Nursing efficiency in patient care: A comparative study in perception of staff nurse and hospital management in a trust hospital.

BACKGROUND AND
OBJECTIVE: While efficient use of resources and cost control is the responsibility of hospital managers, it is the duty of the nurses to carry out patient care and provide high-quality services. The aim of present research was to study the perception of staff nurses and nurse managers about nursing efficiency in patient care in a trust hospital.
MATERIALS AND METHODS: This quantitative and explanatory research has been done on staff nurses as well as nurse managers in a 550-bedded trust hospital in rural Gujarat of India. Data collection tool was a researcher made questionnaire and the data collection method was interview schedules for staff nurse and nurse managers. The total number of staff nurse in this hospital was 450 including 50 nurse managers.
RESULTS: Staff nurses had shown dissatisfaction regarding managers' practice and stated some aspects of managers practice which needed to improve such as keeping competitive salary for staff nurse, providing counseling system to supporting nursing practice, better recognition and acknowledgement system, better job security, providing supportive managerial style, better unit size and Applying vacation system.
CONCLUSIONS: There was a difference between staff nurses' perception and nurse managers' perception regarding professional characteristics for nursing profession and factors, which affect nursing efficiency in patient care (with 95% confidence interval and P < 0.05).

Introduction

World Health Organization's Director General, Gro Harlem Brundtland wrote: “Nurses are the backbone of the health care system.”[1] In health care system, nurses have a duty to comply with their professional codes of ethical conduct and have to provide the best care for patients in accordance with established standards. Nursing services and educational facilities in India have expanded considerably since independence. But it has been observed that there is a workforce crisis due to unemployment and underemployment in nursing across the India.[2]

The main purpose of a hospital is patient care and patient comfort of the patient.[3] Hospital has a well-defined hierarchy of authority, avouches that each lower location is under the supervision and control of a higher one.[4] Hospital managers to run hospital efficiently; they play a vital role in ensuring patient care and achievement of whole hospital.[5] Health care cost represents a major use of resources and today is growing rapidly, so improving the efficiency in the health sector, even in small amounts, can submit substantial savings of resources or expand of community services. Cost effective health care is an important objective for all Governments.[6]

Nursing efficiency includes more than only effective use of resources; it includes competent standard care in keeping with the Code of Ethics for nursing profession, the effective interpersonal relationship/communication, the appropriate use of technology and adequate Nurse-Patient Ratio (Staffing). This level of high-quality nursing practice leads to efficient nursing care with reduced length of hospitalization stay for the patient thereby saving the cost of treatment for the hospital and the patient. Professional managers run the bureaucracy of the hospital and the nurses are accountable to them. These managers may or may not be trained in the medical field and their primary responsibility is to control the allocation of human and non-human resources. While efficient use of resources and cost reduction is the responsibility of hospital managers, it is the duty of the nurses to carry out patient care and provide high-quality services. In many cases, it is found that the decisions of managers to reduce and control health care costs have led to decisions to reduce the number of nursing staff and reduce their salary; so increasing the workload of nurses as a result decreasing the time spent in patient care.

Hence, it seems there is a gap between nurses’ perceptions of efficiency in patient care in keeping with their professional training and that of the hospital manager who sees efficiency in patient care in terms of controlling costs. The result of this gap between nurse's perception and that hospital management's perception leads to dissatisfaction for the professional nurse and poor patient care.

Materials and Methods

This was a quantitative and explanatory research design which has been done on staff nurses as well as nurse managers. It was carried out in a 550-bedded trust hospital in rural Gujarat of India. The total number of professional staff nurses employed in the hospital was 450. In this study, complete enumeration was done and 220 staff nurses who fulfilled the inclusion criteria (more than 1-year work experience) were included and also all those 50 nurse managers were selected. The data collection method was interview schedule with filling of questionnaire for staff nurses and nurse managers.

Male nurses with less than 1-year experience and hospital nurse managers in finance/account department were excluded from this study. The data collection tools were researcher-made questionnaires for staff nurses and nurse managers. The Content Validity and Face Validity of both questionnaires were confirmed by 10 expert professors and professional nurses in Gujarat of India. CVR = 0.95 and CVI = 0.92 and for Reliability of questionnaire it was fulfilled two times with 10 days gap by 15 staff nurses and 10 nurse managers with Test-Re test Method, and for internal reliability, the Cronbach’ alpha was calculated, r = 0.87.

