Journal of Pain and Symptom Management
Volume 38, Issue 5 , Pages 708-716, November 2009

Understanding the Association Between Employee Satisfaction and Family Perceptions of the Quality of Care in Hospice Service Delivery

  • Grady S. York, EdD

      Affiliations

    • College of Business Administration, Belmont University, Nashville, Tennessee, USA
    • ,
  • Janet L. Jones, BSN, FAAMA

      Affiliations

    • Alive Hospice, Nashville, Tennessee, USA
    • Corresponding Author InformationAddress correspondence to: Janet L. Jones, BSN, FAAMA, Alive Hospice, 1718 Patterson Street, Nashville, TN 37203, USA.
    • ,
  • Richard Churchman, DBA

      Affiliations

    • College of Business Administration, Belmont University, Nashville, Tennessee, USA

Accepted 1 April 2009. published online 25 August 2009.

Article Outline

Abstract 

Families often draw their conclusions about the quality of care received by a family member during the last months of life from their interactions with professional caregivers. A more comprehensive understanding of how these relationships influence the care experience should include an investigation of the association between employee job satisfaction and family perception of the quality of care. This cross-sectional study investigated the association at a regional hospice. Using the Kendall's tau correlation, employee satisfaction scores for care teams trended toward a positive correlation with family overall satisfaction scores from the Family Evaluation of Hospice Care (τ=0.47, P=0.10). A trend for differences in employee satisfaction between the care teams to associate with differences in overall family perceptions of the quality of care also was found using the Kruskal-Wallis analysis of variance (χ2K-W=9.236, P=0.075). Post hoc tests indicated that overall family perceptions of quality of care differed between the hospice's Residence Team and Non-Hospice Facilities Team. Finally, positive associations between employee satisfaction and the families' Intent to recommend hospice (τ=0.55, P=0.059) and Inform and communicate about patient (τ=0.55, P=0.059) were noted. Selected employee and family comments provide complementarity to further clarify or explain the respondent data. These results suggest that employee satisfaction is associated with family perceptions of the quality of hospice care. Opportunities for improving both employee job satisfaction and family perceptions of the quality of care are discussed.

Key Words: Hospice, employee satisfaction, family satisfaction, quality of care, hospice service delivery

 

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Introduction 

In the United States, the hospice service delivery system is uniquely designed to interact with patients and families who are confronting death. The close and personal relationships that develop between employees, and patients and families facing end-of-life issues often influence the perceptions of the quality of care. Complex encounters between hospice personnel, and patients and families influence both employee satisfaction and patient and family expectations of service value.

Understanding the association between patient and family expectations of service quality and interactions with hospice employees is essential in constructing a hospice service delivery system that provides optimal quality of care for patients and families during the last months of life. Among the factors that should be recognized in quality improvement efforts is the potential impact of employee satisfaction on family perceptions of the quality of care. Consequently, the need arises for further examination of the association of employee satisfaction with family perceptions of the quality of care.

Research focusing on the employee-customer relationship reflects the growing recognition that achieving superior service quality for the customer depends, in part, on the satisfaction of employees. The service-profit chain model advanced by Heskett et al. establishes the association between employee satisfaction, productivity, and retention with service value and quality, resulting in customer satisfaction and loyalty, ultimately impacting profitability and growth.1 Defining perceptions of service quality by these associations provides a consistent framework for evaluating critical processes and developing performance measures for assessing performance in achieving the organization's goals and objectives. Heskett et al.2 and Reichheld3 concluded that there are direct and quantifiable links between customer variables, employee variables, and financial results. Other studies in commercial business conclusively establish the association between employee satisfaction, customer satisfaction, and loyalty with financial performance.4, 5, 6, 7, 8, 9

In the health care experience, the patients draw conclusions regarding the quality of service from their interactions with professional caregivers based on the perception that care is responsive to individual patient needs.10 Donabedian argues that management of these interpersonal relationships to deliver technical care is key to successful outcomes.11 Although the importance of managing all the interdependent aspects of service delivery has been established, most research has focused on employee or patient satisfaction independently.12, 13 However, studies that have examined both provide evidence that employee satisfaction is related to patient's perceptions of quality of care.14, 15, 16, 17 Further studies have indicated that employee satisfaction influences staff retention and may be associated with patient satisfaction and likelihood of referral or recommendation.18, 19, 20, 21

Perceptions of family satisfaction with care are often the result of the accumulated interactions with staff throughout the episode of care. These interactions often reflect the context of the employee's satisfaction with their job and are related to the quality of care patients and families receive. The principal objective of this study was to examine the association of employee satisfaction and family perceptions of the quality of care in hospice service delivery.

