July 14, 2024

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How does patient-centered hospital culture affect clinical physicians’ medical professional attitudes and behaviours in Chinese public hospitals: a cross-sectional study? | BMC Medical Ethics

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Study design and setting

Multistage sampling was used to select the hospitals. Beijing, the capital of China, Wuhan City, the capital of Hubei province and Yingtan City, a prefectural city of Jiangxi province were selected. In each city, one Grade III Level A hospital and one Grade II Level A hospital were selected. In each hospital, two specialties were mainly chosen (internal medicine and general surgery) to ensure comparability. Ultimately, we chose two hospitals in Beijing in eastern China (B1-Grade II Level A, B2-Grade III Level A), one hospital in Hubei Province (W-Grade III Level A, another hospital was given up because the sample size was less than 30), and two hospitals (Y1-Grade II Level A, Y2-Grade III Level A) in Jiangxi Province in central China (Table 1). Except B1 hospital, the other hospitals were teaching hospitals, and none of them was the site of a professionalism seminar.

Table 1 Characteristics of respondents in this study (n = 232)

Study participants and eligibility criteria

Convenience sampling was used to investigate the physicians. The administrators of the hospital medical service department or human resources office assisted the investigation. They took the researchers to each department to distribute questionnaires and about half an hour later the researchers collected the questionnaire independently. Oral informed consent was obtained from all participants. And this survey was conducted anonymously. Altogether, we distributed the questionnaires to 256 physicians in the five public general hospitals, and 232 valid questionnaires were obtained yielding an overall response rate of 90.6%. Clinical physicians were investigated, and resident physicians and refresher physicians were excluded.

Study instruments

Measurement of medical professional attitudes and behaviours

According to three fundamental principles and ten professional commitments put forward by the Charter, based on the Chinese Medical Physician Declaration in 2011 and the Professional Code of Ethics for Chinese Physicians in 2014 published by Chinese Medical Doctor Association and several instruments in previous studies such as Campbell et al. [14], Roland et al. [15], Lombarts et al. [16] and Chen et al. [17], we developed the professionalism inventory encompassing both professional attitudes and behaviours. The attitude scale consisted of 9 subscales with 20 items: maintaining professional competence (3 items), honesty with patients (3 items), keep patients’ confidentiality (1 item), improving quality of care (5 items), improving access to care (2 items), just distribution of finite resources (1 item), commitment to scientific knowledge (1 item), Maintaining trust by managing conflicts of interest (1 item), and commitment to professional responsibilities (3 items). Professional behaviours included 8 subscales with 10 items: maintaining professional competence (1 item), honesty with patients (1 item), keep patients’ confidentiality (1 item), improving quality of care (1 item), improving access to care (1 item), just distribution of finite resources (2 items), maintaining trust by managing conflicts of interest (2 items), and commitment to professional responsibilities (1 item). The professional attitude items were answered on a 4-point Likert scale (1 = completely disagree, 2 = somewhat disagree, 3 = somewhat agree, and 4 = completely agree). Physicians described the frequency of professional behaviours in the last year on a 4-point Likert scale (1 = never, 2 = sometimes, 3 = usually, and 4 = always). 6 attitude items were reverse scoring. When aggregating the total score, the reversed items were recoded.

Assessment patient-centered hospital culture (PCHC)

According to the widely-used Schein’s model of OC, OC can be divided into three interrelated levels–basic underlying assumptions, espoused beliefs and values, and artifacts [33]. The basic underlying assumptions were difficult to discern because they were taken for granted beliefs and values unconsciously, while the culture will manifest itself at the level of observable artifacts (the visible products, observed behaviours, and structural elements) and shared espoused beliefs and values. Therefore, two levels of the OC, i.e. artifacts level and the espoused beliefs and values level, were designed to be measured in our study. We developed patient-centered hospital culture (PCHC) inventory draft. Experts in hospital culture research fields and hospital managers were consulted to modify the inventory. The final version of the scale had 22 items. Espoused beliefs and values dimension referred to hospital values and beliefs about patient-centered service (5 items, e.g. “my hospital attaches importance to improve patient satisfaction”), artifacts dimension included three sub-dimensions: (a) material culture was about medical equipment and hospital infrastructure, which was been seen as the visible products (5 items, e.g. “the layout of departments is scientific and reasonable”); (b) behaviour culture was about patient-centered service delivery (6 items, e.g. “activities for quality of care improvement achieved greatly in the hospital”, “there were a series of humanized service systems (e.g. emergency green channel system) in my hospital”); and (c) institution culture referred to patient-centered management system and diagnosis and treatment norms (6 items, e.g. “there are comprehensive medical ethics supervision system in the hospital”). 4-point Likert scale was used (1 = completely disagree, 2 = somewhat disagree, 3 = somewhat agree, and 4 = completely agree). Among the 22 items, 3 items were reverse scoring (e.g. my hospital cannot properly handle patient complaints). The reversed items were recorded in the analysis.

Each item of the respective measures was evaluated by the experienced exports and senior physicians during the design and physicians’ comments and suggestions were collected to modify the measures in pre-investigation till information saturation, which guaranteed content validity.

Exploratory factor analysis about the scale of PCHC showed that KMO value was 0.901, and Bartlett’s test χ2 = 2684.953, P < 0.001. After excluding one cross-loading item, we get the final scale of PCHC including 21 items. There are three factors with eigenvalues of 1.00 or higher, and 58.997% of the total variation can be explained. The first factor consisted of items about espoused beliefs and values dimension and one sub-dimension of artifacts (i.e. institution culture, such as “my hospital emphasizes that staff should respect and care for patients, and protect the patients’ rights”), the second factor consisted of items about two sub-dimensions of artifacts (i.e. behaviour culture and material culture, such as “the environment and facilities are comfortable, clean and convenient in the hospital”), and the third factor consisted of all the reversed items (such as “staff in different departments seldom communicates with each other”). According to the theoretical assumption and meaning the items, the three factors are renamed: value/institution culture, behavioural/material culture, and negative evaluation of hospital, respectively. The Cronbach’s α of the whole scale and three dimensions are 0.919, 0.911, 0.897 and 0.705, respectively [34].

Statistical analysis

Data were analyzed using SPSS 24.0 and Amos 24.0. Frequencies and percentages were used to describe categorical variables, and means and standard deviations were used to describe the distributions of continuous variables. The scores differences of different groups were tested by T-test and one-way ANOVA at a significance level of P < 0.05. Pearson’s correlation analysis was used to test the relationship between PCHC and professionalism. The mediation analysis was performed by Amos. The indirect, direct, and total effects three dimensions of PCHC on professional behaviour via professional attitude were determined.


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