The collected data were analyzed by using SPSS 19.0. Frequencies and cross tabulations were used for descriptive analysis. For this study, we used appropriate statistical parametric and non-parametric tests such as Chi-square test, Spearmen correlation, Independent Sample Test from non-parametric tests, and Pearson correlation from parametric tests were applied for the data.

Ethical Consideration

The ethical committee of our institute approved this project and supervised its different aspects. The researchers, after getting permission and being introduced to hospitals managers, and obtaining participants’ consent, asked the participants to fill out the questionnaire and return it. They were ensured of the confidentiality of their personal information.

Results

The study findings are given below:

Table 1

Table 1

Distribution of age, educational qualification, job experience, job experience in current ward, job experience in current hospital and employment status across staff nurse and nurse manager

Groups Demographic profile	Staff nurseF (%)	Nurse managerF (%)
	Age (years):
Age (years)	Mean±SD=29.21±6.4	Mean±SD=46.40±7.09
21-30	157 (71.4)	3 (6.0)
31-40	47 (21.4)	2 (4.0)
41-50	13 (5.9)	30 (60.0)
50+	3 (1.4)	15 (30.0)
Total=270	220 (100.0)	50 (100.0)
	T=16.28, P=0/0
	Educational Qualification:
GNM	211 (95.9)	47 (94.0)
PB.BSc	6 (2.7)	1 (2.0)
BSc Nursing	3 (1.4)	1 (2.0)
MSc Nursing	0 (0.0)	1 (2.0)
Total=270	220 (100.0)	50 (100.0)
Job experience:	Mean±SD=6.85±5.33	Mean±SD=21.20±6.87
	Job experience:
1-5	123 (55.9)	2 (4.0)
6-10	51 (23.2)	2 (4.0)
11-15	27 (12.3)	5 (10.0)
16+	19 (8.6)	41 (82.0)
Total=270	220 (100.0)	50 (100.0)
	T=16.75, P=0.0
Job Experience in Current Ward:	Mean±SD=3.71±3.25	Mean±SD=7.94±7.92
	Job experience in current Ward:
0-1	48 (21.8)	10 (20.0)
1.1-5	125 (56.8)	16 (32.0)
5.1-10	35 (15.9)	10 (20.0)
10.1-15	11 (5.0)	3 (6.0)
15+	1 (0.5)	11 (22.0)
Total=270	220 (100.0)	50 (100.0)
	T=6.01 and P=0.0
Job experience in current hospital (years)	Mean±SD=5.90±5.05	Mean±SD=10.40±10.32
	Job experience in current hospital:
0-1	6 (2.7)	5 (10.0)
1.1-5	131 (59.5)	16 (32.0)
5.1-10	44 (20.0)	10 (20.0)
10.1-15	25 (11.4)	14 (28.0)
15+	14 (6.4)	5 (10.0)
Total=270	220 (100.0)	50 (100.0)
employment status:
	Yates corrected Chi-square, χ2=142.27, P=0.0
	Employment Status:
Permanent	37 (16.8)	50 (100.0)
Temporary	8 (3.6)	0 (0.0)
Contract	175 (79.5)	0 (0.0)
Total=270	220 (100.0)	50 (100.0)

The findings of the research had shown that Nurse Managers were significantly older than staff nurses (at least 10-30 years).

Regarding job experiences, more than half of the staff nurses were in the category of 1-5 years’ job experiences, but for nursing manager, the maximum proportions were in the category of 16 years and above. There was a clear significant difference between staff nurse and nurse manager regarding job experience.

Regarding employment status, the majority of staff nurse were in contract status and a few percentage of staff nurse were temporary staff, so they did not have fixed position and their salary and job security was lower than permanent staff. But all nurse managers were in permanent status that can give them a good job security and fixed position.

Regarding the question, are you satisfied that nurse manager take decision instead of you in the process of patient care? The study had shown that most (58.2%) of staff nurses were not satisfied and not interested to this matter, and regarding to reason of their dissatisfaction, a large percentage of staff nurse (46.9%) stated, nurse manager's decision reduces nurse's autonomy and nurse will be always dependent on nurse manager.