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Methods 

The study was conducted at a Middle Tennessee hospice providing services in a 12- county service area. At the time of the study, the hospice services were delivered in an inpatient hospice-owned facility, homes, hospitals, and long-term care and assisted living facilities. Selected data sources included the hospice's annual Employee Feedback Surveys as well as family satisfaction surveys and performance reports. The Family Evaluation of Hospice Care (FEHC) was also used for the time period available.22

Data Collection and Compilation 

Initial data were sourced from hospice records covering the years 2001–2005. The data for this period were aggregated at the hospice level and served as the basis for trend description and historical understanding of employee and family satisfaction survey outcomes at the hospice. For this purpose, data for employee satisfaction were compiled from 323 employee satisfaction surveys and 2,770 family satisfaction surveys administered during the period, with a response rate of 51.8% and 31.1%, respectively. From the five-year period, the 2005 year was selected for cross-sectional analysis, as it was the first full year of the FEHC for which the hospice's employee satisfaction survey could be compared.

Employee Sample and Satisfaction Survey 

The data for employee satisfaction measures were collected from the annual Employee Feedback Survey for 2005. Of the 206 employee surveys distributed, 101 were returned, for a response rate of 49%. Participants included employees from eight hospice teams. These include six interdisciplinary teams by region: east, north, south, and west; two facility-based teams (hospice-owned residence and all other non-hospice facilities) and two overall support teams (Grief Center and Administration). Table 1 presents the characteristics of employee participants.

Table 1. Characteristics of Employee Participants (n=101)
Characteristicsn%
Gender
Men1716.8
Women8483.2

Age (years)
20–3054.9
31–401413.9
41–503736.6
51–603433.7
60+1110.9

Ethnicity
Caucasian8786.2
African American1211.8
Asian11.0
Hispanic11.0

Education
High school1211.8
Some college2726.8
College degree2625.8
Some graduate76.9
Graduate degree2928.7

Primary occupation
Nurse4645.6
Administration2726.8
Social worker1110.9
Nursing assistant98.9
Chaplain54.9
Other32.9

Years at present organization
Less than 11110.9
1–23534.7
3–52726.8
6–102019.8
11–2065.9
20+21.9

Team
East87.9
Non-Hospice Facilities87.9
North76.9
Residence2726.8
South109.9
West98.9
Grief Center54.9
Administration2726.8

The employee satisfaction survey consists of 32 items scored on a 10-point Likert scale. The items evaluate measures of employee satisfaction which, based on a review of current literature and research, have been shown to have an impact on the overall satisfaction and performance of employees in health care, as well as other work environments.23, 24, 25, 26, 27, 28 Surveys were aggregated at the team level for analysis.

To calculate an average score for each item by team, scores for each employee were summed and divided by the total number of responses for each item. An overall measure of satisfaction rating for each team was constructed by summing the average score for all questions and dividing by the number of questions. Additionally, respondents were asked to provide comments regarding how their work experience could be improved. These comments were compiled for complementarity and provide insight into the interpretation of the quantitative measures. Selected comments are included in the Discussion.

Family Sample and Satisfaction Survey 

To determine the overall family perception of the quality of care, the FEHC was used. The hospice began using the FEHC in 2004, but for purposes of this study, only surveys from 2005, the first full year of data, were considered in the analysis. For the survey year, 1,686 surveys were mailed to families or caregivers of decedents. Of this number, 599 were returned, for a response rate of 35.5%. Table 2 presents the characteristics of decedents and respondent relationship.

Table 2. Characteristics of Decedents and Respondent Relationship (n=599)
Characteristicsn%
Decedents
Gender
Men28046.7
Women31953.3

Age (years)
25 or younger40.7
26–49325.3
50–7424340.6
75 and over32053.4

Ethnicity (n=579)
Caucasian53191.7
African American386.6
American Indian61.0
All other40.7

Primary cause of death (n=463)
Cancer30565.9
Cardiovascular disease449.5
Lung disease357.6
Dementia214.5
Other5812.5

Respondents (n=586)
Relationship to decedent
Spouse/partner28047.8
Child16227.6
Parent8314.2
Sibling233.9
Other386.5

The FEHC assesses the perceptions of the quality of care by the family during the dying process as well as the bereavement period following the patient's death. Evaluation of hospice services through the FEHC offers insight into constructing a service delivery system that provides high quality of care for patients and families during the last months of life. The FEHC survey has been created for use by hospices through the efforts of the National Hospice and Palliative Care Organization and Brown Medical School Center for Gerontology and Health Care Research.22 Participation in the FEHC survey is voluntary.

