Received: 27 July 2018 Revised: 12 August 2018 Accepted: 13 August 2018

DOI: 10.1002/hpm.2656

RESEARCH ARTICLE

Hospital nurse shift length, patient‐centered care,

and the perceived quality and patient safety
Mu'taman Jarrar1,2 | Mohd Sobri Minai3 | Mohammad Al‐Bsheish4 |

Ahmed Meri5 | Mustafa Jaber6,7

1
College of Medicine, Imam Abdulrahman Bin
Faisal University, Dammam, Saudi Arabia Summary
2
Medical Education Department, King Fahd Background: There is no clear evidence that can guide
Hospital of the University, Al‐Khobar, Saudi
Arabia
decision makers regarding the appropriate shift length in
3
College of Business, Universiti Utara the hospitals in Malaysia. Further, there is no study that
Malaysia, Changlun, Kedah, Malaysia explored the value of patient‐centered care of nurses
4
Healthcare Administration Department,
working longer shifts and its impact on the care outcomes.
Batterjee Medical College (PMC), Jeddah,
Saudi Arabia Objective: The study aims to investigate the effect of the
5
Center for Artificial Intelligence and hospital nurse shift length and patient‐centered care on the
Technology, Faculty of Information Science
and Technology, Universiti Kebangsaan perceived quality and safety of nurses in the medical‐
Malaysia, Bangi, Selangor, Malaysia surgical and multidisciplinary wards in Malaysia.
6
Faculty of Civil and Environmental
Engineering, Universiti Tun Hussein Onn
Methods: A cross‐sectional survey has been conducted
Malaysia, Parit Raja, Johor, Malaysia on 12 hospitals in Malaysia. Data have been collected via
7
Nabu Research Academy, Baghdad, Iraq
a questionnaire. A stratified sampling has been used. The
Correspondence
Mu'taman Jarrar, College of Medicine, Imam
Hayes macro regression analyses have been used to exam-
Abdulrahman Bin Faisal University, Dammam, ine the mediating effects of patient‐centered care between
Saudi Arabia.
the effect of working long shifts on the perceived quality
Email: mutaman.jarrar@yahoo.com
and patient safety.
Results: There is a significant mediation effect of patient‐
centered care between the effect of shift length on the
perceived quality ( F = 42.90, P ˂ 0.001) and patient safety
( F = 25.12, P ˂ 0.001).
Conclusion: Patient‐centered care mitigates the effect of
the shift length on the care outcomes. The study provides
an input for the policymakers that patient‐centered care
and restructuring duty hours are important to provide
high‐quality patient care.

KEYWORDS

patient safety, patient‐centered care, quality, shift length

Int J Health Plann Mgmt. 2018;1–10. wileyonlinelibrary.com/journal/hpm © 2018 John Wiley & Sons, Ltd. 1
2 JARRAR ET AL.

