Chapter 2

RELATED LITERATURE AND STUDIES

This chapter presents literature and studies that have certain relations to the

current study. Presumably, the quality of service in hospitals pertains to the overall

manpower competency of the health care team alongside the availability of resources

and patient compliance as well. That includes the quality nursing care provided to

patients. Health economics would not generally dictate which type of agency provides

better nursing care; rather, it is affected by other factors such as patients’ perceived

effectiveness but the perception of the health care providers- doctors, nurses and other

hospital personnel- and the general public as well. Nursing education has its own

interpretations regarding quality of nursing services rendered by student nurses who

aspire to be part of the health care delivery system. This depends also with factors

affecting their performance.

Related Literature

In Australia, as quoted by Croakey (2009), if the private sector provides

additional services, it requires a larger health workforce. These doctors, nurses and

allied health workers are likely to come from public hospitals, thus further depleting

the capacity of the public system. Dr. Herr (2008) compared the cost and technical

efficiency of three types of German hospitals: public, profit, and non-profit private. Its

main finding was that “both private and non-profit hospitals are less efficient than

public hospitals in Germany”. One of the reasons is that private hospitals were paid on
 13

daily rate, thus increasing the hospitals incentive to increase the hospital length of

stay. Herr stressed that health economics tend to ignore hospital quality. Being a

technologically- advanced facility does not correspond automatically to quality; some

hospitals might have facilities and equipment that patients may value but do not affect

their health. An article from [Link] (2008) imparted that “since

the private hospitals offer better facilities they are extremely costly at times; although

there are abundant qualified doctors in a public hospital, a private hospital offers a

better health care treatment”.

Lee and Wan (2008) said that it is important in research to know which aspects

of efficiency are being compared between private and public hospitals. The authors

conducted a study among hospitals in Korea which revealed different conclusions on

three aspects of efficiency: financial, technical and service. Private hospitals in Korea

have higher financial efficiency due to clarity of their organizational goals while

public hospital employees focus on improving their technical efficiency due to

evaluation purposes. Meanwhile, public hospitals’ service efficiency from private ones

is indifferent. Using the 2002 data from 32 Korean hospitals and using a matching

method (16 public versus 16 private hospitals), this study compares Financial

Efficiency (FE), Technical Efficiency (TE) and Service Efficiency (SE) between

public and private hospitals. This research tests three hypotheses. The first hypothesis,

that private hospitals will have higher FE than public hospitals is supported by the

empirical findings. The second hypothesis, that public hospitals will have higher TE

than private hospitals is also supported. The third hypothesis, that private hospitals

will have higher levels of SE than public hospitals have, is not supported. Private
 14

hospitals have clear organizational goals that lead to higher FE. Public hospitals, in

contrast, are less eager to improve FE than to improve TE because they are evaluated

based on TE. The quality of services (i.e. SE) provided by public hospitals is

indifferent from that of private hospitals. It is important to remember which aspects of

efficiency we are dealing with when comparing between public and private hospitals.

As found in a website, Boston College (2007) stated that the Roy adaptation

model believes that human system has a cognitive and regulatory component

embedded in the consciousness and meaning, to make adjustments effectively as the

environmental change happens constantly.

Education, according to the American Association of College of Nursing

(AACN, 2006) has a significant impact on the knowledge and competencies of the

nurse clinician, as it does for all health care providers. Nurses are prized for their skills

in critical thinking, leadership, case management, and health promotion, and for the

ability to practice across a variety of inpatient and outpatient settings. The Brown

report of 1948 (Daniels, 2004) paved the way for the continuing evolution of nursing

education that enabled nurses to demonstrate greater professional competence. Along

with the function of providing care, Kozier (2004) defined other functions of hospitals

as institutions providing sources for health- related research and teaching.

Hospitals can be classified according to ownership or control (Kozier, 2004).

They may be government- or in a public ownership sustained by the state, or private.

Private hospitals are further classified as profit or non- profit. The economics

surrounding the health care delivery system may create a relationship between cost

and technical efficiency of hospitals. Other papers such as Brown (2003) found that
 15

non-profit hospitals are the most technically efficient. Public hospitals, therefore, have

the possibility to have an edge over private hospitals in terms of efficiency, due to the

variety of services they render and the wider scope of client accommodation.

Related Studies

The nurse is the ambassador towards health and wellness, simply because it is

the nurse who is in constant and close contact with clients. The success and failure of a

therapeutic regimen depends on the accomplishment of the nursing care process. With

this, Jordan et. al. (2007) stated that nurses should be geared with adequate nursing

skills (with knowledge and attitude). This includes not only the actual delivery of

nursing interventions in the hospital setting, but also the efficient use of technology

and communication techniques. Nursing education is the most appropriate venue to

relay and apply the foundations of nursing.