For overall family satisfaction with hospice care, the question “Overall, how would you rate the care the patient received while under the care of hospice?” was examined. Responses to this question were scored on a five-point Likert scale. As stated above, intent to recommend has been associated with patient satisfaction. The question “Based on the care the patient received, would you recommend hospice service to others?” was included in the analysis. For this response, the survey requires a “yes” or “no” response. For purposes of this study, these responses received a score of 1 or 0, respectively. Additionally, the FEHC consists of questions that address four specific domains of care: Coordination of care, Attend to family needs, Inform and communicate about patient, and Provide information about symptoms. Each domain comprises items scored on a Likert scale from 1 to 4, where 4 represents a positive response and 1 represents a negative response, and items scored with a “yes” or “no” response. For study purposes, all item scores were converted to a dichotomous score, where optimal or affirmative responses received a score of 1, whereas negative responses received a score of 0.

The hospice care team is identified for each patient and family on the FEHC. As such, the respondent scores were aggregated at the team level for this study. For overall family satisfaction, the average satisfaction score was calculated. The dichotomous scores for likelihood to recommend were calculated on a team level, with each team being assigned a score between 0 and 1 based on all responses. To analyze the four domains at the hospice team level, subset responses were converted to a dichotomous score and the average of all subset responses for a domain was calculated. Based on this average, a domain score was assigned. For instance, a respondent including all affirmative or desired responses to the three subset items for “Inform and Communicate about Patient” would be scored at 4, where possible averages to the subset questions are 4 if 3/3, 3 if 2/3, 2 if 1/3, or 1 if 0/3. An average domain score can then be calculated. The survey also provides for open-ended comments from respondents. Comments were compiled and a small number included in the Discussion for insight into the interpretation of the data.

Data Analysis 

Characteristics of the data, context of the service delivery, and sample limitations were considered in selecting a technique to conduct the study. Investigation was initiated with a simple trend line of employee satisfaction with family perceptions of satisfaction over a five-year period. Second, a cross-sectional analysis of 2005 data (first full year of FEHC) examined the association between employee satisfaction and family perceptions of the quality of care at the hospice team level. Nonparametric correlation, Kendall's tau, was used to test for association between employee satisfaction and family perceptions of the quality-of-care measures. The Kendall's tau coefficient is the appropriate nonparametric measure of association when data do not meet parametric assumptions, are at least at the ordinal level, and sample size is relatively small.29, 30 Given the small sample size, P-values equal to or less than 0.10 are reported.

To examine possible differences in overall family perceptions of the quality of care, family respondents were grouped by interdisciplinary team, and the Kruskal-Wallis analysis of variance (ANOVA) was used. The Dunn multiple comparison procedure was used to undertake post hoc comparisons to determine which teams differed significantly. The Holms step- down procedure was used to adjust for inflated Type I error.

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Results 

The Kendall's tau correlation coefficient was used to examine the extent to which employee satisfaction scores were associated with Family perceptions of quality of care, family's Intent to recommend hospice, and the domains of care: Coordination of care, Attend to family needs, Inform and communicate about patient, and Provide information about symptoms. Table 3 presents the results of the correlational analysis for all teams. The results of this analysis (τ=0.47, P=0.10) reveal a trend that teams with higher employee satisfaction scores were positively associated with families that reported higher perceptions of the quality-of-care scores. Additionally, Table 3 shows an association between the employee satisfaction and the families' Intent to recommend hospice (τ=0.55, P=0.059) and Inform and communicate about patient (τ=0.55, P=0.059). The procedure noted no significant association with Coordination of care, Attend to family needs, and Provide information about symptoms. Table 4 shows the mean score and standard deviations for the six dependent variables by hospice interdisciplinary team.

