate-type management, reducing running
cost and upgrading performance are measures targeted
toward dealing with these challenges.
In order to reduce manpower costs, the case hospital
inthisstudyimplementedorganizationalreengineeringin
2003. The number of permanently employed nurses was
reduced from 81 to 67, with 40 nurses contracted as tem-
porary employees by the case hospital. However, the
nurses were not sufficient to deal with the increasing
demand. The case hospital thus flexibly hired 20 out-
sourced nurses supplied by another organization con-
tracted by the case hospital. At present, outsourced nurses
are not widely accepted by hospitals in Taiwan. The case
hospital is the first pioneer public hospital with regard to
outsourcing nursing needs.
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JournalofNursingResearchVol.14,No.3,2006
RN, MS, Chief of Nursing Department, WanCiao Veterans Hospital; *PhD, Associate Professor, Department of Public Health, China
Medical University.
Received: December 23, 2005
Revised: May 24, 2006
Accepted: June 26, 2006
Address correspondence to: Jwo-Leun Lee, No. 91, Hsueh-Shih Rd., Taichung 40402, Taiwan, ROC.
Tel: 886(4)2207-5170; Fax: 886(4)2203-1108; E-mail: jllee@mail.cmu.edu.tw

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Mostly recent graduates from junior nursing schools,
outsourced nurses have relatively low salaries. The em-
ployer hospitals must spend more clinical manpower to
regulate these young nurses and hence take on increased
management costs. Other costs include the departure of
experiencednurseswhomayhavemanyyears’workexpe-
rience in the hospital. Yet as these young nurses gain expe-
rience, the low pay can be expected to encourage them to
leave the hospital. All of these situations make the study of
nursing care quality important for evaluating policy.
This study aims to understand the nurse caring quali-
ties at varied dimensions by comparing care quality among
outsourced nurses, permanently employed nurses, and
contracted nurses. This study also aims to offer some evi-
dences for human resource management operating st-
rategies in hospitals in developed as well as developing
countries.
Literature Review
Performance of temporarily and permanently
employed nurses
International studies addressing the performance of
contractedandpermanentlyemployednursesrevealincon-
clusive research findings. Porter (1995) and Kidder (1995)
both pointed to no difference between the two. However, a
studybyStrzalkaandHavens(1996)revealedsignificantly
different results. Some scholars have mentioned that when
temporary nurses felt they would remain in a position over
the long term, they were stimulated to have positive atti-
tudes and working performance (Dyne & Ang, 1998). One
local research found no significant correlation between a
temporary nurses’ organizational commitment and work-
ing performance (Lin, 2002). It is assumed that profes-
sional commitment allows nurses to be responsible for
patients and they would not treat the job carelessly because
of low benefits. To date, there has been no study dealing
with issues related to outsourcing nursing. In addition,
researchoncontractpersonnelrevealedthatfinancialcom-
pensation did not significantly effect job satisfaction
(Chang, 2003).
Nursing care quality
Crosby, Evans, and Cowles (1990) defined quality as
“to meet the requirement” from the perspective of design-
ers or managers. The Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) defined medical
carequalityas“usingtheupdatedprofessionalknowledgeto
care patients, to improve the expected caring effectiveness,
and to reduce the unexpected consequences.” (JCAHO,
1991). The patients, on the other hand, would define good
quality of care as when nurses deliver updated medical
information to them, and when nurses are willing to com-
municate with them to help them deal with their health
problems and needs (Oermann & Templin, 2000).
Evaluation instruments for nursing quality
Nursingqualitycanbeevaluatedintermsofstructure,
process and outcome (Donabedian, 1982). Nursing quality
measuresshouldbeconnectedwithnurses’knowledgeand
be evaluated by services delivered and their behavior
(Gunther & Alligood, 2002).
The Department of Health authorized the Taiwan
Joint Commission on Hospital Accreditation (TJCHA) to
proceed with the accreditation of hospitals in Taiwan.
TJCHA modified its evaluation standard in 2004, which
reinforced the assessment of process and result, as well as
the structure component. In this new scheme, evaluation
items related to nursing quality included complete nursing
and caring activities and records as well as other related
nursing services, e.g, checking on patients, nutrition man-
agement and diet instruction (TJCHA, 2004).
