Nursing as a profession has always been associated with the word caring. Caring, conceptually defined, involves “looking after people's physical welfare, e.g. nursing or social work” (M. Encarta, 2007). According to Leininger, care as a verb is identified as “action directed toward assisting, supporting, or enabling another individual with evident or anticipated needs to ameliorate or improve a human condition of life way” (George, 1995). It is a sad thing to note, though, that caring is slowly disappearing from nursing (Stewart, 1968). Nurses have become so busy operating machines and attending to paperwork that they tend to forget all about their patients. Some nurses would even treat their patients as though they were objects instead of human beings. They are so adept yet so mechanical at doing their routine work of checking vital signs, intravenous lines, etc., that they forget to ask their patients how they feel, whether they were able to sleep well, and so on.

“Delivering health care is a great task for nurses. The health care delivery system is the totality of services offered by all health disciplines. The Health care delivery system provides two general types of services, restorative and health care services, and preventive health care services” (Wolf et.al.). This health care delivery follows a particular process which should not be altered, regardless of the patient's status, physical, economic, or otherwise. This is called the nursing process.

The nursing process is a systematic method of planning and providing care to a client. The purpose is to provide client care that is individualized, holistic, effective, and efficient. It is a dynamic process which requires creativity in its application. Although the steps remain the same in each client situation, the application and results will differ. “The nursing process is designed to be used with clients throughout their lifespan and any care setting. It is a problem-solving framework for planning and delivering nursing care to their patients and their families” (Atkinson, 1992).

In order to maintain the proper observance and good performance of this process by nurses in hospitals, monitoring and evaluation procedures have to be followed by the management. Should this be neglected, chances are that nurses will not be performing at their best level, but will instead revert to just doing the routine duties of recording vital signs, providing the prescriptions given by the doctors, and other mechanical tasks or functions.

Nurses are accountable for their own actions as well as for the consequences of such acts. They are accountable for the quality of care they provide to their patients. Thus, nurses must have some ways to assure themselves that the care they render is a adequate quality care.

To expound on the findings from such assessment, this study further made a comparison with the findings of a similar study made among government hospitals. It attempted to determine any significant difference between the level of performance of nurses in secondary private hospitals as assessed by the current researcher, and that of nurses in government hospitals in Albay as studied by Geronimo J. Veloso, III in his research of March 2006 entitled, “Factors Affecting the Quality of Nursing Care in Two District Hospitals in Albay”. This undertaking is therefore both an independent assessment, and a correlational study on nurses' performance in hospitals in Albay.

According to Venzon, hospitals are categorized into three levels, according to service capabilities they offer. The primary level is composed of municipal and Medicare hospitals which have facilities and capabilities for first contact emergency care and hospitalization for simple cases. The secondary level consists of district hospitals with facilities and capabilities for medical care of cases requiring hospitalization, and which have the expertise of trained specialists. The tertiary level, is its part, is specialized centers, regional hospitals, medical centers, provincial, or general hospitals with capabilities for providing medical care to cases requiring sophisticated diagnostic and therapeutic facilities for specific medical problem areas. Examples are the Lung Center of the Philippines, Philippine Children's Medical Center, and the National Kidney Institute (Venzon, 1997).

In the Province of Albay, there are a number of private hospitals that can be categorized under the three levels according to Venzon. Sixteen (16) are classified as primary, seven (7) as secondary, and four (4) as tertiary (CHD-Bicol, 2005). The secondary hospitals which are the focus of this study, are the following: Ludovic General Hospital in Daraga, Dr. Esteban V. Ante Memorial Hospital in Legazpi City, Lumbis Rances General Hospital in Oas, Zapanta General Hospital in Pioduran, Dr. Amando D. Cope Memorial Hospital, Jaime B. Berces Memorial Hospital, and Cabredo General Hospital, all in Tabaco City.

Government hospitals in Albay, on the other hand, are comprised of four (4) primary, four (4) secondary, and one (1) tertiary healthcare facilities. They are under the provincial government pursuant to the Local Government Code of 1991, mandating all Department of Health facilities at the local level to be devolved to the local governments at the barangay, municipal, city, and provincial levels. This placed the district and municipal hospitals under the jurisdiction of the provincial government. Veloso's study focused on two secondary government hospitals in Albay, namely, Ziga Memorial District Hospital (ZMDH) in Tabaco City, and Josefina Belmonte-Duran Memorial District Hospital (JBDMDH) in Ligao City. Both are government-owned secondary-level district hospitals capable of the following services: treating ordinary and complicated cases; performing minor, medium, and emergency major operations; handling normal deliveries; performing routine laboratory diagnostic procedures; and providing family planning and other outpatient services.

With formal permission from Mr. Veloso, his study was herein compared and analyzed side by side with the current study. This study therefore utilized the same instrument as Veloso's in order to make such correlation possible and valid. The instrument, a questionnaire-checklist structured by the said researcher as his main data gathering tool, was duly validated and has passed final defense. Hence, there was no need for the current researcher to validate the same.

Observations have sadly revealed that there is a “deterioration of quality nursing care” in the country (Barcelo). Further, the trend of nurses going abroad to practice predicts that the country might be depleted by the best people in its nursing workforce, which, in turn, would reduce the quality of nursing care services. With the cost of health care services becoming more and more expensive, consumers have the right to expect or demand quality services. If these expectations or demands are not met, the public will surely lose confidence in the nursing profession in general.

What will happen to the public image of nurses and the nursing profession if this situation continues? Instead of lamenting this fact, the concerned people must work harder to address the problem. This is the reason why this study was conducted—to gather data about the performance of nurses in the secondary private hospitals in Albay. In the light of the current status and projected future of health and nursing situations, those in this profession need to pool their efforts together so that such issues can be addressed. Hence, this study attempted to assess whether nurses in the local hospitals are performing quality care and are globally competitive and updated.

