ARTICLE IN PRESS
International Journal of Nursing Studies 44 (2007) 545–555
www.elsevier.com/locate/ijnurstu
A comparative study of patients’ and nurses’ perceptions of
the quality of nursing services, satisfaction and intent
to revisit the hospital: A questionnaire survey
Mi Aie Leea, Young-Hee Yomb,
a
Department of Nursing, Dongguk University, 707 Sukjang-Dong, Gyeongju, Kyeonbuk, Korea
Department of Nursing, Chung Ang University, 221 Heukseok-Dong, Dongjak-Gu, Seoul City, Korea
b
Received 26 February 2005; received in revised form 13 February 2006; accepted 14 March 2006
Abstract
Background: Although it is very important to clarify the factors influencing the patients’ and nurses’ satisfaction with
nursing services, very little research has been performed in this area.
Objectives: The purpose of this study was to compare the nursing service quality, satisfaction and intent to revisit the
hospital perceived by hospitalized patients and nurses in Korea.
Methods: SERVQUAL scale, an overall satisfaction and intent to revisit the hospital questionnaires were used. The
sample consisted of 272 patients and 282 nurses. The data were collected using paper and pencil self-rating
questionnaires and analyzed using frequency, %, mean, standard deviation, t-test and Pearson correlation coefficient.
Results: Overall, nurses’ expectations and performance were higher than those of patients, while patients’ overall
satisfaction with nursing and medical care was higher than that of nurses. There was a strong positive relationship
between satisfaction with nursing and medical care and intent to revisit the hospital for both groups.
Conclusions: The performance was relatively lower than expectations, resulting in poor nursing care quality.
Differences between expectations and performance for both patients and nurses need to be further reduced.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Service quality; Satisfaction; Intent to revisit; Korea
What is already known about the topic?
There
has been very little research into how
consumers and providers perceive nursing care
service and service quality differently.
Consumers
and providers have different standards
and criteria in evaluating service quality.
Most of the studies using SERVQUAL instruments
have identified a gap between perceived expectations
and performance, with expectations consistently
higher than performance.
Corresponding author. Tel.: +82 2 820 5700;
fax: +8 2 824 7961.
E-mail address: yhyom@cau.ac.kr (Y.-H. Yom).
What this paper adds
Korean hospitals have performed poorly in providing
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.03.006
service quality, which is considered important by
both patients and nurses.
Managerial efforts should be required to reduce the
differences between patients’ and nurses’ perceptions
of quality of nursing care services.
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M.A. Lee, Y.-H. Yom / International Journal of Nursing Studies 44 (2007) 545–555
546
This study will have important implications for the
cross-cultural application of SERVQUAL scale.
1. Introduction
One of the drastic changes in health care services in
Korea during recent years is that customers, who used to
be passive, tend now to ask actively for detailed or
specific services which they need and then evaluate the
services provided. Consumerism begins with the essential perspective of the consumer at the center (Morath,
2003). In the health care industry, consumerism means
that having a voice, information and participating in
decision making are critical factors for patients. However traditionally in Korean hospitals these factors were
defined and judged mainly by providers, usually
physicians and nurses, rather than by patients in Korea.
Accordingly, health care institutions need to check and
be highly concerned about consumers’ requests and
evaluations periodically and continuously. However,
Lee (2003) found that consumers, by and large, have a
different baseline and standard than health-care specialists, who are the providers.
Consumers and providers have also been shown to
have different standards and criteria in evaluating
service quality in the nursing area (Bond and Thomas,
1991; Chai, 1996; Greeneich, 1993; Harrison, 1995; Lee,
2001; Lee, 2003; Lim and Kim, 2000; Peter, 1995). These
different standards and criteria of consumers and
providers for evaluating quality of service need to be
brought closer together. Usually, consumers purchase
products and evaluate them through their experience of
using them. If they decide to purchase the products
again, because of their positive experience, they then tell
others of the qualities of the products. So the image of
the products may be established during the consumer’s
usage, evaluation and word-of-mouth advertising. On
this reason, it is meaningless for providers to evaluate
the products and make efforts to improve the products
based only on their own standards and criteria without
considering consumers’ standards and criteria.
In the service area, the quality is very superficial and
subjective, and thus it is difficult to evaluate precisely or
control the service. (Yoo, 1996). According to Parasuraman et al. (1985), quality is an elusive and abstract
construct that is difficult to define. Quality can be
described in terms of effectiveness and efficiency, and
can also refer to characteristics of and the pursuit of
excellence (Huber, 2000). According to Omachonu
(1990), quality consists of two interdependent parts:
quality in fact and quality in perception. Quality in fact
means confronting to standards and meeting one’s own
expectations, while quality in perception refers to
meeting the customer’s expectations. However, quality
is a strategic factor for the efficiency and productivity of
providers and for the valuation and willingness of
consumers to purchase services, thus it should be
measured and controlled. Therefore, in modern society,
various methods are used to measure the quality of
services.
