International Journal of Nursing Studies 39 (2002) 79–84

Relationship of nurses’ assessment of organizational culture,

job satisfaction, and patient satisfaction with nursing care
Huey-Ming Tzenga,*, Shaké Ketefianb, Richard W. Redmanc
a
Department of Nursing, I-Shou University, Kaohsiung, Taiwan
b
Doctoral and Post-Doctoral Studies and International Affairs, University of Michigan School of Nursing, Ann Arbor MI 48109, USA
c
Academic Affairs, University of Colorado Health Sciences Center School of Nursing, Denver, CO 80262, USA
Received 17 March 2000; received in revised form 18 July 2000; accepted 18 November 2000

Abstract

This exploratory study investigated the relationship among staff nurses’ assessment of organizational culture, job
satisfaction, inpatient satisfaction with information about home care and follow-up, and general inpatient satisfaction
with nursing care. A conceptual path model was tested using a secondary data analysis research design. Staff nurses and
inpatients were sampled from inpatient units. The unit of analysis was patient care units. Pearson correlation and
regression analyses were used. We found that strength of organizational culture predicted job satisfaction well and
positively; job satisfaction predicted inpatient satisfaction significantly and positively; and inpatient satisfaction
predicted general inpatient satisfaction well and positively. Methodological challenges of this study are
discussed. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Health care outcome; Organizational culture; Job satisfaction; Patient satisfaction; Nursing care services

This exploratory project is aimed to investigate the
relationship of nurses’ assessment of organizational
culture, job satisfaction, and inpatient satisfaction with
nursing care. The purpose of this study was to develop
and test a conceptual model on the cause – effect
relationship from organizational variables to clinical
outcome indicators, and to contribute to the developing
domain of nursing outcome studies.
Patient satisfaction has been considered as one of the
critical healthcare outcome indicators. Healthcare pro-
viders also have incorporated continuous quality meth-
ods into process improvement of health care delivery.
One such quality improvement strategy is directed
toward modifying an organization culture as a means
to improve the quality of services (Fitzpatrick, 1994).
Nurses’ job satisfaction, patient education, and general
inpatient satisfaction with nursing care have been
identified in the Nursing Report Card for Acute Care
(American Nurses Association, 1995) as important
nursing quality outcome indicators. Current literature
suggests that organizational culture is directly and
positively related to quality assurance implementation
and employee job satisfaction, and is indirectly and
positively related to patient outcomes as perceived by
health care providers (Hinshaw and Atwood, 1979;
Bateman and Organ, 1983; Weissman and Nathanson,
1985; Lucas, 1988,1991; Nakata and Saylor, 1994;
Mitchell et al., 1996). Several quality health outcome
models for nursing service deliveries have been devel-
oped, but have not been tested yet (Aiken et al., 1997;
Mitchell et al., 1998).

*Correspondence address: I-Shou University, Department of
Nursing, 1, Section 1, Hsuen-Cheng Road, Ta-Hsu Hsiang,
Kaohsiung County, Taiwan 840, R.O.C. Tel.: +886-
926150912/ +886-7-6577711 Ext. 5752; fax: +886-7-6577056.
E-mail address: tzeng_hueyming@yahoo.com
(H.-M. Tzeng).
1. Conceptual framework
The conceptual model as tested in this study is
illustrated in Fig. 1. This framework proposed the
linkages from staff nurses’ perceptions of strength of
an organization’s culture (organizational structure