The findings of this study will hopefully contribute towards such upgrading of the nursing curriculum, thus preventing further deterioration of nursing care in the country, and instead contributing to its improvement.

While other studies have been made regarding performance of nurses in hospitals, there have been none to cover the private hospitals in Albay, more so a correlational study on nurses' performance between secondary private and government hospitals in Albay. The researcher found it important to cover these kinds of hospitals since many people still prefer to avail the services of these medical institutions, especially when tertiary hospitals are either difficult to access or not so affordable. They may seem less significant than the tertiary hospitals, but patients who go to them for medication deserve the same quality of nursing care as any other hospital in the province, or anywhere else, for that matter. And as an Albayano himself, the researcher would like to extend his help towards uplifting the quality of nursing care specifically in his locality.

Specifically, it sought answers to the following questions:

1. What is the demographic profile of the nurse respondents in terms of:

• age
• sex
• religion
• civil status
• salary
• the number of years in service

2. What is the demographic profile of the patient respondents in terms of:

• age
• sex
• civil status
• highest educational attainment
• diagnosis

3. What factors affect the performance of nurses in terms of:

• Nurse-related factors
• Patient-related factors
• Environmental factors

4. What is the level of performance of nurses in providing nursing care to patients as perceived by the respondents?

5. Is there a significant difference between the level of performance of nurses in secondary private and government hospitals in Albay?

6. What measures may be proposed to enhance the performance of nurses in rendering quality nursing care to patients?

The study employed the survey method of research which is categorized under the descriptive research design, and involves observing, describing, and documenting aspects of a situation as it naturally occurs. Specifically, it focused on a description of the respondents' profile, and the level of performance of nurses in private secondary hospitals. Its correlational angle is likewise descriptive since it presents a comparison between nurses' performance in secondary private hospitals and that in government hospitals, both in the province of Albay.

This study was specifically correlated with the findings of Veloso, another researcher who focused on two selected secondary government hospitals in Albay, namely, Ziga Memorial District Hospital in Tabaco City, and Josefina Belmonte Duran Memorial District Hospital in Ligao City (Veloso, 2006). It aimed to find out if there was a significant difference between the level of performance of nurses in secondary private hospitals and that in government hospitals in Albay, thereby establishing a trend on nurses' performance in the province, regardless of the type of hospital.

Instrumentation

The survey questionnaire-checklist was utilized as the main data-gathering instrument for the study. With permission from Geronimo J. Veloso III, author of the study entitled “Factors Affecting the Quality of Nursing Care in Two District Hospitals in Albay”, the researcher used the ready-made questionnaire-checklist prepared and utilized in that study. Since the study was to be correlated to the previous undertaking, the researcher found it needless to come up with his own instrument, since not only has the abovementioned questionnaire been properly validated, but it has also been used for an actual study, rendering it effective and valid beyond question. It was approved by the members of the panel and the patient questionnaire check list was translated into Filipino version for easy understanding. As approved by the thesis committee, parts two and three of Veloso's questionnaire were interchanged in this study for both nurse and patient respondents' questionnaire-checklist. That is, “Factors Affecting the Quality of Nursing Care” which was originally the third part in Veloso's study, became Part II of this study's questionnaire. Likewise, “Quality of Nursing Care Rendered” which was originally the second part of Veloso's study, comprised Part III of this study's questionnaire. Two sets of questionnaires were prepared for the two groups of respondents. Both have four parts, but there were some variations in the demographic profile and the portion on the quality of nursing care.

The first part of the questionnaire for the nurses consist of the demographic profile. Part II focuses on the factors affecting the quality of nursing care. These factors were classified into nurse-related factors, patient-related factors, and environment-related factors, containing nine, six, and seven factors, respectively. Both nurse and patient respondents identified those items which they believed affected the quality of nursing care being rendered to the patients. Part III of the instrument determines the quality of nursing care rendered by nurses to their patients. The performance factors were classified according to the steps of the nursing process – assessment, planning of nursing intervention, implementation of nursing care, and evaluation. These four steps were assessed according to a varying number of items. The respondents made a check mark on the appropriate column corresponding to their answer based on the following scale (Veloso, p. 59)

To interpret the obtained weighted means from this portion, the following scale was structured (Veloso, p. 59):

The last portion, Part IV, contains the measures to enhance the quality of nursing care being rendered by the nurses to their patients. These measures were grouped into two classes. The first group contained the health-care provider measures, while the other group included the health-care recipient measures. Through a check mark, the respondents identified those they believed would improve the quality of nursing care.

Data-Gathering Procedure

Having established the respondents for the study, the researcher then proceeded with the data collection. He underwent the following stages in the data-gathering process.

Securing permit from hospitals. A letter was hand-carried to the different hospitals involved, securing permission from their heads to conduct a survey among its nurses and patients. Certain factors rendered difficulty to the researcher in the conduct of this undertaking, one of which is that not all of the seven secondary private hospital administrators were willing to accept the letter of permission.

About two hospitals were resistant in allowing the researcher to conduct the said survey. The researcher had to exercise utmost patience in explaining to the respective administrators the very purpose of the study despite their negative reactions. There were times when the researcher wanted to exclude these two private hospitals from his study, but through prayers and perseverance and by using charm, these two specific hospital administrators surprisingly and finally got the real essence of this endeavor. After two to three days of continuous follow up, a positive response became a precious gift to the researcher himself.

Distribution of the Survey Questionnaire:

With a cover letter attached as a way of informing the respondents of the purpose of the research activity, the questionnaire was distributed to the two sets of respondents. This comprised the actual field work in the data gathering process, and was done personally by the researcher.

