The Karen instruments for measuring quality of nursing care: construct validity and internal...

The Karen instruments for measuringquality of nursing care: construct validityand internal consistencyMARGARETA LINDGREN AND INGER S. ANDERSSON

Department of Medicine and Health, Division of Nursing Science, Faculty of Health Sciences, Linkoping University, SE-581 85 Linkoping,Sweden

Address reprint requests to: Margareta Lindgren, Department of Medicine and Health, Division of Nursing Science, Faculty of HealthSciences, Linkoping University, SE-581 85 Linkoping, Sweden. Tel: þ46-10-1031785, þ46-13-310467; Fax: þ46-10-1033285;E-mail: [email protected]

Accepted for publication 19 December 2010

Abstract

Background. Valid and reliable instruments for measuring the quality of care are needed for evaluation and improvement ofnursing care. Previously developed and evaluated instruments, the Karen-patient and the Karen-personnel based onDonabedian’s Structure–Process–Outcome triad (S–P–O triad) had promising content validity, discriminative power andinternal consistency.

Objective. The objective of this study was to further develop the instruments with regard to construct validity and internalconsistency.

Design and Settings. This prospective study was carried out in medical and surgical wards at a hospital in Sweden. A total of95 patients and 120 personnel were included.

Methods. The instruments were tested for construct validity by performing factor analyses in two steps and for internal con-sistency using Cronbach’s alpha coefficient.

Results. The first confirmatory factor analyses, with a pre-determined three-factor solution did not load well according to theS–P–O triad, but the second exploratory factor analysis with a six-factor solution appeared to be more coherent and the dis-tribution of variables seemed to be logical. The reliability, i.e. internal consistency, was good in both factor analyses.

Conclusions. The Karen-patient and the Karen-personnel instruments have achieved acceptable levels of construct validity.The internal consistency of the instruments is good. This indicates that the instruments may be suitable to use in clinical prac-tice for measuring the quality of nursing care.

Keywords: quality of nursing care, the Karen instruments, instrument development, patient’s perspective, personnel’sperspective

Introduction

To be able to fulfil the requirements in nursing care, there isa need for valid and reliable instruments measuring thequality of care as a pre-requisite for the development and theimprovement of the care given. The quality of care ought tobe measured from the perspectives of both the patients andthe staff and their opinions should be possible to compare[1, 2]. On the basis of Swedish legislation, authorized health-care professionals are required to follow-up and continuouslydocument quality of care. An important factor is patientsafety [3, 4] aiming to prevent injuries related to the caregiven. This study is a part of a major project aimed to test

the validity and reliability of new instruments measuring thequality of care.

Quality of care is a complex and multi-dimensionalconcept, thus the assessment of the quality of care must bebased on a conceptual and operational definition [5]. Manyresearchers have attempted to define quality of care and findout what the core of the concept constitutes [6].Donabedian, who is perhaps the foremost researcher in thisfield, maintains that the essence of such quality involves thebalance between benefit and harm. He also made a synthesisof earlier attempts to define quality of care based on patients’wishes concerning three closely interrelated factors, namely:technical care, interpersonal relationship and amenities in the

International Journal for Quality in Health Care vol. 23 no. 3

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care environment [7]. Caring is the basis of nursing care [8].Good quality care should be individualized and focused onpatient needs, performed in an atmosphere of involvement,commitment and concern from the staff [9]. Nursing careshould be performed by competent nurses who develop aconnection with the patients leading to trust, empowermentand well being. Care performed by indifferent or incompe-tent nurses leads to a sense of distrust, uneasiness and dis-couragement [10].

Donabedian describes a three-dimensional model formeasuring the quality of care where he defines concepts suchas Structure, Process and Outcome based upon organiz-ational theory and behaviour science [11]. Kitson [12] devel-oped a method for quality assessment in nursing care calledthe Dynamic Standard Setting, i.e. levels for quality improve-ment. The system is inspired by Donabedian’s concepts butalso includes staff participation and involvement as pre-requisites for improving the quality in nursing care.