0020-7489/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 7 4 8 9 ( 0 0 ) 0 0 1 2 1 - 8
80 H.-M. Tzeng et al. / International Journal of Nursing Studies 39 (2002) 79–84
Fig. 1. The conceptual model with hypothesized linkages.
factor), nurses’ job satisfaction (organizational process
factor), to inpatients’ perceptions of satisfaction with
information about home care and follow-up (clinical
process factor), to general inpatient satisfaction with
nursing care received (clinical outcome factor). Dona-
bedian’s (1966) views on evaluating quality of care from
structures (having the right things), process (doing
things right), to outcomes (having the right things
happen) have guided this study.
In the study of Aiken et al. (1997) nurses’ job
satisfaction was considered as an outcome factor. In
the model proposed and tested here, nurses’ job
satisfaction was conceptualized as an organizational
process factor because this framework focused on the
delivery process of inpatient nursing care service. This
framework was a streamlined path model where both
direct and indirect effects were tested from the strength
of organizational culture to general inpatient satisfac-
tion with nursing care. In addition to the direct linkages
shown in solid lines with arrows, there are three positive
and indirect effects, which were illustrated using dotted
lines with arrows.
This project hypothesized that: (1) the higher the staff
nurses’ scores on strength of organizational culture, the
higher their job satisfaction would be; (2) the higher the
staff nurses’ job satisfaction, the higher inpatients’
satisfaction with information about home care and
follow-up would be; and (3) the higher the levels of
inpatients satisfaction with information about home
care and follow-up, the higher their scores on general
inpatient satisfaction with nursing care would be.
This framework was intended to capture the variance
among nursing care units. Because more than one nurse
is usually involved in contributing to a given patient
clinical nursing care services, both nurse and patient
variables were aggregated by patient care units (mean
values were calculated). The inpatient data used to test
this model were collected 4–6 weeks after being
discharged. As an exploratory project with a relatively
small sample size, other demographic characteristics
were not included as controlling variables in the model
and analyses.
2. Method
This exploratory study was a secondary analysis of
data from a large on-going study (Redman and
Ketefian, 1995). The project was conducted in a tertiary
health care organization in the Mid-west. In general, the
response rates for both inpatient and nurse samples were
low. Results, therefore, should be treated in the caution,
and difficulties for generalization must be noted.
2.1. Sample
Self-administered questionnaires were distributed to
eligible members of unit-based registered nurses. Staff
nurses who performed direct patient care, held regular
appointments, and had worked on inpatient units for at
least 6 months prior to data collection, were the target
population. Full-time and regular part-time employees
on all shifts were included, but nurses who were
temporary or ‘‘floating’’ staff were excluded. The
questionnaire packets were sent to all eligible nurses
with a follow-up letter sent 4–6 weeks after the initial
mailing. The response rate, however, was 28% with a
total number of 520 nurses completing useable ques-
tionnaires.
The patients, who had been hospitalized for at least
one night in an inpatient setting, were sampled by the
nursing units from which they were directly discharged.
Intensive care units were not sampled because patients
were not discharged directly from such units. The
Nursing Services Inpatient Satisfaction Survey (NSISS)
(Ketefian et al., 1997) and a demographic sheet were
mailed to subjects’ residences 4–6 weeks after they were
discharged from inpatient care units. Reminder letters
were mailed to the identified subjects who had not
returned the questionnaires 4 weeks after they were
mailed. The response rate for the NSISS was 36% with a
total number of 345 returned questionnaires. To avoid
potential differences in perception between patients
themselves and family members responding to patient
satisfaction surveys, only surveys completed by patients
themselves who were at least 17-years-old at the time of
the study were included. Nurse and patient variables
 H.-M. Tzeng et al. / International Journal of Nursing Studies 39 (2002) 79–84
were aggregated by patient care units, resulting in 17
units for analysis.
2.2. Measures
Nurses’ perception of strength of culture was mea-
sured with the Nurse Assessment Survey (NAS) scale
developed by Braskamp and Maehr (1985). Organiza-
tional culture is defined as a set of shared beliefs, values
and norms about the ways things should be done in an