Nurse respondents were very cooperative in answering the questionnaire. Problems were encountered by the researcher only when he started to administer the questionnaire to the patient respondents. There were some patients who could not read and understand the questionnaire despite the fact that it was translated into Filipino. Another problem was the attitude of the patients who were hospitalized; most of them were irritable during the data gathering period, and had a limited attention span in reading the provided questionnaire. This made the researcher continue reading the questionnaire for them, resulting in a delay in the data gathering process.

The duration of the data gathering in the seven (7) secondary private hospitals was from September to December, 2007. Incidentally, the time frame for the two district hospitals in Veloso's study was from July to December, 2005.

Retrieval of the Questionnaire:

Especially for those respondents who were unable to answer the questionnaire immediately, the researcher had to return to the respective hospitals to collect the accomplished instrument. There were some accomplished questionnaires which were unintentionally lost by other respondents that is why the researcher was made to repeat the process. This stage was concluded only when all the necessary data were secured from the respondents.

Upon accomplishing the above stages, the researcher then started with the analysis and interpretation of the data.

Statistical Treatment of Data

The data which were obtained from the respondents were collated, organized and analyzed based on the problems presented. The following statistical tools were utilized in the interpretation of the data.

Frequency counts and ranking were employed to describe the data on the demographic profile of the respondents. The same was used to interpret the third and fourth parts of the instrument which pertain to the factors affecting nursing care and the proposed measures to enhance the quality of nursing care.

To determine the quality of nursing care, the researcher computed for the weighted mean. The obtained weighted mean was then given the description or adjectival rating of the quality of nursing care based on the scale previously given.

Finally, to test the significant difference between the performance of nurses in secondary private and government hospitals, T-Test was utilized applying the following formula (Levin & Fox, 1997):

 

where t = significant difference

X₁ = mean of the current study

X₂ = mean of Veloso's study

^SX₁ - ^SX₂ = standard error of the difference between means.

Conclusions were derived and recommendations made based on the findings of the succeeding analysis.

Demographic Profile of Nurse Respondents

The study considered twenty six (26) nurse-respondents from the different secondary private hospitals previously named. Their demographic profile was analyzed according to age, sex, civil status, religion, salary, and years in service. These are reflected in Table 1.

Table 1. Nurse-Respondents' Demographic Profile

Age:

Eleven (11) of the nurses were within the age bracket of 21- 25 years, comprising forty-two percent (42%) of the respondents. This was followed by five (5) nurses aged 26- 30 years, comprising nineteen percent (19%) of the respondents. Three (3) nurses aged 31-35 years comprised twelve percent (12%) of the respondents, while two (2) others aged 36-40 made up eight percent (8%) of the total number. One (1) nurse each belonged to the age brackets of 41-45, 51-56, and 56-60, making up four percent (4%) each of the total number. There were two (2) other nurses who were grouped under the bracket of 61 and above, making up the remaining eight percent (8%) of the total number of nurse-respondents.

This information shows that most of the nurses in secondary private hospitals are still young, most of them being only in their twenties, which indicates that they have the ability to perform well. This could mean that they are using these hospitals as training ground for them to gain experience that would qualify them for tertiary hospitals, or better, for going abroad.

According to a study by Angel on job satisfaction, younger nurses are more inclined to leave the country because they have better opportunities for professional and personal development in other countries. Being young, they are more physically predisposed to meet the demands of the nursing profession abroad, and they are more likely to take advantage of the opportunities available for them. However, to prepare them for more challenging roles outside the country, they need experience as well as time to review for the qualifying examinations to work abroad, thus their initial employment in local hospitals.

Sex:

The preceding table gives the information that there are twenty-one (21) female nurses, making up eighty one percent (81%) of the respondents, but only five (5) male nurses, making up the remaining nineteen percent (19 %) of the total number of nurse-respondents. This finding still reflects the stereotype that nursing is a female profession. Although nowadays trends show that the number of males enrolling in BS Nursing is increasing, still, the majority of them remain to be females.

There is also the possibility that hospitals prefer more female nurses than male ones.

Civil Status:

Fifty-four percent (54%) or fourteen (14) of the respondents were still single at the time of the survey, while forty-two percent (42%) or eleven (11) of them were already married. Four percent (4%) or one (1) female was already widowed.

This information may be related to the respondents' age. Since most of them were still in their early twenties, they would normally be yet unmarried. They could still be ensuring the stability of their financial status or even be considering going abroad, thus refraining from engaging in a relationship that may hinder such plan. Angel's study likewise mentioned that nurses who were single were more likely to leave the country because they did not have children or dependents to hold them back (Angel, p. 26) .

Religion:

Out of the twenty-six (26) nurse-respondents, only two (2) or eight percent (8%) were non-Roman Catholics. The majority, comprising ninety-two percent (92%) of the total respondents, were baptized under the Roman Catholic religion. This is a reflection of the fact that Roman Catholicism is still the prevalent religion in Albay.

Salary:

Of the five salary brackets considered in the study, the bracket for salaries of PhP4,501-6,000 had the highest number of respondents. Ten (10) nurses, making up thirtynine percent (39%) of the total, receive such compensation. This was followed by the bracket for PhP7,501 and above, with five (5) or nineteen percent (19%) of the respondents. This was closely followed by brackets for PhP2,500-3,000 and PhP3,001-4,500, both with four (4) or fifteen percent (15%) of the respondents each. The smallest number belonged to the bracket for PhP6,001-7,500, with three (3) respondents, comprising twelve percent (12%) of the total number.

The above information reveals that there are still nurses in the secondary private hospitals who are underpaid, considering the minimum wage of PhP226/day (DOLE, Legazpi, 2008). As seen in Table 1, at least thirty percent (30%) of the respondents are paid below the said wage.