One of the methods to measure quality of service is to
measure the difference between the expectation and
performance. This method has been accepted widely in
the literature dealing with consumers’ overall satisfaction, or service quality (de Carvalho and Leite, 1999;
Lijander and Starndivik, 1994). In particular, interest in
this method has increased dramatically since Parasurman developed SERVQUAL as a measuring model.
Application of this model has been done in many
different types of settings, including business, engineering, and the health-care industry. In the health care area,
research for measuring health care services has been
performed steadily over the past 10 years. (Joo, 2001;
Lee, 1999, 2001, 2002; Lee, 2003; Lim and Kim, 2000;
Lumby and England, 2000; Puay and Nelson, 2000;
Yousself et al., 1996). The essence of this model is to
provide a formula of quality equal to performance minus
expectation (i.e., quality ¼ performanceexpectation),
including perception of the difference between expectations prior to the actual delivery of services and
perception of the performance after the delivery of
services. However, the relationship between the quality
of service and satisfaction with it has not been
established consistently (Lee, 2002).
Most research which has introduced consumers’ views
of nursing services (Chai, 1996; Lee, 2001; Lee, 2003;
Lim and Kim, 2000; Lumby and England, 2000; Peter,
1995, Scarding, 1994), has focused on the consumers,
measuring the nursing service quality in terms of
consumers’ perceptions (Joo, 2001; Jung and Youn,
2001; Lumby and England, 2000; Scarding, 1994), or
measuring simply the consumers’ degree of satisfaction
with the nursing services (Kang, 1997; Kim, 2001; Lee,
1996; Shin, 1999). Consequently there has been very
little research into how differently consumers and
providers perceive nursing service and service quality
(Chai, 1996; Lee, 2001; Lee, 2003; Lim and Kim, 2000).
These differing perceptions of consumers and providers
need to be clarified in order to prevent wasteful efforts
by providers to evaluate and improve service quality
based only on their own standards.
Also, although it is very important to clarify the
factors influencing the patients’ and nurses’ satisfaction
with medical services or nursing services, very little
research has been performed in this area. (Lee, 1998;
Lee, 2003; Jung and Youn, 2003). Thus it is necessary to
clarify this relationship, because this research can be
used by providers as a basis for establishing strategies to
improve consumers’ satisfaction and thus lead them to
visit the hospital again.
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For this purpose, this research will identify the
expectations and performance of the patient as a
consumer and the nurse as a provider regarding nursing
services, will compare the above difference by application of SERVQUAL, created by Parasuraman et al.
(1988a, b) and will determine the relationship between
satisfaction with nursing and medical care, and patients’
intent to revisit the hospital.
The specific aims of this research were:
1. To compare patients’ and nurses’ expectations
of nursing care services;
2. To compare patients’ and nurses’ performance
of nursing care services;
3. To assess patients’ perceptions of the quality
of nursing care services;
4. To assesses nurses’ perceptions of the quality
of nursing care services;
5. To determine patients’ and nurses’ perceptions of the
degree of satisfaction with nursing care services,
medical care services and intent to revisit; and
6. To determine the relationship between patients’ and
nurses’ satisfaction with nursing care services, medical care services, and intent to revisit the hospital.
2. Background literature
Measuring service quality is made more complex by
the characteristics of service (Parasuraman et al., 1985).
Parasuraman et al. (1985) defined service quality as the
extent of discrepancy between customers’ expectations
and their perceptions. Expectations means the wants of
consumers. On the other hand, perception refers to the
consumers’ evaluation of the service. Parasuraman et al.
formulated a service quality model and identified 10
original determinants using in-depth interviews of
executives and focus group interviews of consumers in
1985. Further they developed the SERVQUAL instrument to measure service quality in 1988. The SERVQUAL instrument consists of five dimensions of service
quality: Tangibility, reliability, responsiveness, assurance and empathy (Parasuraman et al., 1988a, b).
Tangibility
includes physical evidence of services,
such as physical facilities, tools or equipment,
appearance of employees, and other customers.
Reliability involves consistency of performance and
dependability. It means that the firm performs the
service correctly the first time and honors its promise.
Responsiveness concerns the willingness or readiness
of employees to provide service. It involves timeliness
of services (e.g., setting up an appointment quickly).
Assurance means knowledge, courtesy of employers
and their ability to convey trust and confidence.
547
Empathy
is the providing of caring and individual
attention to customers provided by staff.
