Overall, nursing staff from all units were satisfied with the quality of care in their units, with 97.7% of nursing staff reporting that their units had very high or rather high quality of care. In comparison, in nursing homes 93.3% of staff in Swiss gave a high or very high rating to the quality of care, 80% of nursing staff in Germany rated the good quality of care;[11, 24] While in the research on hospital, a large study over 12 countries found that the percentage of good quality of care rated by nurses was from 53% in Greece, 65% in Germany, 80% in Switzerland, and 84% in the USA, and to 89% in Ireland.[25] So we guess that the quality of care rated by staff are highly inflated anyway so that it makes sense to contrast the very high quality of care with rather high quality of care are. And we think of very high quality of care equals to Good Quality and rather high quality of care equals to Good Quality with some problems.
Our finding that a higher score on the relationships and communication scale was associated with higher quality of care was similar to previous research.[26] Nursing staff in this study perceived relationships and communication levels in their units to be somewhat lower than the relationships and communication levels in a study conducted in Australia.[21] A high level of communication was a key factor in resident health outcomes, as it allowed staff to receive support and knowledge from peers and to share knowledge more deliberately, and from a series of different perspectives.[27] In addition, in the present study a lower score on work stress was significantly related to higher quality of care. Reducing work stress by 10 and 20 points, the odds of the highest quality of care increased to 1.221 and 1.492, although the OR for work stress in the model (increasing work stress by 1 point) was very close to one (0.980). This is consistent with the findings of the Swiss nursing home study, which noted that high stress due to workload was related to decreased quality of care.[11] The results suggest that management interventions could focus on promoting staff communication and reducing work stress in order to achieve higher quality of care.
Work experience influenced the quality of care by affecting the level of communication and relationships and the level of work stress that nursing staff perceived. Contrary to our expectations, more work experience was associated with higher work stress and lower quality of care. In this study, among all staff who were working flexibly, the percentage of nursing staff who had been working for more than five years (56.6% or 57.8%) is obviously higher compared to nursing staff who had been working for less than five years (38.9%). We found that nursing staff working flexibly scored higher on work stress than those working according to a fixed schedule. Nursing staff in Chinese nursing homes were characterized by their low levels of education and lack of necessary knowledge to care for residents, especially in Hunan, while experienced nursing staff were often asked to care for very ill residents and to handle sudden changes in residents’ health.[6, 28] A recent study in China found that nursing staff with considerable work experience often worked flexibly without a set number of residents, and were more likely to be involved in assisting when adverse events occurred, which might be a reason for them to report higher work stress and lower quality of care.[28] In addition, in China, as in the developed counties, difficult existed in the retention of nursing staff.[29] The high turnover rate of nursing staff led to shortages of experienced workers. In this study, only 12.6% of nursing staff had more than 10 years of experience. A few nursing staff with rich experience in caring for residents were required to care for a large number of high-dependent residents with complex medical conditions. Highly dependent residents asked for high professional requirements in the nursing staff, which led experienced nursing staff to perceive a high pressure environment in caring for residents. This finding indicates that nursing home managers need to reconsider the work schedules of experienced nursing staff and they need to provide them with strong support, such as taking steps to decrease their stress levels and encouraging the development of coping skills to handle stress more effectively. In addition, management interventions could focus on improving the professional abilities of low-seniority nursing staff, which would help decrease stress levels in experienced staff. Management interventions need to focus on decreasing the turnover rate and enhancing the overall working experience of nursing staff in nursing homes.
The interaction effect between the nursing staff to resident ratio and physician to resident ratio on quality of care was significant, and significantly, nursing staff rated care as being of the highest quality when the nursing staff to resident ratio was more than 0.44 and the physician to resident ratio was less than 0.07. This is in agreement with previous research, which found that staffing levels and quality of care had a complicated non-linear relationship.[9] It appears that higher staffing levels are correlated with better quality of care, however, this is not the case for financial constraints.[30] Our study also found that staff earned the highest wages when the nursing staff to resident ratio was more than 0.44 and the physician to resident ratio was less than 0.07. Overstaffing might reduce personal income and lead to a reduction in staff engagement at work.[30] More daringly, we suggest there could be a range between low staffing levels and high staffing levels, in terms of which nursing homes could achieve the highest quality of care possible, however, more research is required to explore an accurate range of what would be the most appropriate staffing levels in Chinese nursing homes. The interaction effect between nursing and physician staffing levels not only impacts quality of care, but also work stress, teamwork and leadership. Under the above mentioned staffing levels, not only did care reach the highest quality, but the teamwork and leadership scores were also obviously higher, and the scores on the work stress scale were obviously lower than the scores under any other staffing levels seen in this study. This indicates that work stress, teamwork and leadership might be factors contributing to this non-linear relationship. Further studies are required to explore these complex relationships. This study finding might provide significant references for the government to set nursing and physician staffing standards in nursing homes.