Table 3. Kendall's Tau Correlation Coefficients for Association Between Employee Satisfaction and Family Perceptions of Quality of Care, Intent to Recommend Hospice, and Domains of Care
Employee Satisfaction
Family Perception VariablesτP
Family perceptions of quality of care0.470.100a
Intent to recommend hospice0.550.059a
Coordination of care−0.040.900
Attend to family needs0.110.705
Inform and communicate about patient0.550.059a
Provide information about symptoms−0.040.900

aSignificant α=0.10.

Table 4. Univariate Association of Family Perception Variables for Hospice Interdisciplinary Teams
Team
Family Perception VariablesEastNon-Hospice FacilitiesNorthResidenceSouthWestP
Respondents (n=573) 11462821289592
Percentage (%) 19.910.814.322.316.616.1

Variables
Family perceptions of quality of careMean4.6754.4684.5494.7814.7264.6960.100a
SD.698.900.863.451.591.835

Intent to recommend hospiceMean0.9820.9680.9641.0000.9790.9570.059a
SD.132.178.1870.144.205

Coordination of careMean3.7183.7933.6833.7183.8113.7470.900
SD.651.554.606.564.598.607

Attend to family needsMean4.6554.6484.3134.5384.6634.5950.705
SD.747.5581.014.676.686.746

Inform and communicate about patientMean3.5753.5263.4003.6833.5753.5980.059a
SD.839.782.936.657.802.839

Provide information about symptomsMean4.6674.9174.5884.7864.7324.8480.900
SD.783.282.957.594.775.515

aIndicates variable significance, with team employee satisfaction at the 0.1 level.

The results of the Kruskal-Wallis test, Table 5, indicate that there were significant differences between the interdisciplinary teams with regard to overall family perceptions of the quality of care as scored on the FEHC (χ2K-W=9.236, P=0.075). Post hoc analyses using the Dunn multiple comparison procedure indicated that families of decedents from Team 2, who cared for patients in all other non-hospice facilities, submitted lower overall scores for perceptions of the quality of care than families in the hospice-owned residence and the West home care team. The Residence Team and Non-Hospice Facilities Team reflect the highest and lowest average family score, 4.781 and 4.468, respectively. For employee satisfaction, these teams reflected similar rankings, with the Non-Hospice Facilities Team having the second lowest score and the Residence Team scoring highest among the care teams.

Table 5. Kruskal-Wallis ANOVA for Family Perceptions of Quality of Care Grouped by Hospice Interdisciplinary Team (n=573)
TeamnMeanRangeχ2K-WP
Team 1: East1144.6751–5
Team 2: Non-Hospice Facilities624.4681–5
Team 3: North824.5491–59.2360.075a
Team 4: Residence1284.7813–5
Team 5: South954.7262–5
Team 6: West924.6961–5

Total sample size adjusted for observations with missing data.

aSignificant α=0.10.

As an association was found to exist for the two variables (1) Families' intent to recommend hospice and (2) Inform and communicate about patient, a second Kendall's tau coefficient was used to examine the association with family perceptions of quality-of-care score to these specific variables. The results in Table 6 indicate that families with higher overall perceptions of quality of care also reported higher scores for Families' intent to recommend hospice (τ=0.48, P=0.095) and Inform and communicate about patient (τ=0.78, P=0.007).

Table 6. Kendall's Tau Correlation Coefficients for Association Between Family Perceptions of Quality of Care, Intent to Recommend Hospice and the Domains of Care
Family Perceptions of Quality of Care
Intent to recommend hospice0.480.095a
Inform and communicate about patient0.780.007a

aSignificant α=0.10.

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Discussion 

For both hospice employees and the patients and families for whom they care, the dying process is a transformational experience filled with a multitude of complex medical, grief, and loss issues. The interpersonal relationships through which care is delivered often influence perceptions of job satisfaction for employees, as well as perceptions of service quality for patients and families. The results of this cross-sectional study contribute further evidence in support of the arguments proposed by the service-profit chain model and support long-standing beliefs and anecdotal evidence by practitioners about the positive association between employee satisfaction and perceptions of quality of care. These relationships find further meaning in employee comments such as “…I go home at night and believe I made a difference.”

Analyses suggest that as employee satisfaction increases, family perceptions of the quality of care increase as well. Actively engaged employees who are satisfied with their jobs are perceived by families as providing value to the services that contribute to high quality of care during the last months of life. Therefore, hospices may want to focus quality improvement efforts on those core organizational processes that contribute to employee job satisfaction and appear to positively influence overall family perception of quality of services.