The most widely used evaluation tool for nursing care
quality is the Rush Medicus Tool-Monitoring the Quality
of Nursing Care (RMT-MQNC). The application of RMT-
MQNC is focused on evaluating the current status, includ-
ing examination of medical records, interviewing patients
and nurses, and direct observation of patients and nurses.
The questionnaire includes 257 rules and can be catego-
rizedaccordingtodiseaseseverity(Haussmann,Hegyvary,
&Newman,1974).TheRMT-MQNCwasmodifiedinTai-
wan in order to evaluate the quality of nursing care for
elderly patients (Hsu, Feng, Su, & Wang, 1992).
Factors affecting nursing quality
Radwin and Fawcett (2002) pointed out that nurse
caring outcomes are highly correlated with all components
in the health care system, including the characteristics of
the nursing system and other supporting personnel, the
plan under which personnel were hired, recruited and re-
tained, and cooperation among departments. Radwin and
Fawcettalsopointedoutthatthecharacteristicsandexperi-
ence of the case hospital directly affect caring results. The
nursing quality of different types of nurses directly affects
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Shiou-HuaWuetal.

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patient evaluations of hospital service quality. Reference
has been made in the local literature that personal charac-
teristics affect patients’ satisfaction. When patients recog-
nize that their health status has improved, and in cases
where they are older and have a lower educational back-
ground, satisfaction levels tend to be higher (Li, 2001).
Based upon the above findings, the organization and hiring
policyofinstitutions,operationofhealthcaringsystemand
patients’ personal factors affect the evaluation on the qual-
ity of medical care.
Research framework
TheresearchframeworkisshowninFigure1.Thehired
groupisthemainexplanatoryvariable;nursingcarequalityis
the explained variable; and nurse and patient characteristics
are control variables. To control for possible confounding in
the statistical regression model, the characteristics of nurses
and patients, as well as the main explanatory variable, are all
included as independent variables in the equation. In this
way, we interpret the regression coefficient as the estimated
effect of an explanatory variable on an explained variable,
holding other independent variables constant (Retherford &
Choe, 1993). Most often, data will have been collected under
non-experimental conditions in which very little can be
controlled by the investigator. The task of regression analy-
sisistolearnasmuchaspossibleabouttheenvironmentrep-
resented by the data (Chatterjee, Hadi, & Price, 2000).
Methods
Measurement Instruments
Because over 80% of research samples represented
hospitalized elderly patients, this research used a modified
version of Hsu’s (1992) nursing quality questionnaire of
hospitalized elderly patients as its measurement instru-
ment.Thisstudyfollowedthenewnursingevaluationstan-
dard TJCHA 2004 for hospital accreditation, emphasizing
especially the principle directly correlated to nursing qual-
ityandinvolvingprocessandoutcomedimensionsofnurs-
ing quality. The process dimension included the five sub-
dimensions of nursing evaluation, nursing plans, nursing
activities, nursing instruction and nursing evaluation. The
single nursing outcome dimension included patient satis-
faction with nursing instruction. After modifying the ques-
tionnaire, the authors invited the original local researchers
of these questionnaires to review the study instrument and
manage its validity. Each option was scored between 1 and
3 points to assess care quality. The total Cronbach’s ? of
the study questionnaire was .75.
Research Hypothesis
This research assumed that overall nursing quality at
the case hospital would be significantly inferior due to the
outsourcing of nurses. We further assumed that nursing
quality among the three groups would reveal significant
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Hired Groups
Permanently employed
nurses
Contracted nurses
Outsourced nurses
Population Properties of Nurses
Age
Marriage
Educational background
Working experience
Professional licenses
Patients’ Characteristics
Age
Marriage
Educational background
Classification of nursing
requirement
Nursing Quality
ProcessResult
Nursing assessment
Nursing plans
Nursing activities
Nursing instruction
Nursing evaluation
Patient satisfaction with
nursing instruction
Figure 1. Population properties of nurses and patients’ characteristics are the control variables.

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differences and that nursing quality provided by out-
sourced nurses would be the worst, that of contracted
nurses would rank in the middle, and that of permanently
employed nurses would rank the highest.