Based on the report of the National Economic Development Authority (NEDA), the poverty line in the Philippines is pegged at PhP13,500. The implication is that all the 26 nurse-respondents are receiving salaries rendering them way below the poverty line. This could be the very reason why many nurses seek for greener pastures outside the country. According to Angel, nurses who work in private hospitals have the higher intention to leave, since nurses in private hospitals are paid less than their equivalent in government hospitals (Angel, p.26). It should be noted though, that Sec. 33 of RA No. 6758, otherwise known as the “Compensation and Classification Act of 1989” dictates that the minimum base pay of nurses working in public health institutions should not be lower than the first step or hiring rate prescribed for salary grade 15 which is PhP 15,000/month (Venzon, 2005).

Years of Service:

Among the twenty-six respondents, ten (10) or thirty-eight percent (38%) of the total have worked in the hospital for only a year. This category has the highest number of respondents. Curiously, this is followed by nurses who have worked in the hospital for five years or above, under which nine (9) respondents have been categorized, making up thirty-five percent (35%) of the total number. Nurses who have worked for four years follow, with three (3) of them in the category, comprising twelve percent (12%) of the total number. Those who have worked for only two and three years have the smallest number, both with two (2) respondents, each making up eight percent (8%) of the total number of nurse-respondents.

These findings reveal that, while there are a number of nurses who stay long in the hospitals they serve, it seems that newer nurses do not continue their employment in the same health care facility, but most probably just stay for a year or two for training purposes, then move on to larger hospitals, or else go abroad. This is shown in the number of nurses who stayed for two to four years, which is much smaller than the number of either newly-hired nurses or those who have stayed for five years or more. Those who stayed for longer than four years are usually the ones who hold the higher positions in the hospital staff, such as Chief Nurses, Nurse Supervisors, or Senior Nurses, as those nurses who are mostly old in age who may not anymore qualify for other employment.

Holding their jobs for quite a while suggests that these nine out of 26 respondents who have worked in the same hospital for over four years are very experienced in the performance of the assigned tasks. This further implies that as healthcare givers, these personnel are quite skilled especially along promoting wellness, preventing illness, and restoring health. It is however of utmost importance that these healthcare providers continue their pursuit for excellence in line with quality healthcare services for the people, and doesn’t develop burnout as they age in their profession.

Demographic Profile of Patient-Respondents

As previously mentioned, this study considered one hundred forty-six (146) patient-respondents from the different hospitals included herein. Most these patients had been admitted in the respective hospitals for a minimum of three (3) days and were present during the data-gathering period. Respondents were at least twenty-one (21) years old and above, conscious, coherent, and not in serious condition upon admission. Their demographic profile was analyzed according to age, sex, civil status, educational attainment, and diagnosis. Table 2 gives a summative description of the information.

Table 2. Patient-Respondents' Demographic Profile

Age :

The patients' age ranged from twenty (20) years to eightynine (89) years. These were categorized into brackets, coming up with the following data: the highest number of patients fell under 30-39 years old, with thirty-nine (39) patients, comprising twenty-seven percent (27%) of the total respondents; this was followed by patients 40-49 years old, with thirty (30) respondents or twenty-one percent (31%) of the total; patients 50-59 years old followed, with twenty-five (25) respondents making up seventeen percent (17%) of the total; this was closely followed by the patients 20-29 years old, with twenty-four (24) respondents or sixteen percent (16%) of the total; patients 60-69 years old followed, with fifteen (15) respondents making up ten percent (10%) of the total; next were patients 70-79 years old, with twelve (12) respondents or eight percent (8%) of the total; the least number of patients under the age bracket 80-89, with only one (1) respondent, taking up one percent of the total number of respondents.

It can be noted that, most of the patients are in their thirties or forties. This may be due to the fact that this is usually the age where people get stressed out most, coping with the demands of both work and family. Many of them do not mind their health much, until such time that their body shows signs of overwork, and they end up in the hospital.

It can also be noted that there is only one patient in his eighties. This, of course, may be attributed to the fact that there are really less people who reach that age and those who do so and need hospitalization are usually brought to the tertiary level facilities, since their cases tend to be more complex and needs more specialized services.

Sex:

The majority of patients were found to be females; they numbered eighty-six (86), making up fifty-nine percent (59%) of the total number of respondents. The remaining 60 respondents were males, making up forty-one percent (41%) of the total. This may be due to the fact that females have a more delicate physique compared with males and are more prone to illnesses.

Civil Status :

Most of the patients were married, with one hundred one (101) respondents under this category, comprising sixtynine percent (69%) of the total number. Thirty two (32) were single, making up twenty-two percent (22%) of the total number. Thirteen others were widows, making up the remaining nine percent (9%) of the total number of respondents.

It is usually among the married people that illnesses occur due to the many concerns in their lives. More married people get sick compared to unmarried ones since being a family man or woman means more stress factors and more obligations to meet, thus greater chances of becoming ill. As already pointed out, they may not pay too much attention to their health until such time that they need to be hospitalized.

Educational Attainment:

The majority of the respondents are college students or undergraduates. There are forty-five (45) respondents under this category, comprising thirty-one percent (31%) of the total number. This is followed by the high school graduates, with thirty-three respondents or twenty-three percent (23%) of the total. Next are the elementary graduates, with thirty (30) respondents or twenty percent (20%) of the total. The college graduates follow, with twenty-six (26) respondents or eighteen percent (18%) of the total. The least number is that of the high school undergraduates, with only twelve (12) patients or eight percent (8%) of the total number of respondents.