Table 2

Table 2

Distribution of professional characteristics of the staff nurse across staff nurse and nurse manager

Group	Staff nurseF (%)	Nurse managerF (%)
	1. Professional Education Place of nursing training
School of nursing	176 (80.0)	30 (60.0)
College of nursing	44 (20.0)	20 (40.0)
Total	220 (100.0)	50 (100.0)
Can staff nurse apply her professional education in routine work?
Yes	129 (58.6)	50 (100.0)
No	91 (41.4)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2=31.19, P=0.0
Total	220 (100.0)	50 (100.0)
2. Loyalty to Code of Ethics
Can the staff nurse apply nursing Code of Ethics in routine patient care?
Yes	93 (42.3)	50 (100.0)
No	127 (57.7)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2=54.49, P=0.0
Does nurse manager support you in applying Nursing Code of Ethics? Do you as nurse manager support nurse for applying Code of Ethics?
Yes	94 (42.7)	50 (100.0)
No	126 (57.3)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2=40.62, P=0.0
3. Standardization in nursing practice Is the Nursing Protocol displayed in your hospital?
Yes	94 (42.7)	50 (100.0)
No	126 (57.3)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2=53.69, P=0.0
Does hospital support nurse to applying Nursing Standards?
Yes	83 (37.7)	50 (100.0)
No	137 (62.3)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2=63.20, P=0.0
4. Evidence-based Practice
Can staff nurse apply evidence-based practice in patient care?
Yes	90 (40.9)	31 (62.0)
No	130 (59.1)	19 (38.0)
Total	220 (100.0)	50 (100.0)
χ2=7.32, P<0.01
5. Professional Organization
Are you a member of TNAI?
Yes	90 (40.9)	34 (68.0)
No	130 (59.1)	16 (32.0)
Total	220 (100.0)	50 (100.0)
χ2=12.04, P<0.001
6. Autonomy in Practice
Can the Staff nurse express her view to the doctor?
Yes	79 (35.9)	50 (100.0)
No	141 (64.1)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2=67.07, P=0.0
Can nurse have independent decision related to patient?
Yes	90 (40.9)	45 (90.0)
No	130 (59.1)	5 (10.0)
Total	220 (100.00	50 (100.0)
χ2=39.27,P=0.0
Whenever you do independent decision making, does the hospital acknowledge you?
Yes	90 (40.9)	45 (90.0)
No	130 (59.1)	5 (10.0)
Total	220 (100.0)	50 (100.0)
χ2=39.27, P=0.0
Do you work as a team member?
Yes	141 (64.1)	50 (100.0)
No	79 (35.9)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2=25.38, P=0.0
Is nurse's opinion asked in team work?
Yes	95 (43.2)	50 (100.0)
No	125 (56.8)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2=52.90, P=0.0
Whenever you give your opinion in team is acknowledged?
Yes	95 (43.2)	50 (100.0)
No	125 (56.8)	0 (0.0)
Total	220 (100.0)	50 (100.0)
χ2>=52.90, P=0.0

The table shows that the majority of staff nurse and majority of nurse managers studied in school of nursing and not in college.

The study shown that unlike the nurse managers, the staff nurse expressed dissatisfaction and inability to apply their professional education, Nursing Code of Ethics and Nursing Standards in their routine work and mentioned obstacles such as nursing shortage, high workload, insufficiency in equipment and did not perceive any support for applying all these aspects.

Table 3

Table 3

Distribution of perception of factors affecting efficiency across staff nurse and nurse manager