The empirical based instruments, the Karen-patient andthe Karen-personnel, used in this study were generated fromqualitative interviews and analysed inductively using qualitat-ive and quantitative content analysis. The instruments hadearlier been tested for discriminant and content validity, aswell as internal consistency. The results gave instruments rel-evant to quality of care and nursing and seemed to be suit-able to handle in clinical practice [1, 2]. According toNunally and Bernstein [13], instruments must achieve goodreliability, good validity in different aspects and good pre-cision, and thus further psychometric testing of the Kareninstruments is needed.

Objective

The objective of this study was to further develop theKaren-patient and Karen-personnel instruments with regardto construct validity and internal consistency.

Methods

Respondents and procedure

The study was carried out at a regional hospital in the southof Sweden. Two study groups were included. The first groupconsisted of 95 inpatients and the second study group of120 personnel, of whom 61 were registered nurses and 59were nursing aids. The respondents were selected from sixwards with surgical and medical treatment. The inclusion cri-teria for the patients were: 18 years of age or older, a hospitalstay of at least 3 days and an ability to read and understandthe Swedish language. The patients were informed verballyand consecutively included in the study by the clerk in therespective ward. Participation was voluntarily. Written infor-mation about the study, the Karen-patient instrument andstamped envelopes were given to the patients on the day ofdeparture. The patients were instructed to respond anon-ymously and send the instrument back to the researcherwithin a week. A total of 120 patients were invited to partake

in the study and 95 (79%) agreed to participate. TheKaren-personnel instrument, additional information aboutthe study and stamped answering envelopes were sent to thehome address of a total of 195 registered nurses and nursingaids, of whom 120 (62%) answered. Both categories wereincluded since they share the responsibility, in relation totheir level of education, for the care of the patients.

Development of the instruments

In the study the above-mentioned instruments, theKaren-patient and the Karen-personnel, were used. Thedevelopment of the instrument started by Andersson in1995 [1]. As a base for the instruments development,Andersson conducted thematic interviews with patients andpersonnel to be able to focus on important aspects of qualityexpressed by the two main interested parties in nursing care.The interviews included the following areas: ‘the meaning ofthe concept quality of care, factors influencing the quality,important aspects of care, the meaning of health and qualityof life, the goals of nursing care, quality of care related toself-care and factors increasing the quality of care’[1]. Thecontents of the areas chosen were inspired by Donabedianand Kitson [8, 14]. From the thematic interviews, a total of134 items were generated inductively by analysing thecontent of the interview material and then put together inthe Karen instruments. The items were divided into theKaren-patient and the Karen-personnel instruments andgrouped according to Donabedian’s Structure–Process–Outcome quality triad (the S–P–O triad). The gradingsystem used in the instrument was a three-grading scaleaccording to Lynn [15]. Then a content validation was madeby an expert panel consisting of 197 registered nurses todetermine the relevance of items in relation to quality.Sixty-six items were thereafter discarded [2]. The next stepin the development performed by Andersson and Lindgrenwas to further analyse the remaining items concerning thediscriminative power and the internal consistency as ameasure of reliability [16]. Sixty-four patients and 42 person-nel from a surgical and a medical ward were included in thestudy. The item analysis resulted in further reducing thenumber of items to a total of 35 in both the Karen-patientand the Karen-personnel instruments, a number suitable tohandle in clinical practice. The grading system was changedto a five-grade Likert scale [17]. The remaining items in bothinstruments discriminated well and the internal consistencywas 0.86 and 0.88, respectively [2]. This study is the nextstep in the psychometric testing of the instruments as isdemanded for valid and reliable instruments according toNunally and Bernstein’s Psychometric theory [13].