This information shows the kind of clienteles that are admitted in the secondary private hospitals. Most of them are at the college level or lower, and only a few, making up only eighteen percent (18%) of the total number of respondents actually graduated from college. This points to the fact that the people who patronize these healthcare facilities mostly come from the middle to lower class, since those who usually do not finish college are not from the upper class of society. Thus, they go to the more affordable secondary private hospitals especially when the government hospitals are too far or when they do not wish to be borne down by government regulations and limitations.

Diagnosis :

Thirteen diseases/illnesses were mentioned as diagnoses of the different patient-respondents of the study. They are named herein from the highest number of incidence to the lowest: twenty-two (22) patients or fifteen percent (15%) had high blood pressure; twenty (20) patients or fourteen percent (14%) of them had fever and flu; fifteen (15) patients each had diabetes and cough/colds, separately making up ten percent (10%) of the total number of respondents; thirteen (13) or nine percent (9%) had headache; twelve (12) of them or eight percent (8%) had asthma; ten (10) or seven percent (7%) were diagnosed to have UTI; nine (9) patients or six percent (6%) each also had heart/chest pain and stomach pain; seven (7) or five percent (5%) each had diarrhea and lung ailment; five (5) of them, comprising three percent (3%) of the total, had dengue; and two (2) patients or two percent (2%) of the total number of respondents had viral infection.

As evidenced by the above information, high blood is the most common ailment that sends the patients running to the hospitals, closely followed by fever and flu or influenza. These are actually illnesses that are symptoms of stress, and would commonly strike overworked thirty to forty year-olds. It can be noted, though, that the diseases or illnesses of the patients who have themselves confined in these secondary private hospitals are not very serious cases and are fit to the capability of the level of such healthcare facility.

Factors Affecting Nurses' Performance

Both nurse and patient-respondents were asked to identify the factors that affect the performance of nurses in their workplace. The factors were categorized into three, namely, nurse-related factors, patient-related factors, and environment-related factors. Results of the survey are given below.

Nurse-related Factors:

The perceptions of the nurses and patients somewhat vary, as seen in Table 3. The majority of the nurse-respondents believe that their performance is greatly affected by their professional competence as well as their professional growth and development. Both factors were identified by eighty-five percent (85%) of the nurse-respondents. On the other hand, all, or one hundred percent (100%) of the patient-respondents believe that the factor that affects the nurses' per formance most is their professional competence, only fifty-six percent (56%) believe that professional growth and development affect nurses' performance.

Table 3. Nurse-Related Factors Affecting Nurses' Performance

Still, these show that professional status is given a highest importance by the respondents, especially among the nurses themselves. This means that they really joined the nursing profession because they believe in its significance, and they put more importance on what they can contribute to the society as healthcare providers, rather than what they can expect out of their job (Angel, p. 25).

Significantly, eighty-seven percent (87%) of the patients believe that the nurses' workload and scheduling greatly affect the performance of their duties. Seventy-three percent (73%) of the nurses also believe the same.

It can also be seen that the nurses believe that the factor that least affects their performance is the giving of incentives and motivations. Only fifty-eight percent (58%) identified this factor as affecting their performance. This, however, is still more than half of the total number of respondents, meaning that this factor is still important to the majority of them. Nurse respondents admit that incentives and motivations do have an effect on the way they perform in their workplace. This would mean that many of them work better when they feel that they are also compensated well for their hard work.

In the study of Angel, it was similarly revealed that pay or compensation also only ranked third in importance among the components of job satisfaction among nurses. While it is commonly thought that people go into nursing because of financial remuneration, the results of the study showed that among the respondents, this was not entirely true. Even if the nurses were concerned about the amount of money that they made, other components such as professional status and interaction figured more highly in their hierarchy of important components for job satisfaction (Angel, p. 26).

DeCoughery explains that professional job satisfaction is actually important to the nurse entering and remaining in the profession, and that locus of control (perception of autonomy) has been identified as a vital ingredient to have such satisfaction. Stress was pointed out to be the major reason for dissatisfaction and burnout (DeCoughery, 1995).

This would suggest that job satisfaction, and not necessarily pay, is a priority among nurses. Likewise, low salary may not necessarily be the cause of job dissatisfaction.

“Maslow defines motivation as the need that influences people to try to get something. Other motivations come from the outside and affect the person's reaction to his work environment and to the group of people to which he belongs” (Veloso, p. 90). In the case of nurses, examples of such motivation would include promotions, salary increase, satisfactory performance ratings, and the like. However, as pointed out previously, especially in the case of the young nurses, they are more concerned with gaining experience and training for their professional growth that they do not consider motivations and incentives as the most important.

Only the remaining forty-two percent (42%) feel that incentives or motivations should not affect the way nurses perform their duties. They believe that whether they are given such or not, they should still perform at their best in their chosen career. Another possible explanation for this, though, is the fact that many of the nurses are quite young and have worked for only a year in the hospital. Young nurses may be less concerned about the salaries and incentives, since their priority is to acquire training and experience in the field.

The patients seem to share the same view. Less than half of them, specifically forty one percent (41%) believe that incentives and motivations affect nurses' performance. However, they consider family and personal problems as least affecting nurses' performance. The majority of the patient-respondents have the impression that nurses can very well set aside their problems and concentrate on the work at hand. Ironically, though, the nurses themselves do not seem to think so. Sixty-five percent (65%) of them have identified this as one of the factors that affect their work performance. They acknowledge that family and personal problems do affect the way they handle the work set for them.

Other factors that majority of the nurse-respondents identified as affecting the work performance are: interest in and commitment to the job (81%); skills and training (73%), physical health and mental fitness (73%), and communication skills (69%). Among the patient respondents, the other factors that more than half of them perceive to affect nurse performance are skills and training (85%), and communication skills (56%). Less than half (49%) of them believe that physical health and mental fitness affect the performance of nurses in the workplace.

