1. Introduction
Hospital organizations in the Portuguese context today involve a complex process. The new health policies constitute new challenges, either through the introduction of changes in the structure of the Portuguese National Health System or through the management models, with the aim of increasing the quality of the services provided and reducing the costs. However, nurses and patients are not always involved in the process of change, creating unfavorable environments in relation to change and the future, which may lead to the failure of the process. The reasons for and the questions stimulating this study resulted from observations of the importance of the hospitalized patients’ participation in assessments of their satisfaction with nursing care.
A reference framework was established, where the concepts and assumptions that correspond to the conception of care in nursing were developed, revealing the state of the art of the themes. As major thematic areas, we identified the characteristics of the environment of the nursing practice and the activities of nurses, which included the different interactions of care and were characterized by a set of deeply interdependent technical and human dimensions constituting an inseparable whole. The Quality-Care model© [
1] guided the investigation path. This integrates the concept of satisfaction as a result reflecting nursing care that is appropriate to the hospital context and the therapeutic relationship established between the patient and the nurses. Improving the hospital work environment can be a relatively low-cost strategy to improve care and, consequently, the outcomes for patients and nursing professionals [
2,
3]. In the Portuguese context of hospital nursing, it is a priority to implement measures that can support decision-making by nurse managers, and improve the working conditions in hospital organizations, the quality of nursing care provided and the results for patients [
4]. There is strong scientific evidence showing that improvements associated with the practicing environment can be a strategy to improve the quality of hospital care, thus consequently increasing patients’ satisfaction [
5,
6]. Quality has become more and more important, constituting a constant journey of learning and improvement through the involvement of nurses [
7].
Care is a central element of nursing care and indicates the importance of favorable environments [
8]. Nursing care is a multidimensional concept, involving a set of dimensions and conditions that describe the attitudes and behaviors related to showing an interest in and respect for the psychological, social and spiritual values of patients [
9,
10]. This develops as a specific competence in stages through nursing education and clinical practice, in parallel with other nursing competences, such as “acting in a professional manner”, “clinical reasoning in nursing” and “clinical nursing leadership” [
11]. Nurse–patient interactions based on care behaviors have been tested by several theorists [
9,
10,
11]. These authors claimed that caring is the essence of nursing and is the key element of nurse–patient interactions for high-quality healthcare. The implementation of nurse–patient interaction models, based on care behaviors in health systems, can improve the work environment, provide a higher level of satisfaction in nurses and patients [
12,
13], and guarantee a higher level of patients’ safety and quality healthcare [
14,
15,
16].
Regarding patients’ satisfaction with nursing care, in the hospital context, researchers have sought to find the factors that increase it and have focused on the attributes of care that most influence it. Hospitals respond to the health needs of patients with the best possible quality [
17,
18]. The patients’ satisfaction is an important and legitimate indicator of the quality of healthcare. It is therefore extremely important to define, measure and evaluate the quality of healthcare provided to promote the patients’ satisfaction [
19,
20].
There is a consensus on the influence of nurses, as health professionals, on the patients’ satisfaction, particularly in the hospital context [
21,
22]. Compared with other health professionals, nurses spend more time with hospitalized patients and interact with them more frequently, thus having a significant impact on the experience of hospitalization [
23,
24]. In this way, nurses have the opportunity to approach patients and learn about their expectations [
25]. There is a shortage of studies in the Portuguese context, as well as studies that integrate all perspectives and articulate contributions of the patients and nurses, which can broaden our view of the subject.
The study’s main objective aims to assess the existence of relationship between the nursing practice environment, nurse–patient interactions and patient satisfaction with nursing care in a hospital context. Thus, the following research question was defined: What is the relationship between the nursing practice environment, the nurse–patient interactions evaluated by the nurses, and the patient’s satisfaction with nursing care in the hospital context? Specific questions emerge: What is the assessment of the nursing practice environment in a hospital context? What is the assessment of the frequency and importance of nurse–patient interactions, from the perspective of nurses? What is the assessment of patient satisfaction with nursing care in the hospital context? What is the assessment of the relationship between the variables of the nursing practice environment and patient satisfaction in the hospital context? What is the assessment of the relationship between nurse–patient interactions and patient satisfaction in the hospital context?