1 | B A CKG R O U N D

The Institute of Medicine (IOM) has reported that service quality is a challenge and a priority for the healthcare
managers to deliver “safe, effective, patient‐centered, timely, efficient and equitable” healthcare.1 Since the time
IOM reported the adverse events in hospitals that resulted in human errors, there are several global initiatives and
reforms conducted to prevent patient harm2; however, patient harm and preventable deaths are still substantial.3
In the United States, there are 400 000 harm that lead to 210 000 deaths annually.4 In Malaysia, the number of
patient harm is increasing in private hospitals.5 Working longer hours is associated with service quality and
safety,6-8 nursing fatigue,9 and occupational hazard.10 Thus, the undertaken study is regarded as relevant in the
private hospitals to explore the impact of working longer shifts on service quality and patient safety in Malaysia.
Insight highlights that working longer shifts is associated with the nurses' perceived quality of care and patient
safety.8 There is also a lack of clear evidence that might guide the decision makers regarding the best shift length
of the nurses working hours.11 This highlights the importance to explore the impact of the shift length on the per-
ceived quality and safety of patient care. Many studies have revealed that the outcomes of care (length of stay
and adverse events) of treating patients with coronary heart disease improved as a result of restructuring the length
of duty hours.12 Further studies found that restructuring the duty hours leads to enhanced patient and family satis-
faction, decreased length of stay, and improved quality of care.13 Working long shifts lead to fatigue, medication
errors, and increase in the risk of employees to be involved with cigarettes and alcohol.7
However, there are studies that illustrate the shift length of nurses working hours had a mixed impact on the
care outcomes.7,11,14 Some studies illustrated that working 8‐hour shifts led to the decrease in the continuity of
patient care and the increase in the workload.14 These jeopardize the performance of staffs, care quality, and patient
care outcomes.14 Some other studies reveal that nurses who are assigned to work on a 12‐hour shift had a lower
workload and lower fatigue with higher joy at work than had nurses assigned to work on an 8‐hour shift.11 Interest-
ingly, insights also reveal that those who are working on an 8‐hour shift are said to experience decrease in fatigue and
burnout. It also improves the nurses' sleeping hours and thus optimizes their performance.14 These contradicting
insights show that it is important to explore intervening factors or predictors that affect the service quality and
patient safety.
Internationally, nurses are either working on an 8‐hour shift (morning, afternoon, or evening shift) or working
on a 12‐hour shift (night or day shift).11 In Malaysia, there is a slight differece in the shift type than in the interna-
tional nursing shift length (7‐h morning, 7‐h afternoon, and 10‐h evening shifts). The longer hours during nighttime
could be associated with the effect of surgeries conducted during daytime and nighttime. In the United Stated,
surgeries conducted at nighttime in the tertiary hospital had higher rate of readmission and resulted in a longer stay
in the hospitals; however, surgeries performed during the night shifts solve the issue of overcrowding at the
hospitals.15 The different working shift time from the international practices is questionable in optimizing the
service quality and providing safer care. Again, this reveals the importance of this study that was conducted
in Malaysia.
As mentioned, shift length had a mixed impact on the service quality and patient safety.7 The restriction of duty
hours had a significant impact on the process quality of patient care.12 However, there is an argument that it is not
associated with outcomes of care such as the mortality.12 This indicates the need to explore the contribution of
structural and process factors, which affect the outcomes of care.12 The study that produces this article kick‐starts
the research work based on the Donabedian theory, by including the shift length as a structural variable that affects
the outcomes of care. A survey conducted in seven Malaysian hospitals has illustrated that the demands for care is
increasing, the nurses are working long duty hours, and there is limited resources, which make it difficult to optimize
the service of healthcare.16 On the contrary insight, shift length is also revealed as inconsistent when it is associated
with the quality and patient safety.17 This insight renders the importance of exploring the process factor that might
explain these inconsistences. Another study that involved 12 Malaysian hospitals found that patient‐centered care
decreases the negative impact of nursing shortage on the hospital performance.18 This shows the importance to
JARRAR ET AL. 3

investigate the impact of patient‐centered care (with different shift length) on the quality and patient safety to
explain these associations.
Patient‐centered care not only is engaging the patient and family in the care decisions but also provides
nutritional guide, treatment consequences, communication, and education to the patient to prevent harm.19
Patient‐centered care helps to enhance the care outcomes.19-27 A patient who is more engaged and participated in
the treatment guides and procedures is less likely to expose himself or herself to potential harm.24 As increased
workload28,29 and working longer shifts tend to increase patient harm in the hospitals,17 the undertaken study
hypothesizes that nurses who provide more person‐centered practices are offering high‐quality services and safer
care regardless of the duty shift length (hours) they work. This is done by positioning the patient‐centered care as
the mediating effect while examining the impact of shift length on care outcomes in Malaysia.

2 | METHOD

2.1 | Design
A cross‐sectional survey was conducted on nurses who were identified according to the stratified random sampling
of the private hospitals in Malaysia. The stratification was based on the number of beds to large, medium, and small
size.30,31 Specifically, data have been collected from nurses who are assigned to work in the medical‐surgical and
multidisciplinary wards.

2.2 | Ethical and research approvals

Ethical approvals were collected from hospitals that agreed to participate in the survey. Ethical approval from
Planetree and Picker Institutes was obtained.