A potential process or factor to consider may be communication of the patient's condition and information from caregivers to families. In the analyses, a positive association was noted for both employee satisfaction and family perceived satisfaction with the quality of care with the variable, Inform and communicate about patient. That is, both employees and families associated communication of information regarding the patient as a key factor influencing overall satisfaction. These results would suggest that hospices develop well-defined channels of communication that provide adequate information to families on a regular basis. Employee job satisfaction may be positively influenced by training aligned to improve employee/family communication. Family perceptions of the importance of communication are reflected in comments such as “…always ready to answer questions…their communication with my family was superb.” Selected employee comments provide further insight into the data. When asked on the survey “What, if anything, can we do to improve your work experience…?”, comments frequently involve “Help me communicate better.”

When examining the differences in family perceptions of the quality care by team, the lowest scores reported by families occurred in situations where the patient was being cared for in a non-hospice facility. This team also reflected the second lowest employee satisfaction score. The highest reported perception of care was received from families where the decedent was cared for in the hospice-owned residence. Employee satisfaction for the Residence Team was scored highest. These findings support the proposition that as employee satisfaction increases, family perception of the quality of care increases. These differences may indicate that location of care and coordination of care activities with non-hospice facilities influence both employee satisfaction and families' perceptions of care. These care situations may present more challenge to the care team and family.

Employee satisfaction and family perceptions of the quality of care were positively associated with the families' Intent to recommend hospice. Scores for intent to recommend display a positive skewness for the hospice teams (range 0.95–1.0). Of the 576 surveys with responses, 14 (2.4%) respondents reported “no,” whereas 562 (97.6%) responded “yes” to their Intent to recommend hospice. Comments made by families on the FEHC offer further insight: “I would highly recommend the hospice team. They are a very special team…” and “I was so satisfied with the service provided… would recommend to anyone.” Individual family responses underscore the association between satisfaction scores, and that Intent to recommend hospice requires excellence in satisfaction. Opportunities for improvement may be limited given the significantly high range of scores.

Although this study did not find a significant association between employee satisfaction and Coordination of care, Attend to family needs, and Provide information about symptoms, more investigation is needed. Increased sample size and expanded representation of hospice organizations may improve the power of the statistical tests to detect significance.

In conclusion, the study found a positive association between employee satisfaction and perceptions of the quality of care by families of decedents. The outcomes of the analyses suggest that the job satisfaction of employees and perceived quality of care by families are positively associated with meeting the communication needs of the family. Although families generally score intent to recommend positively, there is benefit in examining this indicator further to more fully understand overall family perceptions of quality of care. Given these findings, we believe that developing initiatives that seek to improve or strengthen employee satisfaction and family perceptions of the quality of care are consistent with the studies of organizational assessment and evaluation proposed by Kaplan and Norton's balanced scorecard and enhanced by emerging precepts of the Baldrige Health Care Criteria for Performance Excellence, where high-performance management practices lead to improvements in outcome measures.31, 32

Several limitations in the study should be noted. The sample was drawn from a single hospice in one geographical location and thus may not be generalized to other hospices. Nonparametric measures were used due to the sample size and data characteristics. These restrictions may limit the power of some of the analyses to detect significance with larger sample sizes. The data are cross-sectional so that causal relationships among employee satisfaction and family perceptions of quality of care cannot be examined. The type of patients and service settings can differ considerably for each hospice team. These factors may further complicate the relationship between employee satisfaction and family perceptions of the quality of care.

Future research should focus on a more representative sample of hospices and include more robust statistical methods, such as structural equation modeling, to concurrently validate the causal association between the variables within the entire hospice service delivery system.33 With this in mind, the researchers are currently undertaking a study to investigate the specific dimensions of employee satisfaction that are associated with family perceptions of quality of care and analyzing how these may be associated with other performance outcome measures. The vital process interactions and associations identified in this research may be beneficial to hospice leadership in designing, implementing, and improving the quality of care in the hospice service delivery system.

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Acknowledgments 

The authors wish to thank the employees of Alive Hospice, the Alive Institute and the Nashville Center for Non-Profit Management for their contributions and support in the study and assistance in preparing this article. The authors gratefully acknowledge the assistance of Melissa Puri as research associate and her many hours of literature review and data base mining.

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PII: S0885-3924(09)00637-X

doi:10.1016/j.jpainsymman.2009.03.002

Journal of Pain and Symptom Management
Volume 38, Issue 5 , Pages 708-716, November 2009

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