4. Discussion
The study, applied to 169 nurses and 169 patients from the four hospitals mentioned above, has as its general objective to evaluate the relationship of the nursing practice environment, nurse–patient interactions, and patient satisfaction with nursing care in a hospital context. From the evaluation of the nursing practice environment in a hospital context, although the number of participants is lower than in other studies, the values obtained are close to most of the investigations already carried out in Portugal [
26,
32]. Studies conducted in other countries show frankly more favorable values [
5,
33,
34,
35]. We can affirm that the dimension fundamentals of nursing for the quality of care obtained a better classification by nurses, having been positive in all hospitals. These results are, however, lower than those of studies in Portugal [
26,
36,
37] and at the international level, with similar results [
25,
38,
39]. This dimension, when effective, shows a lower mortality rate, higher job satisfaction, improvement in the quality of care and fewer adverse events [
40,
41]. Regarding the dimension of the relationship between physicians and nurses, a favorable overall score was obtained in the present investigation, which was verified in all the hospitals of the present study. This dimension is in line with the studies of [
26,
32,
42], and [
37] showed a negative average for this size. A work environment with a favorable relationship between nurses and physicians is fundamental for the success of the care that occurs in a positive work environment and favorable practice [
36]. At the international level, there were superior results [
38,
39,
42]. According to the literature, a good relational level between nurses and physicians leads to greater professional satisfaction and reduces the rates of intention to leave the service, and improves the climate of support among professionals [
43,
44]. It should also be noted that physician–nurse collaboration and teamwork can improve patient outcomes and reduce healthcare costs [
45,
46], increase job satisfaction and maintain patient safety [
4,
47,
48]. The dimension adequacy of human and material resources and the participation of nurses in the governance of the hospital obtained a lower average rating. Referring to the perception of nurses regarding existing resources affected by the number of nurses present in the unit, but also by the number of beds and typology of patients, all hospitals in the present study presented unfavorable results. Similar results were found at the national level [
26,
32,
37]. At the international level, similar results [
6,
38,
39] were found to the present study. These results demonstrate that this is one of the most sensitive areas of the nursing practice environment, and that without sufficient resources, nurses have more difficulty in providing care of excellence, which has been recurrent and problematic at the level of the National Health System. This result, in relation to the dimension of the adequacy of human and material resources, may probably be associated with the nurse/patient ratio in the services, in which the high complexity of the typology of patients requires nurses to be more vigilant and permanent. This problem rates to the existence of an inadequate nurse/patient ratio in most hospitals in Portugal [
26,
32,
37]. The high and representative work overload of Portuguese nurses and the calculation of the needs of nursing endowment cannot be limited to the criterion of the number of hours of care per patient and per day, or average times used in certain procedures [
49]. It is critical that hospital administrators find solutions to provide safer environments [
49]. Regarding the dimension of nurses’ participation in hospital governance, it presents a lower average rating, as does nurses’ perception of the importance and opportunity to participate in political decisions. Similar results are found at the national level [
26,
32] and the international level [
50,
51]. This raises an opportunity for professional appreciation and the sharing of concerns [
36]. The involvement of nurses in organization and decision-making is considered a good practice and contributes to good results [
36]. The constant transformations and advances in the scenarios of health practices, especially in the hospital environment, have had repercussions on how the teams organize themselves for the provision of care. This situation requires from professionals, especially nurses, specialized knowledge in management, as well as experience in the area of administration [
2,
52], allowing them to act with more autonomy, as well as interfere in decision-making within the organization [
2]. Shared management and involvement in the decision-making process that involves nursing practice increases commitment to the profession, as well as the sense of empowerment and professional satisfaction [
53,
54]. Involvement in the strategic decisions of the organization is related to feelings of satisfaction, emotional exhaustion, and intention to leave the profession, and can help managers find ways to promote the well-being of their professionals, namely, by providing support and effective responses to the concerns and daily problems of nurses [
2,
50]. The possibility of nurses getting involved and participating in the policies and issues of the hospital may represent an opportunity for professional appreciation and sharing of concerns [
36]. The results regarding the dimension of management, leadership and support capacity for nurses obtained a favorable global score; however, there is a differential between the hospitals. In the comparison, results are higher than those presented by [
32,
37], where they identified a negative overall score. Refs. [
26,
36] recorded a higher global average. In international studies, we found results like those of the present study [
6,
38,
39,
42].