SERVQUAL has been tested in various settings,
including health care areas, and the findings have been
mixed (Jun et al., 1998). Some researchers reported that
SERVQUAL is valid and reliable (Babakus and Mangold,
1992) and others argue that SERVQUAL is ambiguous in
its measurement of service quality (Bowers et al., 1994;
Teas, 1993). In particular, Bowers et al. (1994) argued that
SERVQUAL is not sufficient to measure service quality in
health care, since SERVQUAL was developed originally
for other industries. To date, their conceptualization and
measurement of service quality have received widespread
acceptance (Bottle, 1996). When perceived performance is
higher than expectations, SERVQUAL considers this to
be good quality, but the reverse indicates poor quality.
Research on service quality in the health care areas,
including nursing, has mainly focused on the gap
between patient expectations and perceptions of service
quality (Duffy et al., 2001). Lim and Tang (2000)
examined patients’ expectations and satisfaction in
Singapore hospitals. Their findings (2000) indicated that
patients had low expectations related to hospital
services. They also found that assurance was the most
important dimension. Most of the studies using the
SERVQUAL instrument have identified a gap between
perceived expectations and perception, with expectations consistently higher than perceptions (Duffy et al.,
2001; Lim and Tang, 2000; Lumby and England, 2000;
Youssef et al., 1996). In an comparative study of the
expectations of residents, family and administrators in
nursing homes (Duffy et al., 2001), residents expectations were significantly different from administrators’
expectations on service quality. Specifically, residents
had lower expectations than family or administrators.
Some studies have found a positive association
between health care service quality and patient satisfaction (Bowers et al., 1994; Woodside et al., 1989) as well
as a positive relationship between satisfaction with
health care and willingness to revisit the hospital (Atkins
et al., 1996; Lee, 1998; Lee, 2001; Lumby and England,
2000; Scarding, 1994; Zifko-Baliga and Kramp, 1997).
In Lumby and England’s (2000) study using the
SERVQUAL instrument, age and gender were significant predictors of patient satisfaction with nursing care.
That is, older patients were more satisfied with nursing
care than younger patients, and men had more positive
perceptions of responsiveness than women.
3. Methods
3.1. Sample
A total of 300 nurses and 300 patients from six
hospitals in five provinces in Korea were asked to
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participate in this study. Six hospitals with more than
300 beds were selected based on the researchers’ ability
to gain access to the sample. The inclusion criteria were
the following: (a) adult Korean-speaking patients, who
were admitted to general units, excepting psychiatric
units, emergency room, and intensive care units, (b)
nurses working in the same units as patients, and (c)
participants who were willing to participate in the study.
3.2. Instrumentation
Three kinds of questionnaires were used for this
study. First, a Korean version of the SERVQUAL
questionnaire was used to measure nursing care service
quality. The SERVQUAL instrument developed by
Parasuraman et al. (1988a, b) was modified by one of
the researchers. The instrument was translated into
Korean, back-translated into English, and then the
original English and back-translated versions were
tested for equivalence. The Korean version of the
SERVQUAL instrument has shown five dimensions
through factor analysis, such as tangibility, reliability,
responsiveness, assurance, and empathy. This instrument has 20 items related to expectations and 20 items
related to performances, with each dimension having
four items. A five-point Likert scale was used for the
scoring system, with (1) representing ‘‘disagree very
strongly’’ and (5) representing ‘‘ agree very strongly.’’
Second, overall satisfaction was defined here as a
cognitive and affective response to the consumption
experience (Oliver, 1997; Yi, 1990). Overall satisfaction
was measured with ‘the degree of satisfaction’. Overall
satisfaction questionnaire consisting of two questions
was used to measure nursing care services (1 item) and
medical care services (1 item). Two Korean scholars with
Ph.D. degrees, one from business, and one from nursing
reviewed overall satisfaction questionnaire. It was
acceptable. A seven-point Likert scale ranging from
‘‘very strongly dissatisfied’’ (1) to ‘‘very strongly
satisfied’’ (7) was used. A higher score indicated higher
satisfaction with nursing and medical care service
quality.
Last, two items for intent to revisit the hospital after
discharge was used. These two items was selected from
‘repurchase intention’ consisting of 13 items developed
by Parasuraman et al. (1994). Two items were translated
into Korean by the researchers and the translation was
reviewed by two Korean scholars with Ph.D. degrees,
one from business, and one from nursing. Based on their
suggestions, modifications were made on the translation
and finally two items were acceptable. A seven-point
Likert scale ranging from ‘‘do not revisit or recommend
very strongly’’ (1) to ‘‘revisit or recommend very
strongly’’ (7) was used to measure this item, also. A
higher score represents a higher intent to revisit or to
recommend the hospital.
3.3. Procedure
To obtain research permission for the study sites,
preliminary discussion were held with the directors of
nursing departments. One of the researchers visited the
nursing departments to explain the survey. A cover letter
explaining the purpose of the study, a consent form, and
a questionnaire were then administered to the subjects.
Because mail survey have generally yielded extremely
low response rates in Korea, a mail survey was not
employed as the data collection method in this study.