2.3 | Data collection

From all 14 states in Malaysian, 12 hospitals agreed to participate in the survey, and all are deemed to be fit accord-
ing to the research inclusion criteria. A total of 1055 nurses was identified and participated in the survey; however,
only 652 (61.8%) respondents provided complete answers to the questionnaire.
The scale used in the study is the 5‐point Likert scale. Nurses are required to rate from 1 to 5 on the patient‐
centeredness (place patients' interests ahead)32 that considers patient's expectations, preferences, and needs to
deliver care based on these needs33. A similar scale is used for measuring service quality and safety (perceived care
outcomes of health services). The nurses provide rating for care quality in the previous year and in the previous
working shift.34 Further, they rate in a 5‐point scale whether they encourage their relatives or friends to work or
to be treated in the hospital they work.35 For the patient safety, nurses are required to rate the frequencies of the
adverse events in the ward they work during their last shift.4,36 For the overall patient safety, nurses need to respond
to the question designed by the Agency for Healthcare Research and Quality.37 Finally, for the shift length measure-
ment, nurses are required to provide their shift time, whether it is 12, 10, 8, or 7 hours or others (refers to those
working dual shifts). In Malaysia, nurses work 7‐hour morning, 7‐hour afternoon, 10‐hour evening shifts or 12‐hour
night ̸day shifts.

2.4 | Data analysis

Hayes macro has been used in the regression analyses to prove the mediation effect of patient‐centered care
between the relationship of shift length and the care quality and safety of patient care. Hayes macro is considered
as more appropriate and powerful compared with the Baron and Kenny or Sobel method38-40 as Hayes introduces
4 JARRAR ET AL.

the concept of relative indirect effect (a × b paths) for examining the mediation effect.38-40 The study used 5000
sample bootstraps and opted for the significance level of P value less than 0.05 with confidence interval of 95%.
The study independent variable is multicategorical and contains four dummies. So a simple mediation equation
cannot be used because there are more than one a and c′ paths representing the independent dummy variables
affecting the mediator and the dependent variable.38 Following the suggestion of Hayes and Preacher, to adopt
the concept of “relative indirect effect and the relative direct effect” and apply the Hayes macro regression analyses,
the dummy variables can be compared with the reference group as parameterized with the following two equations:

M ¼ b0 þ a1 D1 þ a2 D2 þ ⋯ þ ak−1 Dk−1 þ eM ; (1)

M ¼ b0 þ c′1 D1 þ c′2 D2 þ ⋯ þ c′k−1 Dk−1 þ bM þ ey : (2)

Coefficient a1 is the coefficient quantifying the differences between the first dummy group and the reference
group on the mediator. Coefficient c′1 is the coefficient quantifying between the dummy variable one and the refer-
ence group on the dependent variable holding the mediator constant. Coefficient b is the coefficient quantifying the
effect of the mediator on the dependent variable.38 The reference group is the group that is expected to have higher
or lower perceived outcomes.41-43 Nurses working for a 7‐hour duty are expected to have greater perceived quality
of care than are nurses working longer shifts. Thus, in predicting a negative effect of working longer shift on quality
or patient safety (patient and family complaints), the 7‐hour shift was chosen as the reference group.

3 | FINDINGS

3.1 | Nurses' characteristics

The study participants are mainly of Malaysian nationality with 99.0% ratio. The majority of nurses participated in the
survey are from the Malay ethnic group (60.0%), followed by Chinese (21.6%), Indian (14.2%), and others (2.2%)
(including nurses from Thailand and Filipino). Most nurses are from large‐size hospitals (72.2%), whereas 16.5% and
11.3% are from medium‐ and small‐size hospitals, respectively; 60.9% of nurses who participated in the survey are
in teaching hospitals (those awarding medical degrees), while 39.1% are working in nonteaching hospitals; 72.0%
are working in nonaccredited hospitals, compared with 28.0% in accredited hospitals. In terms of the nurses' working
shift, the 7‐hour shift comprises 47.7%, whereas 17.5%, 16.8%, and 16.0% are the percentages of nurses assigned to
work on the 8‐, 10‐, and 12‐hour shifts, respectively. Only 2.1% of the nurses are assigned to work other shift type,
such as working “double shift.” Most nurses are assigned to work morning shift (38.1%), whereas 15.1%, 19.9%, and
26.9% are assigned to work afternoon, evening, and other (12‐h night ̸day) shifts, respectively. Further, 31.9% of
nurses are working in the multidisciplinary ward, whereas 23.3%, 26.1%, and 7.4% are working in the medical,
surgical, and general wards, respectively. The remaining 11.3% of the nurses are working in the other wards, such
as the oncology, endoscopy, cardiothoracic, and cardiology wards.