Data analysis

The data was analysed using Stat View for Windows version5. To estimate underlying dimensions as a part of the validityin the Karen-patient and Karen-personnel instruments,factor analyses were performed in two steps using principal

Instruments for measuring quality of care

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component analysis with varimax orthogonal rotation. Thefactor analysis was performed according to Gorsuch [18].

The first-factor analysis was performed for confirmativepurposes using three pre-determined factors related to theS–P–O triad. The purpose of the second-factor analysis wasexplorative. The criterion used for the second-factor analysiswas an eigenvalue of ��1 which resulted in six factors. Thecriterion for including variables in a factor was a factorloading of �0.40, and all 35 items were included in bothfactor analyses [18].

Cronbach’s alpha coefficient was used to measure theinternal consistency, i.e. reliability of the Karen-patient andKaren-personnel instruments [16, 19]. A satisfactory level ofCronbach’s alpha might range from above 0.70 but probablynot higher than 0.90 [19].

To further assess reliability in the six subscales of the twoinstruments, intercorrelations were calculated usingSpearman’s rank correlation. A satisfactory result is con-sidered .0.30– ,0.70 [13]. The demographic data wereanalysed by the mean values, standard deviation and range.

Approval for the study was given by the Research EthicsCommittee of the Faculty of Health Sciences, LinkopingUniversity, Sweden, F97-405.

Results

The study included 95 patients of whom 47 were women.The mean age was 64.4+ 15.8 years, with a range of 22–86. The mean length of hospitalization was 9.1+ 13.4 days,with a range of 3–105. Forty of the patients had previouslybeen treated in the same ward. There were 120 participantsin the personnel group, of whom 111 were women and 9were men. The personnel group consisted of 61 registerednurses and 59 nursing aids. The mean age was 43.6+ 8.3with a range between 27 and 60 years.

Construct validity

Three-factor solution. In the first-factor analysis, three factorswere pre-determined in accordance with Donabedian’s triadof Structure–Process–Outcome. Overall, the survey itemsdid not load as predicted onto the three-factor solution ofStructure, Process and Outcome. Twelve of the 35 variablesloaded to a factor different from that expected. Dualloadings were found in three variables in the Karen-patientinstrument and five in the Karen-personnel instrument. Inthe Karen-patient instrument, two Structure variables loadedin Process, four Process variables loaded in Structure, fourOutcome variables loaded in Structure and two Outcomevariables loaded in Process. Five variables in theKaren-patient instrument loaded ,0.40 and were thusexcluded (Tables 1 and 2).

In the Karen-personnel instrument, ten Structure variablesloaded in Process, two Structure variables loaded inOutcome, five variables in Process loaded in Structure, onevariable in Process loaded in Outcome and three variables inOutcome loaded in Structure. In summary, 21 variables

loaded in different factors. None of the variables loaded,0.40 (Tables 1 and 2).

The total variances explained for the Karen-patient(Table 1) and the Karen-personnel (Table 2) instrumentswere 32.6 and 46.3%, respectively.

Six-factor solution. The second-factor analysis was madeusing the same variables as in the first-factor analysis, namelythe 35 variables from the respective instrument. Thevariables emerged in six factors in both the Karen-patientand the Karen-personnel instruments. The six factors(Table 1) in the Karen instruments were labelled and termedin accordance with their meaning. The interpretation wasmade from a nursing care perspective using the four centralconcepts (person, environment, health and nursing) thatidentify the phenomenon of interest to the nursing discipline[20]. Dual loadings were found in four variables in theKaren-patient instrument and in three in theKaren-personnel instrument. One variable, No. 35 ‘The arton the walls makes me depressed’, did not correlate with anyother variable and was thus excluded. Another variable, No.27 loaded 0.41 in Factor 1 and 0.37 in Factor 4. No. 27 wasfinally included in Factor 4 because it was not suitable inFactor 1. Remaining variables in the Karen-patient and theKaren-personnel instruments are 34 and 35, respectively, ofwhich 12 are equally formulated. The total varianceexplained for the Karen-patient instrument was 56% and forthe Karen-personnel instrument 59.2% (Tables 1 and 2).