Completed questionnaires were collected by both the
researcher and by head nurses in the units.
3.4. Analysis
To compute nursing care service quality, the SERVQUAL score was used as follows: SERVQUAL score ¼ performance scoreexpectation score (SQ ¼ PE).
SPSS 10.0 was used for data analysis using frequency,
%, mean, standard deviation, t-test, and Pearson
correlation coefficient.
4. Results
4.1. Reliability
Analyses showed good reliability on the overall
SERVQUAL scale. Overall, Cronbach’s a was .9705
and ranged from .8478 to .9185. Cronbach’s a on the five
subscales were: .8478 for tangibility; .9023 for reliability;
.8737 for responsiveness; .9067 for assurance; and .9185
for empathy. The coefficient a for tangibility was
relatively lower than that of other subscales of
SERVQUAL scale. According to Duffy et al. (2001),
tangibility subscale has historically produced the lowest
coefficient alpha. In the intent to revisit scale, Cronbach’s a for the patients was .93 and for nurses, .78.
4.2. Description of the sample
The number of completed questionnaires returned
was 293 (95%) for patients and 298 (99%) for nurses.
Thirty-eight of the 591 were unusable due to incompleteness. Thus the sample for the analysis comprised 272
for patients and 282 for nurses.
About 52.6% of the patients were male and 44.5%
were female. Also, approximately 33.8% of the patients
were less than 30 years of age; 28% were 31–40 years of
age; 19.9% were 41–50 years of age; and 14% were older
than 51. Almost half of the patients were high school
graduates (42.7%) or college graduates (39.7%).
All of the nurses were female. Most of the nurses were
under age 30 (70.2%), and more than two-thirds
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(76.6%) had a 3-year diploma. The majority of the
nurses (81.9%) were staff nurses.
4.3. Expectations of patients and nurses
Results from the t-test (Table 1) show significant
differences in expectations between patients and nurses
for all the dimensions of service quality. The mean
scores of nurses’ expectations were consistently higher
for all five dimensions than the mean scores of patients.
The highest ratings were given to reliability, followed by
assurance, responsiveness, empathy, and tangibility, by
both nurses and patients. The most important expectation for the patients was for nurses to ‘‘possess nursing
knowledge in performing their own job’’, followed by
‘‘provide precise and skillful nursing service’’ and
‘‘provide medication and treatment at the correct time’’.
On the other hand, the most important expectation of
nurses was for nurses to ‘‘ provide precise and skillful
nursing service’’, followed by ‘‘ provide medication and
treatment at the correct time’’ and ‘‘be concerned about
and solve patient’s problems’’. The least important
549
expectation of the patients was for nurses to ‘‘provide a
comfortable enough environment to rest in’’, while the
least important expectation of nurses was to ‘‘provide
courage and hope’’.
4.4. Performance perceived by patients and nurses
Results from the t-test (Table 2) show significant
differences in performance between patients and nurses
in all the dimensions of service quality. The mean scores
of nurses’ performance were consistently higher in all
five dimensions than the mean scores of patients. The
highest score of dimension perceived by patients was
reliability, followed by assurance, empathy, responsiveness, and tangibility, while the highest score of dimension perceived by nurses was also reliability, followed by
empathy, responsiveness, assurance, and tangibility. The
highest performance perceived by patients was for
nurses to ‘‘provide medication and treatment at the
correct time’’, followed by ‘‘possess nursing knowledge
in performing their own job’’ and ‘‘provide good feeling
by nurses’ being good-looking’’. On the other hand, the
Table 1
The perceived difference of nursing service expectations by group
Nursing service attributes
Patients (n ¼ 272)
Mean (SD)
Nurses (n ¼ 282)
Mean (SD)
t (p)
Be concerned about the hygiene of the patient’s room
Provide a comfortable enough environment to rest in
Provide nursing service in well-equipped facilities
Provide good feeling because of appearance
Tangibility
Provide precise and skillful nursing service
Give information and get permission
Be concerned about and solve patient’s problems
Be reliable as nurse
Reliability
Immediately correct environment problems of patient’s room
Help patient willingly whenever help is needed
Provide nursing service immediately even if too much busy
Provide medication and treatment at the correct time
Responsiveness
Possess nursing knowledge in performing their own job
Give information about hospitalization
Give assurance about reliable nursing care
Provide nursing service with a sense of duty
Assurance
Understand the patient’s feeling and induce emotional comfort
Respect patient’s personality
Listen to patient’s complaints
Provide courage and hope
Empathy
Total
3.42
3.37
3.38
3.78
3.48
3.82
3.71
3.77
3.72
3.75
3.53
3.76
3.56
3.82
3.67
3.87
3.61
3.74
3.78
3.75
3.61
3.67
3.58
3.53
3.60
3.65
3.98
3.89
3.89
4.06
3.96
4.25
4.09
4.18
3.96
4.12
3.92
3.97
3.90
4.21
4.00
4.10
3.99
4.10
3.97
4.03
3.95
4.05
4.06
3.88
3.99
4.02
8.445
7.525
7.062
4.209
8.678
6.307
5.153
5.536
3.999
6.341
5.118
2.649
4.534
5.716
5.487
3.184
5.062
5.062
2.486
4.649
4.538
5.347
6.609
4.308
5.973
7.080
po.05.
po.01.
po.001.