In the Filipino setting, even when there is a shortage of nurses or new

graduates exceed the demand however, some patient needs are still not met. It really

takes extra time management vis - a- vis proper nursing skills to accommodate every

need of patients. Hospital policies vary and therefore may hinder or improve patient

conditions whether it is physically or psychologically.

The thesis of Jordan, et. al. added that there are limitations to the nursing

students’ capacity to perform in the actual hospital setting, in both the private and

public hospitals. Such are differences in equipment available, the guidelines imposed

by the agencies in relation to performing procedures and protocols that may either

allow or hinder students to maximize their related learning experiences, and the
 16

characteristics of the clientele. The thesis contained a comparative study on the

effectiveness of skills performance of nursing students in private and public hospitals

in Tarlac City as perceived by the nursing students themselves, using a survey

questionnaire filled by 88 respondents. Based on the study, it was concluded that

private and public hospitals are significantly different in the development of skills and

attitude of nursing students. The difference was determined by the relationship

between personal attributes of the respondents such as languages or dialects spoken

and perception of the respondents with private and public hospitals.

Taner and Antony (2006) published an examination on the differences in

service quality between public and private hospitals in Turkey. The study had 200

outpatient respondents. Through the identification of 40 service quality indicators and

the use of a Likert-type scale, two questionnaires containing 80-items were developed.

One measured patients' expectations prior to admission to public and private hospital

service quality and another measured patient perceptions of provided service quality.

As a turnout, patients in the private hospitals were more satisfied with service quality

than those in the public hospitals, also with doctors, nurses and supportive services in

the private ones. Satisfaction in public hospitals was only determined by patients’

satisfaction on doctors and low hospitalization costs.

The study by Andrews and Salamonson (2006) was on the influence of age,

ethnicity and part- time employment on nursing students’ performance for second year

pathophysiology and nursing practice subjects in a regional university in Australia.

Based on the study, 78% of the students were partly employed while studying and

majority in nursing- related work. Although demographic variables such as gender,

knowledge, age and the place of exposure positively affects the said experiences in the

hospital setting, there is increasing pressure for nursing students to participate in part-

time employment while undertaking higher education and this may negatively affect

their academic performance due to lessened time allotted for learning.

According to the undergraduate thesis by Taban (2005), which was an

evaluation of NCM 104 Related Learning Experience program of CLDH- EI for the

first semester of 2005- 2006, problems of the students affecting their performance was

mainly financial; clinical instructors had problems on imparting learning due to non-

fixed schedules, unavailability of amenities and inadequacy of equipments. Through a

descriptive study with 50 respondents, it was concluded that students are satisfied with

their clinical instructors and problems were tolerated such that they were able to

perform regardless of such. There was a relationship established on the clinical

instructors’ performance and problems encountered with students’ performance.

Sanchez (2005) and other researchers conducted a study on the skill

competencies in NCM 104 students of CLDH- EI. It was similarly a descriptive study

involving a five- point Likert scale patterned on the five phases of the Nursing Process

(Assessment, Diagnosis, Planning, Implementation and Evaluation). Based from 100

respondents, the study proved the efficiency of NCM 104 students in applying the

Nursing Process. Also, facilities in school, the teacher- learning process and

opportunities for adequate exposure were factors in developing students’ knowledge

and skills.

Meanwhile, De Guzman (2004) alongside co- authors determined the factors

affecting the clinical performance of fourth year students from CLDH- EI in their
 18

exposure at TPH. Making use of a survey research design and obtaining 92

respondents, the main factor determined that affects correct and efficient performance

of the respondents in the clinical area is the student- related variable. This

encompasses the students’ confidence level, willingness to learn, cooperation to

learning and own personalities. Then again, competence of clinical instructors greatly

influences students to perform effectively. Despite the determination of the factors, the

effects of such have been found to be minimal.

Synthesis

Croakey (2008) discussed the decreased capacity of the public work force due

to shifting of health workers to private sectors. This reveals that if private sectors

provide additional services, additional health workers are also needed. His study

differs from the current study in terms of overall manpower competency of health care

team between private and public hospitals while the current study focused more on the

common procedures performed between public and private hospitals. The literature by

Dr. Herr (2008) was based on the concept of health economics versus efficiency of the

health care facilities, which tends to be inversely proportional. Dr. Herr’s main finding

was that both private and non-profit hospitals are less efficient than public hospitals in

Germany. The current study reveals that nursing procedures commonly performed by

their respondents can be affected in terms of the availability of the equipments and

facilities between private and public hospitals. Lee and Wan (2008) became more

specific in terms of comparing the efficiency between private and public hospitals by

limiting their study in terms of three particular aspects of efficiency. Furthermore, the
 19

above mentioned study stated how factors such as facilities and quality of treatment

affect the aspects of efficiency between a public and private hospitals. Hence the

concept of their study is somehow related to the current study in which aspects of

efficiency are being compared between public and private hospitals.