3.2 | Analyses
The results of the regression analyses, as shown in Table 1, indicate the insignificant impact of the shift length on
both service quality ( F = 1.27, P = 0.28) and safety ( F = 1.81, P = 0.13). The results open up the potential mediating
effect of patient‐centeredness if the relation to this variable could be proven significant. Tables 2 and 3 provide the
mediating effect results of patient‐centered care between the relationships of shift length on the quality and patient
safety. These results are required to answer the following hypotheses:

H1. Patient‐centered care mediates the relationship of shift length and quality.

H2. Patient‐centered care mediates the relationship of shift length and patient safety.
JARRAR ET AL. 5

TABLE 1 Shift length, quality, and safety

Shift Length Quality (B) Patient Safety (B)

8‐h shift 0.07 −0.03

10‐h shift −0.11 −0.17*
12‐h shift −0.01 −0.11
Other shift 0.03 −0.15
R2 0.01 0.01
F 1.27 1.81
P 0.28 0.13

Abbreviations: B, Beta Coefficient.

*Significant at P < 0.05.

TABLE 2 The mediation effect of patient‐centered care between the relationship of shift length and quality
a×b
Shift Length a b c′ LCI, UCI Mediation Type
Constant 3.70 0.96
8‐h shift 0.02 0.75*** 0.06 −0.06, 0.08 No mediation
10‐h shift −0.13** 0.75*** −0.01 −0.17, −0.03 Suppressor
12‐h shift −0.15** 0.75*** 0.10 −0.18, −0.05 Suppressor
Other shift −0.05 0.75*** 0.06 −0.20, 0.16 No mediation
R2 0.03 0.27 Suppressor
F 4.31** 42.90***
Significance of F 0.000 0.000

Abbreviations: LCI, lower confidence intervals; UCI, upper confidence intervals.

**P < 0.01.
***P < 0.001.

TABLE 3 The mediation effect of patient‐centered care between the relationship of shift length and patient safety
a×b
Shift Length a b c′ LCI, UCI Mediation Type
Constant 3.70 1.34
8‐h shift 0.02 0.62*** −0.04 −0.05, 0.07 No mediation
10‐h shift −0.13** 0.62*** −0.09 −0.14, −0.02 Suppressor
12‐h shift −0.15** 0.62*** −0.02 −0.15, −0.04 Suppressor
Other shift −0.05 0.62*** −0.12 −0.17, 0.12 No mediation
R2 0.03 0.18
F 4.31** 25.12*** Suppressor
Significance of F 0.000 0.000

Abbreviations: LCI, lower confidence intervals; UCI, upper confidence intervals.

**P < 0.01.
***P < 0.001.

The results shown in Table 2 indicate a significant mediation effect of patient‐centered care on the relationship
of shift length and quality ( F = 42.90, P = 0.000). On the basis of the relative indirect effect (a × b) values, nurses
assigned to work on a 10‐hour shift (95% CI, −0.17 to −0.03) and nurses assigned to work on a 12‐hour shift
6 JARRAR ET AL.

(95% CI, −0.18 to −0.05) are indirectly affecting the care quality (the CI does not include zero) compared with nurses
assigned to work on a 7‐hour shift. As H1 is supported, it is concluded that the patient‐centered care mediates the
relationship of shift length and quality. It can be observed that the longer working hours had a significant negative
association with the care quality through patient‐centered care, and the signs of a, b, and c′ paths are not similar.
This mediation is a type of “suppressor”, where patient‐centered care suppresses the effect of the shift length on
the care quality.
The results shown in Table 3 indicate a significant mediation effect of patient‐centered care linking the shift
length and patient safety ( F = 25.12, P = 0.000). On the basis of the relative indirect effect (a × b) values, nurses
who are assigned to work on the 10‐hour shift (95% CI, −0.14 to −0.02) and nurses who are assigned to work on
the 12‐hour shift (95% CI, −0.15 to −0.04) are indirectly affecting the patient safety compared with the nurses
who are assigned to work on the 7‐hour shift. This result supports H2, and it can be concluded that patient‐centered
care significantly mediates the relationship between shift length and patient safety. Nurses working longer hours had
a significant association with patient safety through patient‐centered care. Similarly, the signs of a, b, and c′ paths are
not the same, meaning the mediation type is also “suppressor”, where patient‐centered care suppresses the negative
effect of the shift length on the patient safety.