Group Influence efficiency	Nurse		Nurse Manager		Total	Statistical test result: Pearson Chi-square test
	Affect Efficiency	Doesn’t affect Efficiency	Affect Efficiency	Doesn’t affect Efficiency
Affective factors	F (%)	F (%)	F (%)	F (%)	F (%)
Importance of the Code of Ethics:
Providing evidence of professional legitimacy of patient care	195 (88.6)	25 (11.4)	27 (54.0)	23 (46.0)	270 (100.0)	χ2=33.43P=0.0
Guiding nurse to effective decision making	197 (89.5)	23 (10.5)	32 (64.0)	18 (36.0)	270 (100.0)	χ2=20.64P=0.0
Decreasing the length of stay in hospital	166 (75.5)	54 (24.5)	28 (56.0)	22 (44.0)	270 (100.0)	χ2=7.62P<0.01
Saving healthcare cost for hospital	94 (42.7)	126 (57.3)	45 (90.0)	5 (10.0)	270 (100.0)	χ2=36.45P=0.0
Saving healthcare expenditure for patient	83 (37.7)	137 (62.3)	43 (86.0)	7 (14.0)	270 (100.0)	χ2=38.14P=0.0
Decreasing use of resource/input in treatment process	101 (45.9)	119 (54.1)	41 (82.0)	9 (18.0)	270 (100.0)	χ2=21.28P=0.0
Empowering the nurse to maintain their focus on the patient as the center of health care	182 (82.7)	38 (17.3)	48 (96.0)	2 (4.0)	270 (100.0)	χ2=5.68P<0.05
Applying standard quality of nursing	17 (7.7)	203 (92.3)	27 (54.0)	23 (46.0)	270 (100.0)	χ2=63.95P=0.0
Importance of Nursing Standards in patient care:
Nursing standards can assist in evaluating nursing	168 (76.4)	52 (23.6)	14 (28.0)	36 (72.0)	270 (100.0)	χ2=43.37P=0.0
Applying higher quality of nursing	188 (85.5)	32 (14.5)	27 (54.0)	23 (46.0)	270 (100.0)	χ2=24.85P=0.0
Standards are based for teaching and practical work with students	186 (84.5)	34 (15.5)	27 (54.0)	23 (46.0)	270 (100.0)	χ2=22.82P=0.0
Assist in determining staffing requirement	212 (96.4)	8 (3.6)	26 (52.0)	24 (48.0)	270 (100.0)	χ2=76.75P=0.0
Empowering nurses to maintain their focus on the patient as the center of health care	47 (21.4)	173 (78.6)	9 (18.0)	41 (82.0)	270 (100.0)	N.S
Giving information to patient, family and healthcare team	11 (5.0)	209 (95.0)	8 (16.0)	42 (84.0)	270 (100.0)	χ2=7.53P<0.01
Allowing to express feeling	16 (7.3)	204 (92.7)	7 (14.0)	43 (86.0)	270 (100.0)	N.S
Importance of appropriate use of technology in patient care:
Automation of clinical information	183 (83.2)	37 (16.8)	26 (52.0)	24 (48.0)	270 (100.0)	χ2=22.65P=0.0
Improving communication between patients and provider	173 (78.6)	47 (21.4)	27 (54.0)	23 (46.0)	270 (100.0)	χ2=12.87P=0.0
Reducing medical error	169 (76.8)	51 (23.2)	18 (36.0)	32 (64.0)	270 (100.0)	χ2=31.88P=0.0
Bringing evidence to the point of care	99 (45.5)	121 (55.0)	16 (32.0)	34 (68.0)	270 (100.0)	N.S
Helping nurses to devote more of their time and expertise to caring for patients	166 (75.5)	54 (24.5)	25 (50.0)	25 (50.0)	270 (100.0)	χ2=12.75P=0.0
Raising nurse job satisfaction	210 (95.5)	10 (4.5)	30 (60.0)	20 (40)	270 (100.0)	χ2=51.85P=0.0
Contributing to improvement in patient care	173 (78.6)	47 (21.4)	17 (34.0)	33 (66.0)	270 (100.0)	χ2=38.93P=0.0
Importance of interpersonal relationship/communication in patient care
Obtaining information about patient, family and healthcare team	207 (94.1)	13 (5.9)	32 (64.0)	18 (36.0)	270 (100.0)	χ2=36.29P=0.0
Giving information to patient, family and healthcare team	198 (90.0)	22 (10.0)	42 (84.0)	8 (16.0)	270 (100.0)	N.S
Allowing them to express feeling	190 (86.4)	30 (13.6)	31 (62.0)	19 (38.0)	270 (100.0)	χ2=16.28P=0.0
Relieve the patient suffering from anxiety, loneliness and pain	163 (74.1)	57 (25.9)	31 (62.0)	19 (38.0)	270 (100.0)	N.S
Effective nurse/doctor relationship	184 (83.6)	36 (16.4)	31 (62.0)	19 (38.0)	270 (100.0)	χ2=11.75P=0.001
Effective ward round	189 (85.9)	31 (14.1)	39 (78.0)	11 (22.0)	270 (100.0)	N.S
Saving time enough for patient care	201 (91.4)	19 (8.6)	43 (86.0)	7 (14.0)	270 (100.0)	N.S
Improving patient-centered care	201 (91.4)	19 (8.6)	47 (94.0)	3 (6.0)	270 (100.0)	N.S
Applying nursing code of ethics in patient care	190 (86.4)	30 (13.6)	25 (50.0)	25 (50.0)	270 (100.0)	χ2=33.21P=0.0
Applying nursing standards in patient care	129 (58.6)	91 (41.4)	20 (40.0)	30 (60)	270 (100.0)	χ2=5.72P<0.05
Reporting and receiving report	182 (82.7)	38 (17.3)	28 (56.0)	22 (44.0)	270 (100.0)	χ2=16.83P=0.0
Building skills for developing communication with the patient and family	194 (88.2)	26 (11.8)	37 (74.0)	13 (26.0)	270 (100.0)	χ2=6.63P<0.05
Importance of staffing in efficiency of patient care
Better compensation to create nurse satisfaction	220 (100.0)	0 (0.0)	35 (70.0)	15 (30)	270 (100.0)	χ2=69.88P=0.0
Promotion opportunity for the staff nurse	220 (100.0)	0 (0.0)	35 (70.0)	15 (30.0)	270 (100.0)	χ2=69.88P=0.0
Role clarity to explain nurse duties/tasks clearly	220 (100.0)	0 (0.0)	29 (58.0)	21 (42.0)	270 (100.0)	χ2=100.19P=0.0
Favorite shift work	220 (100.0)	0 (0.0)	37 (74.0)	13 (26.0)	270 (100.0)	χ2=60.09P=0.0
Patient/Bed ratio	220 (100.0)	0 (0.0)	33 (66.0)	17 (34.0)	270 (100.0)	χ2=79.82P=0.0
Staff shortage: Nurse-Patient ratio	220 (100.0)	0 (0.0)	35 (70.0)	15 (30.0)	270 (100.0)	χ2=69.88P=0.0
Vacation system	220 (100.0)	0 (0.0)	37 (74.0)	13 (26.0)	270 (100.0)	χ2=60.09P=0.0
Workload: appropriate workload	220 (100.0)	0 (0.0)	35 (70.0)	15 (30.0)	270 (100.0)	χ2=69.88P=0.0
Applying nursing standards in patient care	76 (34.5)	144 (65.5)	24 (48.0)	26 (52.0)	270 (100.0)	N.S