Reliability

In the first, ‘the confirmatory’ three-factor analyses, theCronbach’s alpha correlation coefficient was 0.88 in theKaren-patient instrument and 0.93 in the Karen-personnelinstrument. In the ‘exploratory’ six-factor analysis, the corre-lations were 0.89 and 0.92, respectively.

The Cronbach’s alpha coefficients, i.e. reliability for thesubscales in the three-factor solution, were 0.96, 0.74 and0.86 in the Karen-patient instrument. For the Karen-personnel instrument, they were 0.88, 0.73 and 0.73 for eachsubscale (Tables 1 and 2), respectively. For the six-factor sol-ution, Cronbach’s alpha coefficients were 0.88, 0.73, 0.66,0.73, 0.58 and 0.62 for each factor, respectively, for theKaren-patient instrument, and 0.85, 0.89, 0.80, 0.74, 0.81and 0.72 for each factor, respectively, for the Karen-personnel instrument (Tables 1 and 2).

Moderate intercorrelations were found in all theKaren-personnel instrument subscales (Tables 3 and 4). Inthe Karen-patient instrument, the subscales integrity andorganization were less intercorrelated with the other sub-scales (Tables 3 and 4).

Discussion

The Karen-patient and Karen-personnel instruments are newand have been developed to measure the quality of nursingcare. Instruments used for measuring the quality of caremust be reliable and valid in several aspects and thus further

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Table 1 Principal component analysis with varimax orthogonal rotation for the Karen-patient instrument with a three-factorsolution according to Donabedian’s triad and a six-factor solution, n ¼ 95