It can be noted that, there is a slight contrast in the perceptions of nurse and patient-respondents. These can be seen in the way they perceive family and personal problems, professional growth and development, and physical health and mental fitness. For all three factors, a much smaller percentage of the patient-respondents believe that these should affect the job performance of the nurses, whereas most of the nurses themselves believe that such have a big effect on the way they perform their duties. This means that although the nurses actually feel the effects of these factors on themselves, it really does not show in their performance, since the patients seem not to observe such effects on the nurses.

Patient-related Factors

Table 4 shows the perceptions of both nurses and patients on the patient-related factors that affect performance of nurses on the job. Though the rankings vary, the amount and importance given by the two types of respondents were not far from each other.

Table 4. Patient-Related Factors Affecting Nurses' Performance

For the nurses, the willingness of the patient to participate in the care administered to them is the most important factor that affects their performance. One hundred percent (100%) of the nurse respondents agreed to this.

Though not all, but a large number (84%) of the patients think likewise. For the patients, it is their condition and diagnosis that they perceive to affect the nurses' performance most.

This condition and diagnosis determine the care that should be given to a patient. There is this patient care classification system which groups the patients according to the amount and complexity of his nursing care requirements as well as the nursing time and skill they require. Ninety percent (90%) of the patient respondents believe in its importance. On the part of the nurses, such a system will translate into their efficiency in managing their time for each patient, thus affecting their level of performance.

The respondents also considered the attitude of the patients and their educational background to similarly affect the nurse’s performance. Attitude would especially influence nurses' performance of duties, since, human as they are, they respond to patients' attitudes in different ways. If patients show positive and thoughtful attitudes, nurses will tend to take a liking on them and treat them with more kindness than usual; but if patients show negative attitudes, nurses may just try to ignore the bad behavior, but may somehow feel aloof towards such patients. Similarly, educational background would affect nurses' performance, where the educated people tend to show better manners than uneducated ones. Also, it is usually easier to give instructions to the educated patients since they grasp such more readily with little problem.

On the other hand, the factor that least affects their performance, according to the nurse-respondents, is the patients' acceptance of their illness. Only forty-two percent (42%) of the nurses pinpointed this as a factor. They are not affected so much whether the patient accepts his illness or not. They would still perform their duties the same way in either case.

For the patients, however, they believe that the religion of the patient least affects nurses' performance. They must have observed that no matter what religion the patient may be affiliated with, they still treat the patients in the same way.

The other factors that affect nurse performance as related to patients are: attitude of the patients, their educational background, and financial capability.

For nurses, availability of functioning facilities is the most important factor affecting their performance of health care duties. Ninety-six percent (96%) of the nurse respondents claim this. The patient-respondents support this, with eighty-four percent (84%) of them saying so. Functioning facilities, after all, are indeed very important to the nurses because it facilitates the performance of nursing care. Absence or malfunctioning of certain equipment will sure negatively affect the way nurses deliver care to the patients. But should such equipment be available and smoothly functioning, performance of nursing duties will likewise be done in a highly satisfactory level.

The patients, however, put adequacy of supplies as the most important factor for them, such that ninety percent (90%) of them agree on this. Contrastingly, among the nurses, only fifty-eight percent (58%) seem to note lack of supplies as a factor affecting nurses' performance, which is the lowest ranked among the nurse-respondents. This could be because in the absence of certain supplies, the simple solution would be to request the relatives of the patient to procure him outside, for the use of the said patient. This may be something that commonly happens, thus they no longer consider this a problem that could affect their performance. In addition, nurses are also resourceful whenever urgent need of supplies arises.

It is to be noted that, there is a noticeable contrast in the nurse and patient-respondents' opinion when it comes to the attitudes of family members and significant others, as well as the relationship of patients to their family and significant others. While only fifty-one percent each among the patients think that these two factors affect nurses' performance, more nurse-respondents (77% and 65%, respectively) think that these two factors actually affect the performance of their duties.

Other environmental factors that affect the nurses' performance are: administrative support, cooperation of the other members of the health team, and cultural beliefs and practices of the family of the patient. This is expected because nurses are the one that feels the demand of the significant others in terms of patient care. As pay patient watchers expect that all their needs must be taken care of by the health care providers.

Environmental Factors

Similarly, nurse and patient-respondents gave their perceptions on environmental factors affecting nurses' performance in their work stations. Table 5 summarizes the information.

Table 5. Environment-Related Factors Affecting Nurses' Performance

Comparing the evaluation made by the two sets of respondents, it can be noted in Table 6 that for the first three stages, the patients gave a higher rating to the nurses than the nurses did themselves. For the first stage assessment, the nurses arrived at a weighted mean of 2.59, while the patients arrived at 2.91, which is slightly much higher.

Table 6. Summary of Assessments by Nurse and Patient-Respondents

Combined mean for this stage is 2.75. For the planning stage, the nurses' evaluation rendered a weighted mean of 2.65, whereas the patients' evaluation rendered a mean of 2.86, arriving at the combined mean of 2.76. The implementation stage, for its part, was given a weighted mean of 2.78 by the nurses, and 2.97 by the patients, coming up with a combined mean of 2.88. All of these ratings, though, are very well within the Very Satisfactory level.

As can be seen in Table 6 there was a slight contrast with the first three stages, however, the fourth stage got a higher rating from the nurses compared with that of the patient respondents. The nurses rated the evaluation stage with a weighted average of 3.02, whereas the patients rated the same with a weighted average of 2.86. Still, both ratings are well within the Very Satisfactory level.