Statistical tests had shown difference between perception of staff nurse and nurse managers regarding factors which affect efficiency of patient care.

Perception of Staff Nurse and Nurse Manager Regarding Nurse Manager Practice and How It Affect Efficiency

The result shows that regarding nurse manager's perception about manager practice for efficient patient care in total score, the majority of nurse managers (72.4%) perceived that this hospital is doing well and there is no need to improve in nurse manager's practice.

Staff nurses had shown dissatisfaction regarding managers’ practice and stated some aspects of managers practice which needed to improve such as keeping competitive salary for staff nurse, providing counseling system to supporting nursing practice, better recognition and acknowledgement system, better job security, providing supportive managerial style, better unit size and Applying vacation system.

Perception of Staff Nurse Regarding Her Own Efficiency:

The result shows that regarding staff nurse perception about her practice for efficient patient care in total score, the majority of staff nurses (61.8%) were not satisfied with their own practice in this hospital and said that, for improving efficiency of patient care, their practice needs to improve.

The area of nurse practice that was referred by staff nurses which needs to improve for this was: applying Nursing Standards in routine work, providing technical competency, providing good communication with patient care team, providing independent decision making and providing leadership style. In addition, they wanted modern machines as modern technology and more opportunity to do research.

Discussion

According to the findings of our survey, nurse managers were at least 10-30 years older than staff nurses, then it leads to the expectation that nurse managers are more experienced than the staff nurses. Moreover, we expect that according to age and experience, the two groups’ perception should also differ.

In this study, both groups’ educational degree was GNM qualification, so we suggest that Gujarat state should try to improve nursing graduation level in both staff nurses and nurse managers to at least the BSc degree.

The majority of staff nurses said that they had only two assistants under them. So, we can expect that because of excess workload, the staff nurses could not find time to interact with patients and then cannot apply accurate and timely patient care. This will lead to increase in medical error along with increase in hospital stay of the patient. The result is increased cost of hospitalization and treatment for patient as well as hospital, altogether lowering efficiency in patient care.