Factor Structure Process Outcome h2 FactorI

FactorII

FactorIII

FactorIV

FactorV

FactorVI

h2

Variable1. I do not receivethe help/care Ineed

0.75 a 0.82 0.73 0.70

2. I did notreceive the help/care I needed

0.60 a 0.69 0.72 0.62

3. My expectationswere not realized

0.70 a (0.43) 0.74 0.68 0.58

4. I am notsatisfied with mystay

0.71 a 0.77 0.67 0.63

5. I have notreceived help tolive with myillness

0.59 a (0.43) 0.59 0.64 0.49

6. Here they areable to find outwhat’s wrong, todiagnose

– – – 0.37 0.61 0.57

7. I have becomehealthier

(0.44) 0.57 0.55 0.59 0.48

8. I was quicklyrelieved from mysuffering

0.65 0.41 0.58 0.51

9. I do not receiveany informationabout mytreatment

0.78 a 0.76 0.55 0.56

10. Now I can gohome and workwith what Iusually do

0.53 0.41 0.54 0.49

11. Now I can gohome and takecare of myself

0.55 0.51 0.53 0.43

12. I am happywith the care/treatment

0.54 a 0.50 0.46 0.55

13. I get to learnabout my illness

0.44 a 0.54 0.40 0.51

14. I feel that Ihave beenparticipating indecisions of mycare/treatment

0.66 0.60 0.74 0.66

15. My care isplanned togetherwith the staff

0.44 0.51 0.70 0.64

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Table 1 Continued


FactorII

FactorIII

FactorIV

FactorV

FactorVI

h2

16. I have beenencouraged andcan live with myillness

0.67 0.55 . 0.52 0.60

17. One receivesan individual andpersonal treatment

0.76 0.69 0.50 (0.50) 0.62

18. One sleepswell here

0.42 a 0.51 (0.47) 0.49 0.51

19. The staffmakes the patientsfeel calm

0.77 0.68 0.68 0.75

20. There isorderliness on thisward

0.66 a 0.56 0.65 0.49

21. The staff isnice, kind, happy,good

– – – 0.49 0.57 0.36

22. The staff isable to motivate,stimulate andencourage thepatient

0.52 a 0.46 0.55 0.50

23. The staffshows noconsideration

0.65 0.64 0.83 0.70

24. The staffshows nocommitment

0.85 0.82 0.78 0.69

25. The staffshows no interest

0.84 0.78 0.72 0.60

26. The staff hasability to vividrealization

– – – (0.46) 0.43 0.53

27. The staffshows no tact ordignity

0.84 a 0.81 (0.41) 0.37 0.49

28. There is apositiveatmosphere

0.66 a 0.48 0.77 0.72

29. The staff iscalm, assured

– – – 0.66 0.48

30. The stafftreats me withrespect

0.39 0.48 0.52 0.65

31. So many staffcategories

0.56 0.53 0.76 0.62

32. There are somany differentstaff memberstaking care of me

0.51 0.54 0.76 0.59

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psychometric testing of the Karen instruments was needed.The objective of this study was to further develop the twoinstruments with regard to construct validity and internalconsistency.

Factor analyses have been made with a confirmatorypurpose in an attempt to test the validity of the instruments[21] and to try to confirm Donabedian’s theory about theS–P–O triad. In the first-factor analysis, a three-factor sol-ution according to Donabedian’s S–P–O triad [5, 11] waspre-determined. The results showed that the 35 items werenot grouped consistently with the three factors in theS–P–O triad. Donabedian’s model was not confirmed dueto many dual loadings, and four items were excluded due toloading below the inclusion criteria. One possible explanationof the result in this study may be that in the development ofthe Karen instruments the focus was on nursing care andthe instruments were inductively developed. The model is atheoretical model based primarily on medical care and hasnot, as far as we know, been psychometrically tested. Sinceour results could not confirm Donabedian’s model, the nextstep in the testing was an exploratory factor analysis. Theselection criterion was an eigenvalue of ��1 [18] resultingin six factors in which the loadings of the variables, and thetotal variances improved. The six factors in Karen-patientwere; Satisfaction with care given, Influence, Staff compe-tence, Caring/uncaring, Integrity and Organization. The sixfactors in the Karen-personnel instrument were: Psychosocialrelation, Commitment, Work satisfaction, Openness/closeness, Competence development and Security/insecurity.The factors that emerged in both instruments appeared to bemore coherent and the distribution of variables seemed tobe logical, thus indicating that the six-factor solution was the

most preferable for measuring the quality in nursing carefrom both a patient and personnel perspective. Good qualityof care has to be individualized; patient focused and relatedto needs. The relationship between the staff and the patientincluding involvement, commitment and concern is of majorimportance. These aspects are all involved in the factorsmeasured by the Karen instruments [22]. These findings arecontradictory to the common opinion that patients are moreconcerned about technical aspects of care. This may be anindication that the Karen instruments really measure thequality of nursing care.

The internal consistency was good both in the total three-factor solution and the total six-factor solution as well as inalmost all the individual factors [19]. In the Karen-patientinstrument, the alpha coefficient in the factor Integrity waslow (0.58). In comparison with other factors, there seemedto be no intercorrelation between the factor Integrity and theother factors or between Organization and some otherfactors. Despite this, it is valuable to find out whether thereare correlations between the subscales as this will make itpossible to draw conclusions about the reasons behind thelack of quality.

The Karen instruments are general and broad, whereasother instruments often focus on some specific dimensionof quality [23–25]. When using the factors in the Kareninstruments, it is possible to measure important dimensionsof the quality of care both from a patient and a personnelperspective. Using the factors, it will also be possible tomeasure causality between patient satisfaction and work satis-faction for example, or competence development and worksatisfaction. One important result in this study is that 12variables with similar content in the Karen instruments

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Table 1 Continued


FactorII

FactorIII

FactorIV

FactorV

FactorVI

h2

33. I have not gotto know the staff

0.68 0.50 0.58 0.46

34. I have a nurseof my own who isresponsible formy care

– – – 0.44 0.38

35. The art of thewalls makes medepressed

0.44 0.38 – – –

Eigenvalue(before rotation)

5.91 3.30 2.19 8.62 2.77 2.36 1.97 1.84 1.50

% variance 16.9 9.4 6.3 25.3 8.1 6.9 5.8 5.4 4.4Cumulative %variance

16.9 26.3 32.6 25.3 33.5 40.4 46.2 51.6 56

Cronbach’s alphacoefficient

0.96 0.74 0.86 0.88 0.73 0.66 0.73 0.58 0.62

The bold values indicate the factor chosen for each item.aMarks the items placed in the‘wrong’ factor.