The dimension of the NPIS-22-PT that presented the highest overall mean value in terms of importance was comfort care. This dimension indicates how nurses perceive the effectiveness of the process and evaluate aspects related to interactions in the treatment regarding the transmission of information in an understandable way, listening skills, the ability to solve problems in a timely manner, the ability to respond to patients’ needs, and technical competence. The dimension of relational care had the lowest mean value for importance and frequency. According to the perceptions of the nurses, this revealed that the nurses evaluated the aspects related to the challenges perceived by the patients as considerably important. Favorable nurse–patient interactions reduced the days of hospitalization and improved the quality of patients’ and nurses’ satisfaction [
8,
35]. Regarding the clinical care dimension, it presented a favorable average within the total scale (importance and frequency). Nurses’ attitudes influence, and are influenced by, the functional capacity for self-care, self-esteem, and satisfaction with life. These allow us to evaluate aspects related to self-care behavior; this can be associated with personal attitudes towards others and the future. This attitude influences the way nurses perceive the health condition, interact with patients, and position themselves before the negotiated treatment [
10,
13,
16].
With regard specifically to the assessment of satisfaction, we opted for the SAPSNC-18 scale validated in 2016 in Portugal, although no subsequent national or international studies are known. The SAPSNC-18 considers the perceptions of patients in relation to their satisfaction with the care received, that is, the care that patients experienced. The existing literature reveals that, in most studies of patient satisfaction, it has favorable overall satisfaction indexes [
19,
21,
28], which corroborates the results of the present study. The dimension that obtained the greatest satisfaction on the part of patients was the quality of care, which is higher than that in the study by [
28]. Scientific evidence reveals that the assessment of the physical environment, the relationships between professionals and patients, communication [
19,
22], privacy and security [
18] and the provision of information about the care provided [
12] are more relevant factors affecting the perceptions of patients. Regarding the quality of care dimension, it obtained an average higher satisfaction score on the part of patients, according to the study by [
28]. Nurses spend more time with hospitalized patients and interact more frequently with them, so they have a significant impact on the quality of patient care and the hospitalization experience [
18,
21]. The dimension that obtained the lowest satisfaction on the part of patients was the quality of information, which is like what was found in the study by [
28]. The existing literature reveals levels of dissatisfaction in the perceptions of patients when there is a greater lack of continuity in relation to healthcare [
14,
21].
Regarding the relationships of the variables of the nursing practice environment and nurse–patient interactions with patients’ satisfaction in the hospital context, we found that the nurses’ perceptions of the working relationships with physicians, nursing care plans, continuing education and the recognition of work had a positive relationship with how patients perceived the effectiveness of the communication process and the effectiveness of personalized care. These findings are in line with other evidence [
55,
56], being a predictor of overall satisfaction with the healthcare experience, particularly the way nursing care is provided [
57]. It is also agreed that there is a relationship between satisfaction with the health service as regards expectations and perceptions about the care received, that is, the care that the client experienced and what they expected to receive [
56]. In this specific context and according to the scientific literature, there is a growing recognition that quality health services must be effective, safe, and people-centered [
3,
5]. In the study by [
20], they reported care as a special focus in therapeutic relationships since they translate into expressions of the interaction of one or more people. Promoting the resolution of problems is encouraged so that the patient finds alternative ways of seeing the situation, meeting their expectations, and seeking recognition and satisfaction. Refs. [
1,
11] argue that the attitudes and behaviors that nurses put into practice in partnership with patients and families are facilitators of specific interventions in the disciplinary area of nursing, and lead to results “highly” determinative of nursing care. It is important to look at the patients as a relational experience regardless of the situations that occur, whether in health or in disease [
10].