The majority of staff nurses and nurse managers said that they would recommend to family member or friend to join into nursing profession. This was in contrast with Patidar et al. (2010) study in Punjab state of India that suggested that those in nursing profession participants did not want their children or relatives to join the nursing profession.[7] This contrast can because of 5 years difference in date of study between Patidar et al.'s study (2010) and our study (2015), and during this 5-year study, nursing-based salary status might growing in India that increased our staff nurses interested to recommend anybody to join to nursing. We also expect in Gujarat state, staff nurses have more interest to nursing care along with applying better patient care for patient rather than Punjab staff nurses.

The majority of staff nurses and nurse managers in our study were satisfied with current work as staff nurse. We expected these staff nurses had good job satisfaction and may carry out better and efficient patient care. This was corroborated in the study by Noruzi et al. (2012), in Tehran that 72.6% of nurses and 65.4% of students had positive attitude and were satisfied toward their profession.[8] This corroborated may show that in both the studies, staff nurses are interested to nursing practice that means they did not looking to nursing as a job to earn money but they looking to nursing as a profession.

The majority of staff nurses had functional duties, such as for patient cleanliness, teaching Ayah, patient and relatives; as a result, nurses may perceive there is no any difference between Ayah and staff nurse in this hospital, leading to decrease in self-validity. This can increase nurse's job turn over. Also if nurse workload increased, then patient did not receive good care from nurse.

The majority of staff nurses expressed high workload as an obstacle to teach patient, relatives and ayah that showed that although nurses were interested to teach people, their time available was not enough.

The majority of staff nurses was not agreeable with managers’ decision making in patient care because they wanted independent decision making for themselves and managers’ decision making decreased nurses’ autonomy in practice.

Unlike the nurse managers, the staff nurses expressed dissatisfaction and inability to apply their professional education in their routine work. While nurse managers were unaware of the problems that staff nurses faced, they were consequently unable to help and support the staff nurses.

Patient education in this hospital does not have first priority for both study groups.

Staff nurses had shown not-enough knowledge about evidence-based practice. As a result, the nurse cannot apply research in patient care team. These findings are also defended by Dikmen (2016) study in Turkey that professionalism levels for nurses were the lowest in the areas of “autonomy”, “publication”, and “research”.[9] This may show that in most developing countries like India and Turkey staff nurse does not receive support to apply research and work autonomously because the managerial style in these countries do not let them and do not support.

Because of difference between these two groups’ perceptions regarding applying the Code of Ethics, the staff nurses did not feel to get supported by nurse managers.

Interaction with patients and relatives has priority for nurses, but nurse managers did not give priority to this aspect. This was also expressed by staff nurses as a reason for which they cannot apply nursing Code of Ethics in routine work along with high workload, adverse patient ratio and lack of time for interaction with patient.

The findings show a discrepancy between the two groups’ perception regarding nurse managers’ support for applying nursing protocol. As a result, they cannot work together in this aspect for best patient care.

Nurse managers were more aware about elements of evidence-based practice compared to staff nurses. As a result, staff nurses cannot apply Evidence-Based Practice (EBP).

The finding shows that altruism sense in both groups is not high for joining this profession. This shows that for both groups’ economic reason should be the first relief and then they can move towards altruism. This is also corroborated by Patidar study 2010 in Punjab, India.[7]

Three main priorities for staff nurses as regards the meaning of patient service was: To receive patient blessing, to carry out comprehensive nursing care and to receive patient satisfaction, but nurse managers mentioned most different priorities as the meaning of patient service, they said: Nurse's duty is to serve the patient, to care for the sick people and to receive salary and serve the patient. this shows they cannot work in a harmonious way for a high level efficient patient care.

Staff nurses did not show as a member of Trained Nurses Association of India (TNAI) and both groups were not fully aware of the activities of TNAI. This fact also nominated by Hall.[10] This corroborating between two studies nominate that hospital should give more announcement and opportunity for nurses to join professional organization also TNAI as a main nursing professional organization in India should try to reach to all professional staff nurses all over india.

Staff nurses and nurse managers were in disagreement about the possibility of expressing the nurse's view to the doctor; it means that nurse managers are not aware of the problems that staff nurses faced. Then they cannot support nurse or relieve her problem.