(.95)
(.97)
(.97)
(.93)
(.78)
(.98)
(1.04)
(.97)
(.90)
(.84)
(1.03)
(1.00)
(.96)
(.97)
(.84)
(.98)
(1.04)
(1.00)
(1.00)
(.88)
(1.01)
(1.00)
(.95)
(1.06)
(.89)
(.77)
(.59)
(.64)
(.68)
(.57)
(.48)
(.63)
(.61)
(.64)
(.68)
(.51)
(.67)
(.68)
(.74)
(.62)
(.53)
(.60)
(.65)
(.60)
(.73)
(.54)
(.68)
(.62)
(.68)
(.73)
(.57)
(.44)
Note
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.009)
(.009)
(.000)
(.000)
(.000)
(.002)
(.000)
(.000)
(.014)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
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Table 2
The perceived difference of nursing service performance by group
Nursing service attributes
Patients (n ¼ 272)
Mean (SD)
Nurses (n ¼ 282)
Mean (SD)
t (p)
Be concerned about the hygiene of the patient’s room
Provide a comfortable enough environment to rest in
Provide nursing service in well-equipped facilities
Provide good feeling because of appearance
Tangibility
Provide precise and skillful nursing service
Give information and get permission
Be concerned about and solve patient’s problems
Be reliable as nurse
Reliability
Immediately correct environment problems of patient’s room
Help patient willingly whenever help is needed
Provide nursing service immediately even if too much busy
Provide medication and treatment at the correct time
Responsiveness
Possess nursing knowledge in performing their own job
Give information about hospitalization
Give assurance about reliable nursing care
Provide nursing service with a sense of duty
Assurance
Understand the patient’s feeling and induce emotional comfort
Respect patient’s personality
Listen to patient’s complaints
Provide courage and hope
Empathy
Total
3.25
3.33
3.33
3.80
3.43
3.75
3.61
3.74
3.71
3.70
3.44
3.70
3.46
3.84
3.61
3.82
3.51
3.64
3.70
3.67
3.60
3.71
3.63
3.56
3.63
3.61
3.77
3.51
3.23
3.73
3.56
3.85
3.86
3.94
3.78
3.86
3.88
3.84
3.48
3.96
3.79
3.61
3.79
3.84
3.91
3.78
3.79
3.97
4.04
3.65
3.85
3.77
6.885
2.534
1.225
.968
2.294
1.637
3.503
2.936
1.039
2.719
5.763
2.173
.154
1.702
2.959
3.382
3.400
2.740
2.620
1.817
2.648
3.679
6.051
1.061
3.737
2.98
(1.02)
(.91)
(.96)
(.93)
(.79)
(.93)
(.96)
(.96)
(.87)
(.82)
(.99)
(.99)
(.99)
(.97)
(.84)
(.86)
(1.07)
(.87)
(.96)
(.85)
(.99)
(.94)
(.93)
(.97)
(.86)
(.77)
(.66)
(.71)
(.81)
(.64)
(.54)
(.65)
(.68)
(.60)
(.69)
(.51)
(.76)
(.67)
(.66)
(.63)
(.53)
(.64)
(.74)
(.62)
(.76)
(.55)
(.63)
(.63)
(.58)
(.73)
(.53)
(.46)
Note
(.000)
(.012)
(.221)
(.334)
(.023)
(.103)
(.001)
(.004)
(.300)
(.007)
(.000)
(.031)
(.878)
(.090)
(.003)
(.001)
(.001)
(.007)
(.009)
(.070)
(.009)
(.000)
(.000)
(.290)
(.000)
(.003)
***
*
*
po.05.
po.01.
po.001.
highest performance perceived by nurses was for nurses
to ‘‘listen to patients’ complaints’’, followed by ‘‘respect
patient’ personality’’ and ‘‘provide nursing service with a
sense of duty’’. The lowest performance perceived by
patients was ‘‘be concerned about the hygiene of the
patient’s room’’, while the lowest performance perceived
by nurses was to ‘‘provide nursing service in good
facilities.’’
4.5. Difference in perceived service quality between
patients and nurses
Results from the t-test (Table 3) show significant
differences between nurses’ expectations and performance in all of the dimensions of service quality. The
mean scores of nurses’ expectations were higher than the
mean scores of their performance. This negative
SERVQUAL scores implies that the nurses’ performance never exceeded their own expectations. The
largest difference between expectations and performance
was in the tangibility dimension, while the smallest
difference was in the dimension of empathy.