This finding reveals that in the first three stages, patients showed a little bit more confidence in the nurses on the performance of their duties than the nurses themselves; whereas for the fourth stage, it is the nurses who have greater confidence in the performance of duties in line with the evaluation of nursing care. Considering all aspects of the nursing process and putting together the assessments of both sets of respondents, however, the important thing is that the overall level of performance of the nurses in secondary private hospitals is Very Satisfactory, having gained the overall average weighted mean of 2.83 as reflected on Table 6. This implies that nurses perform the nursing care based on the nursing process logical steps.

Legend: vs -Very Satisfactory;

WM -Weighted Mean; AD -Adjectival Description

The overall performance of the nurses for both private and government hospitals is clearly Very Satisfactory. The patients from both types of hospitals have very similar assessments of their performance of all the steps in the nursing process. According to the above results, both types of nurses in the said hospitals in Albay, perform with equal efficiency and effectiveness.

To sum up the nurse-respondents' evaluation of the nursing process in their respective hospitals, all steps of the nursing process were given Very Satisfactory ratings. Table 8 is a summative presentation of the above discussion.

Clearly, nurses from government hospitals have a slightly higher overall mean rating of 2.91 than the nurses from private secondary hospitals, who gained an overall mean of 2.76 only, but both mean ratings fall under the Very Satisfactory level. In other words, it can still be said that the performance among nurses in Albay, whether from private or government secondary hospitals, are comparable, or that, according to the findings from the evaluation by the nurses themselves, they perform equally well.

Comparison of Nurses' Level of Performance (Combined Respondents)

Combining the assessments made by both nurse-and patient-respondents for each type of hospital, the following results shown in Tables 7, 8 and 9

Table 7. Comparative Summary of Nurses' Level of Performance (Patient-Respondents)

Table 8. Comparative Summary of Nurses' Level of Performance (Nurse-Respondents)

Table 9. Comparative Summary of Nurses' Level of Performance (Combined Respondents)

All stages of the nursing process were given Very Satisfactory ratings. For assessment, private hospital nurses got a mean score of 2.75, while those of government hospitals got a mean score of 2.72. For planning of nursing intervention, private hospital nurses got a mean of 2.76, the government hospital nurses, 2.74. For implementation of nursing care, private hospital nurses were rated with a mean of 2.88, and the nurses of government hospitals, with 2.90. Finally, evaluation of nursing care got a mean of 2.94, while those of government hospitals got 2.73.

All in all, secondary private hospital nurses' performance was found to be Very Satisfactory, with an overall average weighted mean of 2.83. Similarly, government district hospital nurses' performance was assessed to be also Very Satisfactory, with an overall average weighted mean of 2.77.

Correlational Analysis between the Level of Nurses' Performance in Secondary Private and Government Hospitals

Below is the correlational analysis between the level of performance of nurses in private secondary hospitals and nurses in government secondary hospitals in Albay. Table 10 renders the results.

Table 10. Significant Difference between the Levels of Performance of Nurses in Secondary Private and Government Hospitals as Perceived by Nurse and Patient Respondents

where, df = degrees of freedom at 5% level of significance

To determine the significant difference between the level of performance of nurses in private and government hospitals as perceived by the nurse- and patient respondents, the T-test was used. It can be gleaned from the table that there is a significant difference between the level of performance of nurses in private secondary hospitals and that of nurses in government secondary hospitals.

While the foregoing assessments have shown similarities in results, gaining ratings falling under the same category, still, the above test shows that even though results were within the same bracket, still a significant difference was detected to exist between the means rendered by the two sets of respondents. Simply said, the ratings given by the respondents of the current study had a marked difference from the ratings given by the respondents of Veloso's study.

Analyzing the comparative tables presented earlier, it can be noted that most of the average means gathered from responses of both nurses and patients in secondary private hospitals are higher than those taken from nurses and patients in government hospitals. In other words, based on the above comparison, the performance of nurses in secondary private hospitals is better than that of nurses in government hospitals.

This phenomenon may be due to the fact that since private hospitals thrive on their income from patients who avail of their services, private hospitals want to attract more patients and wanted them to go back for further treatment or even invite other patients to their hospital. Nurses therefore have to put their best foot forward, that is, give quality service in all ways possible, and including in the kind of nursing care offered. Thus they are more careful in monitoring their nurses' performance. Of course, if the patients are satisfied, they will want to return back to avail of the health services.

In contrast, government hospitals are more for charity for the masses and the poor residents of a locale. They therefore tend to be less concerned about monitoring nurses' performance, because of the volume of patients they handle in a day. The administrators in government hospitals are not as anxious as those in private hospitals to please their clients, since they still keep coming back, not necessarily because they want to, but more because they have to, considering their financial capability. Many patients in the government hospitals are indigent and only few belonged to the middle class or can afford to pay hospitalization. For this reason, nurses are burdened of the nurse-patient ratio which jeopardizes the delivery of quality service to patients. Added to this is the inavailability of supplies and other facilities that contributes to the effective and efficient performance of nurses.

Measures Proposed for the Enhancement of Nurses' Job Performance

The two sets of respondents for the current study were also asked to give their views regarding measures that can be proposed or adopted to enhance the performance of nurses in the health care facilities they serve, especially those in secondary private hospitals in Albay. The nurse respondents and the patient-respondents gave their propositions as to provide with possible measures for both the Health Care Providers and Health Care Recipients. Below are the results of this portion of the survey. Tables 11 and 12 likewise give the information in detail.

Table 11. Health Care Provider Measures to Enhance Nurses' Performance

Table 12. Health Care Recipient Measures to Enhance Nurses' Performance

Health Care Provider Measures

Table 11 shows the measures that can be carried out by health care providers in order to improve nurses' job performance. It reveals the differences in the nurse respondents' and patient-respondents' perceptions as to which measures are most important for them, or which ones they think should be given more attention.