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Table 2 Principal component analysis with varimax orthogonal rotation for the Karen-personnel instrument with athree-factor solution according to Donabedian’s triad and a six-factor solution, n ¼ 120


FactorII

FactorIII

FactorIV

FactorV

FactorVI

h2

Variable1. We are able totalk to each other

0.61 a 0.51 0.73 0.65

2. We all get onwell together

0.60 a 0.42 0.72 0.62

3. The staffcollaborates

0.70 a 0.60 0.72 0.64

4. There is apositive atmosphere

0.66 a 0.56 0.64 0.59

5. There is noenviousness

0.50 a 0.35 0.64 0.56

6. The patientsreceive anindividual treatment

0.52 0.42 0.63 0.53

7. The staff is nice,kind, happy, good

0.62 a 0.44 0.59 0.60

8. The patients getto know the staff

0.47 a 0.31 0.41 0.38

9. The staff showsno interest

0.82 0.69 0.86 0.83

10. The staff showsno commitment

0.69 0.52 0.83 0.76

11. The staff showsno consideration

0.85 0.75 0.83 0.83

12. The staff abilityto vivid realization

0.78 0.66 0.78 0.75

13. The staff is notable to motivate thepatients

0.66 a 0.56 0.47 (0.45) 0.63

14. The workdevelops me as ahuman being

0.73 0.53 0.80 0.67

15. The work givesme a lot as ahuman being

0.68 0.50 0.78 0.64

16. I feel harmonyin the work

0.61 0.54 0.68 0.64

17. The work givesme satisfaction

(0.47) 0.51 0.53 0.59 0.61

18. There isorderliness on thisward

0.49 a (0.49) 0.48 (0.43) 0.53 0.52

19. They are able tofind out what iswrong, to diagnose

0.56 a 0.33 0.51 0.47

20. We do notconsider each other

(0.46) 0.62 a 0.59 0.68 0.71

21. The staff iscalmed, assured

0.75 a 0.57 0.62 0.65

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remain. If nursing quality is to improve, it is important touse both patients’ views and nurses’ conceptions of goodnursing care when developing frameworks for evaluatingcare. By evaluating care from a patient perspective ratherthan from a nursing perspective, patient outcomes will tell usif the care provided had the desired result or effect on thepatient’s perception of the quality of the care given [26]. In areview defining strategies for quality assurance in hospitals, asynthesis was made from many types of research. The strat-egies concerned the improvement of quality, safety and

rights, giving patients a voice through a complaints system orpatient satisfaction questionnaires. It was found that the strat-egies may be useful to improve quality of care and patientsafety in hospitals [27]. The Karen instruments, tested fordiscriminative power and internal consistency as a measureof reliability in an earlier study [2], and the results from thisstudy regarding validity and reliability are in line with thestrategies presented by Ovretveit 2003 [27]. The instrumentsare designed to measure the quality of care from differentperspectives and point out improvement requirements in