Only the assurance dimension showed a significant
difference between patients’ expectations and performance. Although there were no significant differences in
the service quality between patients’ expectations and
performance, the mean scores of patients’ expectations
in the dimensions of tangibility, reliability, and responsiveness were higher than the mean scores of performance, except in the dimension of empathy.
4.6. Analysis of the overall satisfaction with nursing
services, overall satisfaction with medical services, and
intent to revisit the hospital
Table 4 shows the overall satisfaction with nursing
care and medical care services, and the intent to revisit
the hospital of patients and nurses. In contrast with the
service quality, the mean scores of patients for overall
satisfaction with nursing and medical care were significantly higher than those of nurses. This indicates that
patients as consumers are more satisfied than nurses are
as providers.
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551
Table 3
The comparison of perceived nursing service quality by group
Nursing service attributes
Patients (n ¼ 272)
Be concerned about the hygiene of the patient’s room
Provide a comfortable enough environment to rest in
Provide nursing service in well-equipped facilities
Provide good feeling because of appearance
Tangibility
Provide precise and skillful nursing service
Give information and get permission
Be concerned about and sole patient’s problems
Be reliable as nurse
Reliability
Immediately correct environment problems of patient’s room
Help patient willingly whenever help is needed
Provide nursing service immediately even if too much busy
Provide medication and treatment at the correct time
Responsiveness
Possess nursing knowledge in performing their own job
Give information about hospitalization
Give assurance about reliable nursing care
Provide nursing service with a sense of duty
Assurance
Understand the patient’s feeling and induce emotional comfort
Respect patient’s personality
Listen to patient’s complaints
Provide courage and hope
Empathy
Total
Exp
Per
t (p)
3.42
3.37
3.38
3.78
3.48
3.82
3.71
3.77
3.72
3.75
3.53
3.76
3.56
3.82
3.67
3.87
3.61
3.74
3.78
3.75
3.61
3.67
3.58
3.53
3.60
3.65
3.25
3.33
3.33
3.80
3.43
3.78
3.61
3.74
3.71
3.70
3.44
3.70
3.46
3.84
3.61
3.82
3.51
3.64
3.70
3.67
3.60
3.71
3.63
3.56
3.63
3.61
2.83
.54
.80
.34
1.302
1.29
1.63
.50
.15
1.216
1.70
1.21
1.70
.44
1.466
1.13
1.83
2.06
1.57
2.155
.20
.90
.99
.44
.648
1.36
Nurses (n ¼ 282)
(.005)
(.558)
(.423)
(.737)
(.194)
(.200)
(.105)
(.617)
(.882)
(.225)
(.091)
(.228)
(.090)
(.663)
(.144)
(.260)
(.068)
(.041)
(.117)
(.032)
(.845)
(.372)
(.323)
(.659)
(.518)
(.174)
Exp
Per
t (p)
3.98
3.89
3.89
4.06
3.96
4.25
4.09
4.18
3.96
4.12
3.92
3.97
3.90
4.21
4.00
4.10
3.99
4.10
3.97
4.03
3.95
4.05
4.06
3.88
3.99
4.02
3.77
3.51
3.23
3.73
3.56
3.85
3.86
3.94
3.78
3.86
3.88
3.84
3.48
3.96
3.79
3.61
3.79
3.84
3.91
3.78
3.79
3.97
4.04
3.65
3.86
3.77
4.77
7.83
11.85
7.78
11.472
8.60
5.06
5.30
4.07
8.557
.878
2.65
8.48
6.09
6.524
11.0
7.78
6.30
1.35
8.472
3.56
2.20
.54
4.93
3.725
10.35
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.381)
(.008)
(.000)
(.000)
(.000)
(.000)
(.000)
(.000)
(.178)
(.000)
(.000)
(.029)
(.587)
(.000)
(.000)
(.000)
Exp, expectation; per, performance.
po.05.
po.01.
po.001.
Table 4
Nursing service satisfaction, medical service satisfaction, intent to revisit the hospital by group
Statistics
Patients (n ¼ 272)
Mean (SD)
Nurses (n ¼ 282)
Mean (SD)
t
p
Note
Item
Nursing service satisfaction
Medical service satisfaction
Intent to revisit the hospital
5.11 (1.32)
4.66 (1.41)
4.83 (1.49)
4.52 (.89)
4.32 (.86)
4.61 (.83)
5.951
3.410
1.960
.000
.001
.051
***
**
*po.05.
**po.01.
***po.001.
4.7. Relationship between satisfaction with nursing service
and medical services and intent to revisit the hospital
care services, and willingness to revisit the hospital for
both nurses and patients.