As shown in Table 11, the nurse respondents revealed three measures to be the most important for the enhancement of nurses' performance. These are: the evaluation and regular monitoring of the performance of nurses in order to ensure quality and effectiveness of care; the provision of opportunities for professional growth and development through post-graduate studies; and the observance of the standard nurse-patient ratio. For the patient-respondents, it is the evaluation and regular monitoring of nurses' performance that they think is of utmost importance.

The nurses assigned importance to the rest of the given measures as follows: next in rank is the encouragement of the utilization of research findings; tied at the next rank are the strengthening of admission policies to accept only academically and professionally qualified nurses, and the provision of optimal facilities basic to the care required for patients; also equally ranked on the next slot are the conduct of pre- and in-service training to nurses and the provision of incentives and motivation; ninth in rank is the involvement of nurses in research and research-related activities; and the least important to them is the provision of copies of the manual of the standard operating procedures for nurses. Apparently, the content of such manual is something they know quite well.

Comparatively, the ranking by patient-respondents of the same measures is as follows: second in rank for them is the conduct of pre- and in-service training to nurses; ranked next are the involvement of nurses in research and research-related activities, and the provision of opportunities for professional growth and development through post-graduate studies; fifth is the strengthening of admission policies to accept only academically and professionally qualified nurses; ranked next are three measures, namely is the encouragement of the utilization of research findings, the provision of optimal facilities basic to the care required for patients, and the observance of the standard nurse-patient ratio; ninth in rank is the provision of copies of the manual of the standard operating procedures for nurses; and tenth or least important to them is the provision of incentives and motivation.

Clearly the two types of respondents have different priorities, though both ranked the evaluation and regular monitoring of the performance of nurses as first. Looking at the rankings presented on Table 11, there are several things that are important to the nurses which were not given the same importance by the patients. For instance, while nurses found importance in the observance of the standard nurse-patient ratio, this was only ranked seventh by the patients. Another is, while patients deemed attendance to training as quite important, nurses believe otherwise. They probably feel that their constant exposure to hospital duties is training enough for them. Also noticeable is that the least important to nurses is the provision of the manual of standard operating procedures for nurses, while for the patients; it is the provision of incentives and motivations. To the latter, perhaps, it is ideal for nurses not to think of the material benefits of the job but rather the care and service they are able to offer to those who need such.

Health Care Recipient Measures

Having been asked to likewise give their perceptions on measures that health-care recipients could observe towards the enhancement of nurse’s job performance, the respondents revealed the following results.

For nurse-respondents and patient-respondents alike, the proper orientation of patients as to their role in the treatment of their disease is the most vital. Similarly, second on their list is the adequate giving of information to patients regarding the capability of the hospital to provide resources for their treatment. For their third priority, however, nurses uphold that patients should understand the shortcomings and needs of the health-care facility, which, for the patient-respondents, is fourth in rank. For the patients, third would be that patients should consider the functions and responsibilities of the nurses rendering care to them. This measure is least important for the nurses. On the part of the patients, least important for them is that patients should be well-educated. Although this is the fourth priority of nurses, it is understandable for patients to consider this as last, since, after all, not only the educated have the human tendency to get sick. Still, in fairness to nurses, they find it easier to deal with patients who are educated since they grasp instructions and explanations more quickly. Table 12 shows the details of the foregoing discussion: In conclusion, it can be said that the perspectives of nurses and patients somehow differ, though there are times when they also agree on certain aspects. What is important is that they become aware of each others' points of view in order that they are able to understand each other better and help each other in their common goals of improving the health condition of the patient.

The foregoing findings led to the following conclusions:

1. The nurse-respondents have varying demographic characteristics, but are mostly young and single.

2. The patient-respondents likewise have varying characteristics, and usually belong to middle class of the society.

3. A combination of nurse-related, patient-related and environment-related factors contribute to and affect the level of performance of nurses.

4. Both nurses and patients are well convinced of the Very Satisfactory performance of nurses in all aspects of the nursing process, but there is still room for improvement of such to a highly satisfactory level.

5. Performance of nurses in private secondary and government district hospitals have a significant difference specifically that nurses in secondary private hospitals perform better than those in government hospitals.

6. There are measures proposed for nurses to enhance their performance in providing quality patient care both in the government and private hospitals.

The following relevant recommendations were made

1. Hospital administrators may use the results of this study as reliable feedback and bases for the improvement of performance of nurses in all types of hospitals, especially considering the health care provider and recipient measures discussed. Hospital administrators and staff should be supportive of nurses in their efforts to perform their duties well by enhancing the factors that affect such performance. Hospital administrators should likewise be aware of the relevance of research as an important component for the improvement and advancement of their institution, thus it is recommended that hospitals be highly research-oriented. Since inadequacy of supplies and equipments is one reason for nurses' poor performance, hospital administrators should also address this problem;

2. Nursing school administrators may utilize the findings of this study as basis for the improvement of their curriculum to include problem areas that may have been revealed herein, or to focus more on those areas that have disclosed poorer performance among nurses.

3. Nursing service administrators should make a further study on how to improve work schedules, observe prescribed nurse-patient ratio, alter workload and provide staff support to enhance health care services. Nursing service should devise a continuous Performance Improvement Implementation Plan to monitor the nurses' effectiveness and efficiency in providing health care service to patients.

4. Nurses themselves should be fully aware of the complexity of the inter-relationships of the people and components involved in the nursing process and capitalize on such knowledge in order to find ways to make things work for the best. Further studies should be made by other nurses, nursing students, and other healthcare providers, focusing on the factors affecting performance of nurses and ways of improving on them. Nurses should continue updating and extending their professional knowledge and skills on new developments and new areas of practice so as to ensure continuing competence in the job.

5. Patients should likewise be understanding of nurses' limitations especially when it comes to the factors beyond their control, since such behavior will help the nurses perform better in difficult situations.