According to the perceptions of nurses in this study regarding their participation in the hospital’s internal governance, several indicators, such as continuity of care and the use of diagnoses and nursing care plans, had a positive relationship with the usefulness of the information transmitted to the patient during hospitalization and after discharge. This information aims to provide the patient with the necessary skills to deal with their illness/health situation, according to a study [
57]. In the scientific literature, we find other studies that confirm that the practice environment is composed of the accumulated effects of numerous interrelated factors, which affect performance and satisfaction [
32]. Others [
16] point out that the nurse–patient relationship/interaction has been described as a process of interpersonal interaction via self-care strategies, medication adherence and psychological interventions. Moreover, they refer to the relational dimension as an attitude of improvement in patient care [
12].
Patient satisfaction with nursing care evidence that patients at the time of hospital discharge experienced a positive relationship between the confidentiality of information, care, treatments, the administration of medications in a timely manner, safety during hospitalization and satisfaction with nursing care [
21]. In fact, satisfaction with nursing care has been systematically discussed in the scientific literature as a predictor of overall satisfaction with the healthcare experience [
20,
21,
22].
It is expected that the development of this research will contribute to the construction of affinity, based on the knowledge of the individual who is cared for, and the deepening of relationships and bonding between those involved. It is noteworthy that this study can help in the provision of care by the nursing team and strengthen the relationship between professionals and clients to achieve better health outcomes. On the other hand, it could contribute as a strategic measure to improve the clinical and organizational quality of health institutions, by increasing accountability for the quality of all levels of the system and increasing the involvement of professionals and leaders.
Limitations and Suggestions
Despite the methodological options chosen, which considered methodological rigor, the constituents of the sample, the evaluation of psychometric properties and the use of statistical tools such as linear regression models, this study had some limitations. For example, the various instruments had different scales: the PES-NWI had a Likert scale from 1 to 4, and the NPIS-22-PT and SAPSNC-18 had scales from 1 to 5. Secondly, the origin of the data made the robustness of the models more difficult to determine, which in this case did not happen, because the final model obtained by the confirmatory analysis had a marginal RMSEA. The integration of the patients’ voices in research studies can also reinforce knowledge and partnership, and improve the focus on the person regarding what is desired, as a model of care where the patient holds power and autonomy over his/her health process/illness. In fact, these constraints are understood as challenges and suggestions for the development of new studies.
Another limitation of the study was the timing, as it took place at the beginning of the pandemic, which may have led to greater dissatisfaction on the part of the participants, as adverse conditions occurred that had not previously been experienced either by patients or by nurses.
Another limitation of the study to be mentioned is the fact that the participants’ responses were based on their perceptions, which may have been affected by the social desirability of patients, with the responses being biased by the tendency of individuals to seek social approval and avoid criticism, according to what is culturally acceptable.
Although this study has specifically focused on nursing care, it is difficult to separate this factor from the complexity of healthcare that hospitalization entails. In this sense, it is important to analyze satisfaction in a dynamic way, considering the various disciplinary areas involved. A study has been proposed to consider the dimensions of satisfaction related to other health professionals as well as those in relation to nursing care, as each one influences satisfaction. On the other hand, different strategic measures must be developed to improve the clinical and organizational quality of health institutions by increasing accountability for the quality at all levels of the system, and by increasing the involvement of professionals and leaders.
Finally, as a suggestion for the development of future research, studies could assess clients in other age groups to understand the associations of age and developmental stage with satisfaction with hospitalization.