Table 5 shows the relationship between satisfaction
with nursing and medical care and willingness to revisit
the hospital. There was a strong positive relationship
among satisfaction with nursing care services, medical
5. Discussion
The highest expectations and the highest performance
ratings were in the dimensions of reliability for both
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M.A. Lee, Y.-H. Yom / International Journal of Nursing Studies 44 (2007) 545–555
Table 5
The relationship among nursing service satisfaction, medical service satisfaction, and intent to revisit the hospital by group
Nursing service satisfaction
Medical service satisfaction
Intent to revisit the hospital
Patients (n ¼ 272)
Nursing service satisfaction
Medical service satisfaction
Intent to revisit the hospital
1.000
.677 (.000)***
.615 (.000)***
1.000
.714 (.000)***
1.000
Nurses (n ¼ 282)
Nursing service satisfaction
Medical service satisfaction
Intent to revisit the hospital
1.000
.618 (.000)***
.565 (.000)***
1.000
.630 (.000)***
1.000
*
po.05.
po.01.
***
po.001.
**
groups, while the tangibility dimension received the
lowest rating for both groups. This implies that
reliability is the most important of the five dimensions
of service quality, and that tangibility is the least
important. This study shows that the expectations of
Korean patients are similar to those of Parasuraman et
al. (1985); Youssef et al., 1996; O’connor et al. (2000),
where patients also placed the most importance on
reliability; but the findings of this study are different
than those of Lim and Tang (2000), in which Singapore
patients placed greatest emphasis on assurance. However, all patients studied in hospitals of the NHS (USA),
Singapore, and Korea perceived nursing care to be
below their expectations.
Based on this study’s findings, the patients’ mean
expectation for nursing services was 3.65, which was
higher than the 3.46 of Lee (2003) and the 3.43 of Joo
(2001), but lower than the 3.99 of Jung and Youn (2003)
and the 3.88 of Jung and Youn (2001). The items
included in the above-mentioned nursing service tests
and the samples are different, so the studies cannot be
compared directly with each other. However, the
research on these services was all measured using a
five-point Likert scale, so the results can be compared
indirectly. Patients showed high expectations for nurses
to ‘‘possess nursing knowledge in performing their own
job’’, ‘‘provide medication and treatment at correct
time’’, ‘‘provide precise and skillful nursing service,’’ but
comparatively low expectations for them to ‘‘provide a
comfortable enough environment to rest in’’, ‘‘provide
nursing service in well-equipped facilities’’, and ‘‘be
concerned about the hygiene of the patient’s room,’’
among the nursing service items. Thus, it can be deemed
that patients expected a lot of by way of professional
knowledge and technology in nursing services, but did
not expect much in terms of environment or nursing
service facilities. Also, the nurses thought that the
patients would have high expectations for nurses to
‘‘provide precise and skillful nursing service’’, ‘‘provide
medication and treatment at correct time’’, and ‘‘be
concerned about and solve the patient’s problems’’. But
they thought that the patients would have low expectations for nurses to ‘‘provide courage and hope’’,
‘‘provide nursing service in good facilities’’, and ‘‘be
concerned about the hygiene of the patient’s room’’.
Nurses thought that patients would expect a lot in terms
of professional knowledge and skill and would have
small expectations for the items related to physical
environment and hygiene. However, the difference of
expectations between the patients and nurses is large, so
the 20 items comprising the nursing services indicated a
significant statistical difference between patients and
nurses.
The patients’ mean performance for nursing services
in this research was 3.61, lower than Lee (2003)’s 3.72,
and Jung and Youn (2001)’s 3.63, but higher than Jung
and Yoon (2003)’s 3.13 and Joo (2001)’s 3.34. The items
which the patients perceived as most important, were for
nurses to ‘‘prove medication and treatment at correct
time’’, ‘‘possess nursing knowledge in performing their
own job’’, and ‘‘provide a good feeling because of
nurse’s appearance’’ in that order, and the least
important items were ‘‘be concerned about the hygiene
of the patient’s room’’, ‘‘provide a comfortable enough
environment to rest in’’, and ‘‘provide nursing services in
well-equipped facilities,’’ in that order. Thus, the
professional knowledge or techniques of the nurse were
perceived as being good, but the environment or
facilities as poor. Meanwhile, the nurses thought they
gave their best service by listening to patient’s complaints, respecting patient’s personality, and providing
medication and treatment at correct time in that order,
and were poorest at providing nursing services in wellequipped facilities, providing nursing service immediately even if too busy, and providing a comfortable
enough environment to rest in, in that order. Thus, the
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nurses felt that they provided all of the necessary
professional knowledge or skill for the patients,
but they could not provide environmental factors
properly, such as facilities, equipment, or human
factors, such as, courage, hope, etc., which were beyond
their capabilities. It is interesting to note that the mean
for tangibility was the lowest for both groups. This
finding clearly showed that the tangibility dimension
constitutes the most serious problem facing Korean
hospitals. No one expected and perceived that nursing
care services would always be provided in good
environment. These findings imply the need for managerial interventions to improve the physical environment
in Korean hospitals.