Research Sample and Data Collection
The research sample targeted 107 nurses, each with
more than 3-month nursing experiences and currently pro-
viding nursing care to patients. The data for these nurses
werethenmatchedwiththoseofpatients.Patientshospital-
ized for over 48 hours were regarded as the research popu-
lation for this study. Patients not comfortable enough to
receive an interview were excluded from consideration.
There were 300 patients accommodated in the following 7
ward units: acute internal medicine ward, surgical ward,
health insurance ward of chronic psychiatry, intensive care
unit, respiration care ward, health insurance ward for the
elderly with dementia, and pulmonary tuberculosis ward.
The interview time was managed by the interviewers and
was limited to daytimes during weekdays. Interviewers
werenotrequiredtoinformthenursingstationinadvance.
Interviewers were 10 senior registered nurses, each
with more than 5 years of clinical experience. They were
all employed by the case hospital, but located in wards dif-
ferentfromthatofthenursesbeinginterviewed.Afterstan-
dardized training and numerous personal discussions dur-
ing the interview process, the interviewers were expected
to reach a consensus regarding the study as well as ques-
tionnairemeasurementconsistency.Inordertoavoidsitua-
tions in which prejudice might affect objectivity, personal
background information on interviewed nurses was pur-
posely not included on the questionnaire, allowing infor-
mation to be treated as blind for interviewers. To control
for inter-rater reliability, every interviewer was assigned to
interview nurses from each of the three nurse categories in
order to help distribute variation among raters randomly
among the three categories. ‘Non-differential misclas-
sification’ occurs when the proportion of subjects mis-
classified on performance, if it does exist, does not depend
on their employee status. Any bias introduced by such
non-differential misclassification is predictable in direc-
tion; namely, toward the null value (Rothman & Greenland,
1998).
Our survey was implemented over a four and a half
month period, between October 1st, 2004 and February
15th, 2005. The evaluation process included reviewing
patient histories (including nursing assessment, nursing
plan,nursingactivities,andevaluationrecords),interview-
ing nurses to assess their understanding of patient condi-
tions, observing patients (including physical position, phy-
sicalsupportneeds,pollingupthebedbars),andinterview-
ing patients about the delivery of nursing instruction and
their level of satisfaction. After collecting interview data,
the researcher used SPSS 10.0 for Windows to conduct
data statistical analysis.
Results
Demographic Statistics of Nurses
The total of 78 nurses interviewed represented 70%
of first-line nurses in the case hospital. Among them were
16 outsourced nurses, 23 permanently employed nurses
and 39 contracted nurses. As to age distribution, there
were 41% under 25 years old and 25.6% nurses between
26~30.Theoutsourcednursesweremostlyunder25years
old and the permanently employed nurses were mostly
older than 31. As to marital situation, there were 62.8%
unmarried nurses. Outsourced nurses were all single.
Contracted nurses were mostly unmarried and perma-
nently employed nurses were mostly married. As to edu-
cational background, 64.1% of the total had matriculated
from a junior college as their highest educational achieve-
ment, and 15.4% had matriculated from a junior nursing
school. All outsourced nurses had junior college degrees,
whichwastheminimumlevelofeducationrequiredinthe
contract. Contracted nurses mostly held junior college
degrees,whilepermanentlyemployednursesweremostly
junior college or university graduates. With regard to se-
niority,30.8%had5~10yearsworkexperienceatthehos-
pital, 29.5% had 1~5 years and 9% had 3~6 months. The
seniority of outsourced nurses was mostly 7 months to
one year. Contracted nurses had seniorities concentrated
mostly in the 1~5 years and 5~10 years ranges. Perma-
nently employed nurses had the greatest seniority, with
most on the job for over 5 years. With regard to licenses,
56.4% had a registered nursing license and 43.6% held a
practical nursing license. Most outsourced nurses had
practical nursing licenses and most of contracted nurses
and permanently employed nurses had registered nursing
licenses.
Overall, outsourced nurses were younger and unmar-
ried;hadlessworkingexperience;andprimarilyheldprac-
tical nurse licenses. Permanently employed nurses were
relativelyolder;mostlymarried;hadmoreworkingexperi-
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ence and primarily held registered nursing licenses. The
condition of contracted nurses was somewhere in between
the previous two.