Staff nurses and nurse managers were in disagreement about the possibility of independent decision making by staff nurses. This is also mentioned in the study by Ghadirian et al.[10] All these studies prove that the managerial style is not agreeing with nurse's independent decision making.

Staff nurses and nurse managers were in disagreement about the possibility of doing team work, the area in which they work as a team, the areas regarding which the staff nurses’ opinion would be asked in team and the acknowledgement of staff nurse's opinion in team.

Unlike the nurse managers, staff nurses gave more priority to application of the Nursing Code of Ethics than nurse managers that guides staff nurses for effective decision making and consequently improves efficiency of patient care. Then staff nurses cannot be fully supported by nurse managers in this application leading to inefficient patient care. This also corroborated in Iyigun study in 2015.[11] This similarity between two studies can show in both hospitals because nursing shortage and nursing workload, the nurse managers give more priority to applying nursing services rather than applying Nursing Code of Ethics.

Unlike nurse managers, the staff nurses were not connecting Code of Ethics to cost saving economic side.

Unlike the nurse managers, the staff nurses give more priority to evaluating nursing practice as the benefit of applying nursing standards and also as basis for teaching and training of students.

The staff nurses were more aware regarding the benefit of providing appropriate use of technology to increasing nurse's job satisfaction and improvement of patient care, as compared with nurse managers.

In contrast to nurse managers, the staff nurses give more priority to obtaining information about patient, family and healthcare team as the benefit of interpersonal relationship.

Unlike the nurse managers the staff nurses did not feel satisfaction about allowing patients, relatives or healthcare team to express feeling. As a result, the patients do not receive efficient patient care.

In contrast to nurse managers, the staff nurses give more priority to efficient nurse doctor relationship for efficient patient care.

Unlike the nurse managers, the staff nurses give higher priority to interpersonal relationship as a way of applying the Code of Ethics and nursing standards along with reporting, skilled development and communication with patient and family as a way to improve patient care.

In contrast to nurse managers, the staff nurses give higher priority to better compensation, promotional opportunity, role clarity, preferred shift, appropriate patient-bed ratio, appropriate nurse-patient ratio, vacation system and appropriate workload to create higher nurse job satisfaction and as factors that can improve efficiency in patient care. This also is corroborated in Deghan Nayeri et al. 2005 study in Tehran, Iran.[12] and the study by Dikmen et al., (2012) in a public hospital of Turkey.[9] The reason of this corroboration can be Abraham Maslow Theory. According to Abraham Maslow's pyramid, if the basic needs of persons are not met, then they cannot apply upper level of needs to provide effective interpersonal relationship to patient's family and healthcare team in addition to accurate nursing practices for improving efficient patient care.

Unlike the nurse managers, the staff nurses perceived that more aspects of management practice are not effective to improve efficiency of patient care. This is a kind of mismatch between these two perceptions. When it occurs, it brings a conflict between these two groups towards perceiving and providing the same. Then both groups do not feel satisfaction about working together. As a result, patient cannot receive efficient patient care from nurses.

Nurse managers give priority to two points of management practices, but the staff nurses referred some more points as management practices which should improve. The staff nurses more than nurse managers, give priority to extrinsic factors (e.g., economic interest) which should improve for efficient patient care. All these findings also were in fact given by Falkenberg and Margaret.[13]

The majority of staff nurses had shown a level of dissatisfaction about their own practice in this hospital. They perceive a need to improve nursing practice for efficient patient care. This shows that staff nurses who are satisfied by their practice can improve efficiency of patient care. If they are not satisfied with their own practice then they cannot use their professional capability for the best and efficient patient care, as given in Al Hamdan et al. study in 2013[14], Ghadirian et al. study in 2014 and Dikmen et al. study in 2016. The reason of this corroborating may show that in all those hospital staff nurses same our hospital want more opportunity for improvement their professional practice.

The majority of staff nurses referred to improve nurse/patient ratio, decrease nurse workload, salary promotion, reduce staff nurse's paper work and good team work as five most important practices for efficient patient care. However, nurse managers referred to: good communication with patient and relatives, right time for administration of drug, basic nursing care, cleanliness of environment and health education as five most important practices for efficient patient care.

This finding shows that for staff nurse four practice of five is related to management practice and staffing from managerial style in this hospital.

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Conflicts of interest

There are no conflicts of interest.