As from AACN (2006), nursing education becomes essential for the

developmental of nurses characteristics that enable them to adapt to change in

different health care settings. This shows a relationship with the current study wherein

factors such as knowledge and competencies of nurses are given emphasis.

Furthermore, the evolution of nursing education such as the Brown Report as stated by

Daniels (2004), and the participation of hospitals in research and teaching accelerated

nursing competence. Kozier (2004) defined hospitals according to ownership and

control, hence, having a relationship between cost and efficiency. Along with this

study Kozier defined other functions of hospitals as institution providing sources for

health related research and teaching same as with the current study wherein the

researchers used both public and private hospital to come up a difference with the

nursing procedures commonly performed. The studies of Jordan (2007), Taban (2005),

Sanchez (2005), and De Guzman (2004) best suit the current study because they

determined the efficiency of the student nurses in their academic and RLE

performance or skill competencies, as influenced by certain factors. Might the factors

be personal, environmental or motivational from instruction, hospital staff and

patients, these were all established to correlate with nursing performance.

Taner and Anthony (2006) determined the service quality between private and

public hospital in Turkey through an examination. As with the current study, the

researchers tried to compare the nursing procedures that are commonly performed

between a public and private hospital and how they are being influenced by certain

factors as to environmental or motivational. In lined with these related studies, the

difference between nursing procedures performed in a private and public hospitals, as

possibly influenced by environmental and motivational factors by which nursing

students should adapt with it.

Theoretical Framework

Based from the related literature and studies known to the research as

presented hereafter, the suitable model for this researchers’ study is Roy’s “Adaptation

Model” which views the person as an adaptive system in constant interaction with

changing environments. It merely cites that a nurse must adapt to any situation she is

in, no matter where or when it is. This is why Roy’s Adaptation Model was most

suitable framework for the study. There are some factors to which the nurse should

adapt, some of these are: availability of equipment, environmental setting, clinical

instructors’ willingness for students to perform and patients’ compliance.

The Adaptation Model - an adaptive system defined by Sister Calista Roy as a

whole comprised of parts that function as unity for some purpose (Delaune and

Ladner, 2006).

This paradigm explains that the person is a biopsychosocial being in constant

interaction with changing internal and external environment. Nursing attempts to alter
 21

the environment when the person is not adapting well nor has ineffective coping

responses.

In the diagram, performance of nursing procedures is affected by whether

nursing students are exposed to a public health care facility or private. These

intermingle with environmental and motivational factors that may create an impact in

performing nursing procedures. NCM 104 students are allowed by their instructor to

do their procedure knowledgably with assistance and also with the permission of the

patient that varies in different hospitals such as TPH and CLDH. The environmental

factors then affect the students’ performance in the availability of the equipments and

hospital machines such as cardiac monitors, defibrillators and mechanical ventilators.

Availability of the resources permits the students on actual learning than merely

reading on or looking on text books. The motivational factors cite that the students do

the procedure confidently when their clinical instructor teaches them thoroughly.

Motivation from the patients also affects the performances of the students by

entrusting them the procedure. Staff nurses, when they allow students to carry out the

procedure with their assistance that enhances internal motivation.

Sister Calista Roy’s adaptation model has gained wide acceptance in nursing

practice, research and education. Roy’s view of the person and the person-

environment interaction clearly represents characteristics of the totality paradigm.

Paradigm

ADAPTATION

Environmental
Factors

Central Luzon Doctors’

Hospital Procedures

Motivational
Factors

Figure 1
Paradigm based from Sister Calista Roy’s Adaptation Model

The paradigm shows the comparison between nursing procedures performed in

Tarlac Provincial Hospital being a public hospital and Central Luzon Doctors’

Hospital representing a private hospital, as signified by the solid black figures. This

difference may be affected by environmental and motivational factors as signified by

the dashed red figures. The nursing procedures performed are directly affected by the

difference between TPH and CLDH. Meanwhile, the factors may affect the nursing

procedures performed in the two hospitals directly or indirectly; therefore the figures

appeared as dashed. The motivational, environmental factors and nursing procedures

performed have direct relationship on one another while the private and public

hospitals have no relationship, only differences. That is why in the paradigm, the black

figures do not overlap on each other, only the other figures overlap with one another.