organization. Staff nurses’ perceptions of Strength of
Organizational Culture describes the extent to which
staff nurses view the organization as having a set of
expectations, direction, policies, and values for clear
communication among members of the organization
(Braskamp and Maehr, 1985; Maehr and Braskamp,
1986).
Nurses’ perception of job satisfaction was measured
with the Nurse Assessment Survey (NAS) scale devel-
oped by Braskamp and Maehr (1985). Job Satisfaction is
described as staff nurses’ satisfaction with pay, promo-
tion, supervision, and co-workers. Both strength of
organizational culture and job satisfaction were oper-
ationalized by sub-scales of the Nurse Assessment
Survey (Braskamp and Maehr, 1985; Maehr and
Braskamp, 1986).
The NAS scale has a 5-point Likert-type design
(1=strongly disagree, 5=strongly agree), and consists
of 91 items with 11 sub-scales. Braskamp and Maehr
reported that Cronbach’s alpha for strength of culture
was 0.82 (7 items), and alpha for job satisfaction was
0.80 (12 items) (Braskamp and Maehr, 1985).
Inpatient satisfaction with information about home
care and follow-up, and general inpatient satisfaction
with nursing care were measured with the Nursing
Services Inpatient Satisfaction Survey (NSISS). The
NSISS was developed around institutional standards of
nursing practice by the MNRP Project team (Ketefian et
al., 1997) to assess inpatients’ perceptions of quality of
nursing care. Patient satisfaction consists of a cognitive
evaluation and an emotional reaction to health care
services received (Pascoe, 1983). General Inpatient
Satisfaction With Nursing Care refers to a patient’s
overall impression of the nursing care services received,
specific to the patient care unit from which he or she was
directly discharged. Inpatient Satisfaction With Informa-
tion About Home Care And Follow-up refers to a
patient’s assessment of the nursing care services received
in the area of patient education as related to home care
and follow-up. Both general inpatient satisfaction with
nursing care and inpatient satisfaction with information
about home care and follow-up were operationalized by
sub-scales of the Inpatient Satisfaction with Nursing
Care Survey (Ketefian et al., 1997).
The NSISS has a total of 30 items using a 5-point
Likert-type scale (1=least favorable, 5=most favor-
81
able). Cronbach’s alpha for general inpatient satisfac-
tion with nursing care was 0.92 (12 items), and 0.82 for
inpatient satisfaction with information about home care
and follow-up (7 items). Tests for construct validity
showed that clustered items reflected the institutional
standards of nursing practice.
2.3. Data analysis
The unit of analysis was the inpatient care unit. To
calculate aggregated measures of staff nurse and patient
perceptions by patient care units, the authors deter-
mined that only those units with at least four staff
nurses’ and patients’ responses would be included to
ensure representation. Descriptive data and Pearson
correlation coefficients were calculated among included
variables. Regression analyses were used to test the
direct linkages in the conceptual model. These regression
models were assured for violations of regression
assumptions by generating scatterplots for the Studen-
tized residuals. The whole path model (from strength of
culture, to job satisfaction, to inpatient satisfaction with
information about home care and follow-up, to general
inpatient satisfaction with nursing care) was not tested
at the same time, because the sample size was not
sufficient for multiple regression analysis based upon
power analysis. Thus, the indirect effects were calculated
based upon the standardized coefficients (BETAs)
between measures from regression analyses.
3. Results
A total of 17 patient care units was used. Among these
17 units, 13 were medical/surgical adult units, 2 were
adult psychiatric units, and 2 were gynecology/obstetric
units. Descriptive information on study variables is
provided in Table 1. Pearson correlation coefficients
among included variables (n ¼ 17) are provided in Table
2. The results of regression analyses are summarized in
Fig. 2, and BETAs (with directions) were listed next to
the corresponding linkages. Table 3 showed the path
coefficients for direct effects (BETAs or standardized
coefficients) and indirect effects which were based upon
BETAs from the simple regression analyses.
4. Discussion and conclusions
This exploratory study examined the path model
linking staff nurses’ strength of culture, to staff
nurses’ job satisfaction, to inpatient satisfaction with
home care, to inpatient satisfaction with nursing
care. The results of simple regression analyses supported
the hypotheses in the conceptual model, where (1) the
nurses’ perceptions of strength of organizational
82 H.-M. Tzeng et al. / International Journal of Nursing Studies 39 (2002) 79–84