Regarding nursing service quality, the patients found
15 out of 20 items to be lower than their expectations,
but nurses found all 20 to be lower than they had
predicted. Thus the nurses as provider seem to value
their nursing services less than the patients, as consumers, value them. The service quality score (i.e., the
difference between performance and expectations) was
1.36 (mean) for patients, significant difference statistically, and 10.35 (mean) for nurses. Therefore, these
negative SERVQUAL scores imply that Korean hospitals have performed poorly in providing service quality,
which is considered important by both patients and
nurses. Thus, improvements are required across all the
five dimensions of service quality.
In terms of patients’ and nurses’ overall satisfaction,
patients were more satisfied with the nursing or medical
services they received than the nurses expected them to
be. One possible explanation of the finding might be that
current hospital structure in Korea affects patients’
overall satisfaction with nursing and medical care
services. For example, many hospitals in Korea are still
operating under the tradition of hierarchical organizational structure, even though consumerism is widely
accepted. This implies that patients themselves feel their
status to be lower than nurses because the nurses, as
providers, have a considerably greater level of knowledge than patients, as consumers, about the disease
process and treatments. This can lead to patients’ low
expectation of and high satisfaction with nursing and
medical care services during the hospitalization.
Regarding nursing services, medical services and
intent to revisit the hospital, the relationship among
these three variables showed a positive correlation, and
r-value was .5 or higher. This suggests that the
correlation among these three is relatively high. Related
to this, patients perceived the relationship among these
three variables to be higher than the nurses themselves
did. This result is consistent with that of other studies,
which showed that nurses had great influence on service
quality (Atkins et al., 1996; Lee, 1998; Lee, 2001; Lumby
and England, 2000; Scarding, 1994; Zifko-Baliga and
Kramp, 1997).
553
Overall, the findings of this study are not much
different from those of other studies in Western
countries. That is, performance was relatively lower
than expectations, resulting in poor nursing quality. It
implicates that the cultural uniqueness of Korea may
not affect the patients’ and nurses’ perceptions of quality
of nursing care. This strongly suggests that quality
management should be continuously implemented in
hospitals universally.
Although nursing service quality using SERVQUAL
scale has been studied in a great deal, there are usually
conducted mainly from Western countries. Therefore, it
is questioned if SERVQUAL scale to measure the
quality of nursing care services would work well in
Korea. Despite a different cultural situation, the
SERVQUAL scale used in this study identified as highly
reliable in Korea. Therefore, this study will have
important implications on the cross-cultural applicability of SERVQUAL scale. In addition, limitations related
to instrumentation should be carefully addressed. The
English version of the instrument, SERVQUAL scale,
has high reliability and validity through a number of
researches in Western country. Because the translated
Korean version of this instrument employed several
steps of translation, back-translation and revisions, the
Korean samples encountered few difficulties answering
the questionnaire. Therefore, it is recommended that
back-translation methodology should be carried out for
cross-cultural studies.
6. Limitations and suggestions for future research
Limitations and suggestions are noted in this study.
Firstly, since the findings of this study is based on the
investigation of only patients and nurses from six
hospitals in Korea, the generalizability of the findings
is limited to Korean patients and nurses. Additional
research using random sample should be performed in
order to enhance the generalizability of the findings. In
addition, further research in other Asian countries, such
as Japan and China, would be helpful to improve the
generalizability of the findings.
Secondly, the expectations were higher than the
performance in both patients and nurses, indicating
poor nursing quality. Especially, the patients’ expectations are critical. Therefore, it should be noted that
nurses routinely measure patients’ expectations as an
important factor in the provision of quality of nursing
care. Further managerial interventions should be clarified to reduce the differences between expectations and
performance in both patients and nurses.
Thirdly, the professional knowledge and techniques of
the nurse were perceived as being good, but the
environment or facilities as poor by patients. Therefore,
change in hospital environment should be needed.
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7. Conclusion
There was a gap between expectations and performance in both patients and nurses related to overall
nursing service quality. The expectations were higher
than the performance in both of these groups. These
negative SERVQUAL scores imply that performance
was relatively lower than expectations, resulting in poor
nursing care quality. In order to provide high quality
service, differences in expectations and performance in
both patients and nurses need to be reduced.
In particular, the mean scores of nurses’ expectations
and performance were consistently higher in all five
dimensions than were those of the patients. Therefore,
nurses should identify exactly what the patients’
expectations are, not simply assume that nurses have
the same expectations for service as the patients. This
will allow them to provide high quality nursing care for
patients.
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