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Table 2 Continued


FactorII

FactorIII

FactorIV

FactorV

FactorVI

h2

22. We cannot talkabout the problems

0.63 a 0.52 0.59 (0.42) 0.58

23. We do not listento each other

(0.40) 0.57 0.48 0.58 0.64

24. Savings haveaffected the patients

20.40 a 0.23 0.55 0.43

25. We never learnanything new

0.57 – 0.66 0.58

26. The patient isnot involved in thetreatment

0.50 a 0.36 0.66 0.61

27. No one isresponsible

0.65 0.44 0.64 0.58

28. The patient hasno say

0.50 a 0.34 0.60 0.54

29. The tasks areperformed routinely

0.67 0.54 0.52 0.61

30. I do not feelsecure in my work

0.47 0.34 0.65 0.54

31. So many staffcategories

0.40 0.17 0.60 0.41

32. I fell no workfellowship

0.59 (0.41) – 0.54 0.60

33. I do not havethe strength for thenursing tasks

0.42 0.49 0.47 0.34

34. No personalcontact with thepatients

0.58 a 0.41 0.43 0.47

35. The staff doesnot make thepatients calm

0.61 a 0.40 0.42 0.48

Eigenvalue (beforerotation)

10.44 3.60 2.17 4.74 4.13 3.23 2.97 2.84 2.78

% variance 29.84 10.27 6.19 13.5 11.8 9.3 8.5 8.1 7.9Cum % variance 29.84 40.11 46.30 13.5 25.3 34.6 43.1 51.2 59.2Cronbach’s alphacoefficient

0.88 0.73 0.73 0.85 0.89 0.80 0.74 0.81 0.72

The bold values indicate the factor chosen for each item.aMarks the items placed in the ‘wrong’ factor.


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specific areas in the quality of care. The instruments couldgive valuable baseline and follow-up data about the percep-tions of patients and personnel regarding the care given, andidentify key areas for continuous quality improvement.

A methodological limitation in this study is that bothnurses and nursing aids were included in the study since

quality in nursing care may be defined differently from anurse’s or nursing aid’s perspective. For instance, nurses havea more advanced education and a supervising role in nursingcare. In summary, the strength of the instruments lies in thecontent in the domains, which is based upon empirical dataas well as the content validity performed by experts [1]. Theresults from the content analysis and the exploratory factoranalysis have been confirmed in earlier studies and they arecharacterized as important aspects of quality [9, 22].

Conclusion

The Karen-patient and the Karen-personnel instruments haveachieved acceptable levels of construct validity. The internalconsistency of the instruments is good. This indicates that itmay be possible to use instruments in clinical practice formeasuring the quality of care. The next step is to use theinstruments to evaluate and to compare the perceptions ofpatients and personnel concerning the quality in nursing care.

Funding

The authors greatly appreciate the research grant receivedfrom Linkoping University and The Swedish MedicalResearch Council of Southwest Sweden, no F96-461.

References

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 4 Spearman rank correlation coefficient between thefactors in the Karen-personnel instrument, n ¼ 120

Factor I II III IV V VI

I Psychosocialrelations, 8items

–

IICommitment,5 items

0.51* –

III Worksatisfaction, 6items

0.52* 0.37* –

IV Openness/closeness, 5items

0.51* 0.47* 0.35* –

VCompetencedevelopment,5 items

0.62* 0.56* 0.47* 0.43* –

VI Security/insecurity, 6items

0.41* 0.52* 0.37* 0.41* 0.51* –

*P � 0.001.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 3 Spearman rank correlation coefficient between thefactors in the Karen-patient instrument, n ¼ 95

Factor I II III IV V VI

I Patientsatisfaction,13 items

–

II Influence,4 items

0.52* –

III Staffcompetence,5 items

0.45* 0.57* –

IV Caring/uncaring, 5items

0.50* 0.13 0.25 –

V Integrity, 3items

0.14 0.18 0.15 0.22* –

VIOrganization,4 items

0.34 0.17 0.26 0.40* 20.013 –

*P � 0.001.


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22. Attree M. A study of the criteria used by healthcare pro-fessionals, managers and patients to represent and evaluatequality care. J Nurs Manag 2001;9:67–78.

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27. Ovretveit J. What Are the Best Strategies for Ensuring Quality inHospitals? Copenhagen, Denmark: WHO Regional Office forEurope’s Health Evidence Network (HEN), 2003.


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