4 | DISCUSSION

The model tests the results in the establishment of the indirect relationship of shift length and the quality and patient
safety through the mediating factor of patient‐centered care. In other words, the shift length is indirectly associated
with the outcomes through an intervening factor, the patient‐centered care. This finding indicates and supports the
fact that the nurses' shift length of working hours is associated with the care outcomes, which then have a relation
with the service quality and patient safety. Moreover, the study found that patient‐centered care suppresses the neg-
ative impact of shift length on quality and patient safety (Tables 2 and 3). These findings actually can be supported
with a number of previous studies and the Donabedian theory. For example, insights reveal that patient‐centered
care helps to enhance the care outcomes.19-27 It is anticipated that highly patient‐centric nurses have more potential
to spend time with the patients,18 and as a consequence, patients who are more engaged and participated in the
treatment guides and procedures are less likely to be exposed to potential harm.24
When the mediating variable of patient‐centered care is introduced, it is proven that nurses working longer shifts
might have higher burnout and fatigue,12,14 resulting in patients receiving improper treatment or services in their
care, which in turn negatively affects quality and patient safety.19,24 However, a nurse who had high perceived
patient‐centered care can compensate the negative association on the perceived quality. It can be said that nurses
with high perceived patient‐centered care are more willing to stay with the patients and give more time to provide
efficient nursing care.
From Table 1, it can be observed, from the direct relationship, that nurses working on the 10‐hour shift had a
significant negative effect on patient safety. However, it is not significant on quality. The associations are negative
on both quality and safety with β coefficient of −0.11 and −0.17, respectively. The explanation is that patient‐
centered care does not compensate the negative association with patient safety. Thus, there are concerns with
patient safety in Malaysia. So a 10‐hour shift is not recommended in the hospitals in Malaysia. A similar finding
was found for the 12‐hour shift that had a negative perception of both quality and safety with β coefficient of
−0.1 and −0.11, respectively. Thus, ensuring the 24‐hour working time, the finding suggests for a change in the
nurses' duty shift in Malaysia from 7‐, 7‐, or 10‐hour duty shifts to 8‐, 8‐, or 8‐hour duty shifts, which show a positive
perceived quality and patient safety among nurse.
The findings of this study contributed to the literature empirical results of the mediation effect of patient‐centered
care between the relationships of shift length, quality, and safety. Managers might allocate resources to train nurses to
be more patient‐centered. These help to suppress the negative impact of the shift length on the care outcomes.
JARRAR ET AL. 7

For future research, as this study has shown that the relationship of working a 10‐hour shift and patient safety is
not compensated by the high perceived patient‐centeredness. There must be further other factors that might lead to
these results and other intervening factors to be examined for better explanations of these relationships. Other
factors such as nurse burnout, work environment, collegial relationships, and manager supports are factors required
to be included in the future studies. Within the context of shift length, this study has explored only specific duty hour
shifts (7‐, 8‐, 10‐, and 12‐h shift lengths) and its associations with quality and safety. Only 2.1% of nurses who
participated are assigned for more than one shift or longer than 12‐hour shifts. So the study is limited to confirm
the role and the effect of patient‐centered care of nurses working longer shifts (more than 12 h). For example, further
study is possible to explore the level of compensation of patient‐centered care of nurses assigned to work more than
12‐hour shifts or “double shifts” on the care outcomes. This may provide an answer to the question “what is the
maximum working hour length than can compensate for patient‐centered care?”