Demographic Statistics of Patients
Nursing care provided should be categorized in ac-
cordance with patients’ self-caring capacities. The first
category involves patients who can take care of them-
selves. The fourth category mainly includes paralyzed
patients. The result of the survey revealed that the first
(33.7%) and the fourth category (38%) had the largest
numbers of patients. Outsourced nurses mostly took care
of patients belonging to the first category, with the fourth
category accounting for the second highest patient care
numbers for this group of nurses. For contracted nurses,
most of their patients were in the four category, followed
by patients in the first category. Permanently employed
nurses took care of first as well as fourth category pa-
tients.Intermsofwardrepresentation,mostsampleswere
from respiration care (27.3%) and psychiatry (30.7%)
wards. Nurses in acute health insurance wards were main-
ly outsourced nurses. Respiration caring wards were mo-
stly looked after by contracted nurses. Permanently em-
ployed nurses mostly served in chronic wards in the psy-
chiatry department.
Becausethemajorityofresearchtargetswereveterans,
patient characteristics were weighted toward the elderly,
unmarried and illiterate. Most elderly patients were over 75
years old and those less than 65 were in a minority (19%).
The majority of patients were unmarried (73.3%), with 21%
married. In terms of educational background, 47.7% of
patients were illiterate. The interviewer was unable to
obtain educational background data on the 12% of patients
inthesurveyeithersufferingfromdementiaorunconscious.
Descriptive Analysis of Quality Variables
The total average score for the quality of all dimen-
sions was 2.49. In the process dimension, quality of nurs-
ing assessment was the best, with 2.81 points, followed by
quality of nursing activities, with 2.63 points, and quality
of nursing instruction, with 2.34 points. The lowest score
wasforqualityofnursingevaluationwithonly2.26points.
In the result dimension, satisfaction of nursing instruction
was just 2.15 points, which fell between the options of
acceptable and satisfied.
Withregardtothequalityamongthreenursinggroups,
permanently employed nurses ranked best, with 2.57 po-
ints, followed by contracted nurses, with 2.52, and out-
sourced nurses with 2.36. Contracted nurses were inferior
to permanent nurses by only 0.05 points. Regarding the
dimension of quality, quality of nursing instruction and
nursing planning showed the most significant differences
among the three nursing groups.
Differences in Patient Characteristics Among
Nursing Groups
TheChi-squaretestwasusedtoexploredifferencesin
patientswhowerecaredforbynursesinthethreegroupsin
terms of nursing requirements, age, education and mar-
riage. The results showed that, apart from nursing require-
ments, other population properties of the three groups of
patients were not significantly different.
Regression Analysis
As differences in nursing care quality provided by
nurses in the three groups, the dimensions of total nursing
quality, nursing planning, nursing instruction and nursing
evaluation revealed significant differences. The results of
regression analysis on nursing quality along various di-
mensions are not shown in the tables. Compared to out-
sourced nurses, permanent nurses and contracted nurses
scored better with regard to total nursing quality, nursing
planning and nursing instruction.
Results of regression analysis on total nursing quality
are shown in Table 1. Compared to outsourced nurses, the
marginal analysis in Table 1 shows that contracted nurses
and permanently employed nurses had, respectively, 6.2%
and 17.8% higher total nursing quality scores. The differ-
ence of nursing instruction dimension was more significant.
Compared to outsourced nurses, contracted nurses had a
17.9% higher nursing instruction quality score, while per-
manently employed nurses had a 37.4% higher score. In
addition, permanent nurses also scored significantly better
than outsourced nurses in terms of nursing evaluations.
Regarding nursing activities and nursing instruction
satisfaction,regressionanalysisindicatedthatonlyageand
education had significant relationships to these quality
variables. Nurses in the 36~40 and over 41 years old cate-
gories demonstrated better nursing activity quality in com-
parison with nurses less than 25 years of age. In terms of
education, nurses who holding a junior college degree per-
formed better quality of nursing activities than those who
graduated from junior nursing schools only. The nurses
who had graduated from a university achieved a better
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