Table 1
Descriptive information on staff nurses’ (n ¼ 17) and inpatients’ perceptions (n ¼ 17)

Staff nurse variables Mean (SDa) Minimum Maximum

Strength of culture 46.27 (2.68) 42.00 52.80

Job satisfaction 47.79 (4.43) 40.20 53.40
Patient satisfaction variables
Information about home care 6.47 (1.22) 4.64 9.00
General inpatient satisfaction 6.28 (1.15) 4.36 8.12
Percentage of female respondents 56% (24%) 22% 100%
Patient age (years) 51.11 (7.76) 30.44 61.50
a
SD: Standard deviation.

Table 2
Pearson correlation matrix among study variables

Coefficient

(1) (2) (3) (4)

Job satisfaction (1) }
Strength of culture (2) 0.76a }
General inpatient satisfaction with nursing care (3) 0.21 0.47b }
Satisfaction with home care and follow-up (4) 0.60a 0.51c 0.65a }
Percentage of female patient respondents (5) 0.48b 0.62a 0.54c 0.69a
a
p50:01,
b
p50:10,
c
p50:05.

findings contribute significantly to the development of

Fig. 2. The tested model including the values of standardized
coefficients from the simple regression analyses.
culture predicted the level of nurses’ perception of job
satisfaction; (2) job satisfaction predicted the level of
inpatient satisfaction with home care; and (3) the level of
inpatient satisfaction with home care predicted the level
of general inpatient satisfaction with nursing care. These
nursing science by providing empirical evidence that
links organizational factors with patient process and
outcome factors.
The direct effects and the calculated indirect effects
(based upon standardized coefficients from regression
analyses) demonstrated that nurses’ variables, strength
of culture and job satisfaction had cause – effect
relationship with a path coefficient of 0.297 (strength
of culture on general inpatient satisfaction with nursing
care) or higher on inpatient satisfaction variables.
Although the path coefficients for the indirect effects
were calculated, these values provide evidence that the
identified organizational structure variable (staff nurses’
strength of culture) did contribute to the level of the
identified clinical outcome indicator (general inpatient
satisfaction with nursing care), through the organiza-
tional process variable (staff nurses’ job satisfaction) and
the clinical process variable (inpatient satisfaction with
home care). These indirect effects ranged from 0.30
(from strength of culture to general inpatient satisfac-
tion) to 0.46 (strength of culture to inpatient satisfaction
with home care) which are moderate to low. These
findings suggest that the strength of organizational
culture does have observable indirect effects on general
inpatient satisfaction, and strategies to modify organiza-
tional culture should contribute to the level of general
inpatient satisfaction indirectly through organizational
or clinical factors.
 H.-M. Tzeng et al. / International Journal of Nursing Studies 39 (2002) 79–84 83

Table 3
Path coefficients based upon simple regression analyses: direct effects and calculated indirect effects

Predictor variables\dependent variables Job satisfaction Inpatient satisfaction General inpatient

direct effect (D) and indirect effect (ID)a (2) with home care (3) satisfaction (4)

Strength of culture (1) 0.765 (D) 0.457 (ID) 0.297 (ID)

Job Satisfaction (2) } 0.597 (D) 0.388 (ID)
Inpatient satisfaction with information } } 0.650 (D)
about home care and follow-up (3)
a
Direct effects were the BETA values from simple regression analyses. Indirect effects were calculated by multiplying the BETAs of
the corresponding path linkages. For example, the indirect effect from strength of organizational culture to inpatient satisfaction with
home care through job satisfaction is 0.457 which is equal to 0.765 multiplied by 0.597.

Within nursing services, strategic planning efforts by
hospital and nurse administrators can be guided by the
findings in this study where organizational factors
contribute to clinical outcome variables. As emphasized
by Tate et al. (1995), patient perception/satisfaction
surveys should serve as an internal audit of patient care
practices as well as producing comparisons across
hospitals with similar contextual characteristics. By
promoting continuous quality improvement efforts,
organizations may improve patient retention, increase
patient referrals, and improve patient compliance.
4.1. Methodological limitations
The methodological limitation of this study is the
small sample size. Based upon power analysis, at least 23
cases would be required to test the hypotheses with one
predictor for a power of 0.80 and an alpha value of 0.05
for a large effect. In this project, the response rates for
both inpatient and nurse samples were low. This
situation might lead to spurious results and difficulties
for generalization. The limitations for practical implica-
tions are centered in measuring patient’s perceptions.
In the Rosenthal and Shannon (1997) report, they
summarized the methodological limitations for prior
research, which measured patients’ perceptions, but not
limited to nursing care services. Their conclusions,
which are also reflected in this exploratory study, are
summarized below:
* Patient perceptions and expectations for health care
services might vary systematically according to
sociodemographic and clinical characteristics.
* The distribution of patient perceptions is often
skewed toward the highest response categories (most
satisfied or most dissatisfied). This situation resulted
in decreased variability and being insensitive to
detecting difference across delivery systems or nur-
sing care units.
* It is difficult to get around non-response bias, which
may limit clinical implications.
* The mode of data collection (personal versus
telephone interviews versus self-administered ques-
tionnaire) and the site of data collection (home versus
health care systems) may lead to somewhat different
conclusions when testing the same conceptual model.
* The timing of data collection (after discharge versus
before discharge) also may influence patients’ re-
sponses.
Moreover, because of a small sample size, the number
of predictive variables to be included in the regression
models was limited, when considering the power analysis
and the possibility of making a Type II error. When
testing a similar model (a larger, follow-on study) due to
the necessity of using the patient care unit as the unit of
analysis, a larger sample size is desirable. It might be
difficult to obtain a sufficient unit-level sample size
within a single healthcare organization, however. For
future study in the area of nursing outcomes research,
these limitations described above have important
implications for similar projects.
Acknowledgements
This study is a secondary analysis of data from the
Michigan Nursing Role Professionalization Project. We
are grateful to the research project team and acknowl-
edge the following members, Richard W. Redman,
Ph.D., RN, University of Colorado Health Sciences
Center; Shaké Ketefian, Ed.D., RN, FAAN; Beverly
Jones, M.PH., RN, FAAN; Debra Finch, Ph.D., RN;
Sheri Dufek, MSA, RN; Joan Robinson, M.S., RN; and
Carol Spengler, Ph.D., RN, FAAN. All of them are at
the University of Michigan and hold positions in the
School of Nursing or Health Systems.
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