5 | C O N CL U S I O N

The study explored the effect of patient‐centered care between the relationship of shift length and care quality and
safety. The study provided insight that working longer hour is negatively associated with care quality and safety.
Working longer hours is indirectly associated with the care outcomes. Patient‐centered care explains the mixed
effect of shift length on the care outcomes. Nurses with long duty shift and had high perceived patient‐centered care
are prone to provide proper education regarding the treatment consequences and nutritional guide and communicate
effectively with their patients. They are staying longer to spend more time with their patients; this help to prevent
errors and patient harm and enhance the quality of care. Patient‐centered care suppresses the negative impact of
shift length on the care outcomes. The study results strengthen the mission of IOM of providing “safe, effective,
patient‐centered, timely, efficient, and equitable” healthcare. Managers and policymakers are required to move
towards patient‐centered hospitals by allocating more resources to train nurses for providing personalized care.
However, this study is limited in exploring specific duty hour shifts (7‐, 8‐, 10‐, and 12‐h shift lengths) and its
associations with quality and safety. It is limited in confirming the role of patient‐centered care of nurses working
longer shifts. Further study is required to explore the level of compensation of patient‐centered care of nurses
assigned to work more than 12‐hour shifts or “double shifts” on the care outcomes. Other intervening factors are
required to be examined for better explanations of these relationships. Nurses' burnout, work environment, collegial
relationships, and manager support are factors required to be included in the future studies.

ACKNOWLEDGEMEN T
The authors would like to offer prayers to the late Prof. Dr. Hamzah Dato Abdul Rahman who passed away on March
27, 2018, and to acknowledge his critical advice, guidance, critics, patience, and motivations that helped to produce
this work.

CONF LICT S OF I NTE R ES T

The authors declare no competing of interest.

ORCID
Mu'taman Jarrar http://orcid.org/0000-0001-7748-2069

RE FE R ENC ES
1. IOM. Quality chasm summit project description. [Internet]. Washington DC: National Academy Press; 2003 Available
from: www.iom.edu/iom/iomhome.nsf/pages/QCSummitProjectInformation.

2. IOM. To Err Is Human: Bulding a Safer Health System. Washington DC: National Academy Press; 2000.
8 JARRAR ET AL.

3. Leape L. Hospital readmissions following surgery turning complications into “treasures”. JAMA. 2015;313(5):467‐468.
4. James JT. A new, evidence‐based estimate of patient harms associated with hospital care. J Patient Saf [Internet].
2013;9(3):122‐128. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23860193
5. Jarrar M, Abdul Rahman H. Optimizing quality of care and patient safety in Malaysia: the current global initiatives, gaps
and suggested solutions. Glob J Health Sci [Internet]. 2016;8(6):75‐85. Available from: http://www.ccsenet.org/journal/
index.php/gjhs/article/view/44132
6. Griffiths P, Dall'Ora C, Simon M, et al. Nurses' shift length and overtime working in 12 European countries: the associ-
ation with perceived quality of care and patient safety. Med Care. 2014;52(11):975‐981.
7. Estabrooks CA, Cummings GG, Olivo S a, Squires JE, Giblin C, Simpson N. Effects of shift length on quality of patient care
and health provider outcomes: systematic review. Qual Saf Health Care [Internet]. 2009 Jun [cited 2013 Nov
6];18(3):181‐188. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19467999
8. Stimpfel A, Aiken L. Hospital staff nurses' shift length associated with safety and quality of care. J Nurs Care Qual [Inter-
net]. 2013 [cited 2014 Nov 30];28(2):122‐129. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3786347/
9. Patterson PD, Weaver MD, Hostler D, Guyette FX, Callaway CW, Yealy DM. The shift length, fatigue, and safety conun-
drum in EMS. Prehospital Emerg Care. 2012;16(4):572‐576.
10. Fransen M, Wilsmore B, Winstanley J, et al. Shift work and work injury in the New Zealand Blood Donors' Health Study.
Occup Environ Med. 2006;63(5):352‐358.
11. Stone PW, Du Y, Cowell R, et al. Comparison of nurse, system and quality patient care outcomes in 8‐hour and 12‐hour
shifts. Med Care [Internet]. 2006 Dec;44(12):1099‐1106. Available from: http://www.ncbi.nlm.nih.gov/pubmed/
17122714
12. Bhavsar J, Montgomery D, Li J, et al. Impact of duty hours restrictions on quality of care and clinical outcomes. Am J Med
[Internet]. 2007 Nov [cited 2013 Nov 9];120(11):968‐974. Available from: http://www.ncbi.nlm.nih.gov/pubmed/
17976424
13. Gajic O, Afessa B, Hanson AC, et al. Effect of 24‐hour mandatory versus on‐demand critical care specialist presence on
quality of care and family and provider satisfaction in the intensive care unit of a teaching hospital. Crit Care Med [Inter-
net]. 2008 Jan [cited 2013 Nov 9];36(1):36‐44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18007270
14. Philibert I, Nasca T, Brigham T, Shapiro J. Duty‐hour limits and patient care and resident outcomes: can high‐quality stud-
ies offer insight into complex relationships? Annu Rev Med [Internet]. 2013 Jan [cited 2014 Jan 14];64:467‐4683.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/23121182
15. Turrentine FE, Wang H, Young JS, Calland JF. What is the safety of nonemergent operative procedures performed at
night? A study of 10,426 operations at an academic tertiary care hospital using the American College of Surgeons
national surgical quality program improvement database. J Trauma [Internet]. 2010 Aug [cited 2013 Nov
15];69(2):313‐319. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20699739
16. Drake R. Nursing workforce planning: insights from seven Malaysian hospitals. Br J Nurs. 2013;22(2):95‐100.
17. Jarrar M, Rahman HA, Sebiany AM, Abumadini MS. Nursing duty hours' length and the perceived outcomes of care. Glob
J Health Sci. 2018;10(4):2‐7.
18. Jarrar M, Rahman HA, Minai MS, AbuMadini MS, Larbi M. The function of patient‐centered care in mitigating the effect
of nursing shortage on the outcomes of care. Int J Health Plann Manage [Internet]. 2018;(August 2017):1‐10. Available
from: http://doi.wiley.com/10.1002/hpm.2491
19. Tappenden K a, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving
quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet [Internet].
2013;22(3):147‐165. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23871528
20. Ludin SM, Parker S, Arbon P. A survey of Malaysian critical intensive care unit nurses' awareness of patients' transition
experiences (PE) and transitional care practice (TCP). Intensive Crit Care Nurs [Internet]. Elsevier Ltd. 2014 Aug [cited 2015
Feb 18];30(4):196‐203. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24534582
21. Muntlin A, Gunningberg L, Carlsson M. Patients' perceptions of quality of care at an emergency department and identi-
fication of areas for quality improvement. J Clin Nurs [Internet]. 2006 Aug [cited 2013 Nov 14];15(8):1045‐1056.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/16879549
22. Scott I a, Poole PJ, Jayathissa S. Improving quality and safety of hospital care: a reappraisal and an agenda for clinically
relevant reform. 2008 Jan [cited 2013 Nov 14];38(Intern Med J [Internet], 1):44‐55. Available from: http://www.ncbi.
nlm.nih.gov/pubmed/18190414
JARRAR ET AL. 9

23. Sriram S, Chack LE, Ramasamy R, Ghasemi A, Ravi TK, Sabzghabaee AM. Impact of pharmaceutical care on quality of life
in patients with type 2 diabetes mellitus. J Res Med Sci [Internet]. 2011;16(Suppl 1):S412. Available from: http://www.
pubmedcentral.nih.gov/articlerender.fcgi?artid=3252774&tool=pmcentrez&rendertype=abstract
24. Weingart SN, Zhu J, Chiappetta L, et al. Hospitalized patients' participation and its impact on quality of care and patient
safety. Int J Qual Health Care [Internet]. 2011;23(3):269‐277. Available from: http://www.pubmedcentral.nih.gov/
articlerender.fcgi?artid=3140261&tool=pmcentrez&rendertype=abstract
25. You L, Aiken LH, Sloane DM, et al. Hospital nursing, care quality, and patient satisfaction: cross‐sectional surveys of
nurses and patients in hospitals in China and Europe. Int J Nurs Stud [Internet]. Elsevier Ltd. 2013 Feb [cited 2014 Jan
28];50(2):154‐161. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22658468
26. Da Silva GSM, Chambela MC, Sousa AS, et al. Impact of pharmaceutical care on the quality of life of patients with Chagas
disease and heart failure: randomized clinical trial. Trials [Internet]. 2012 Jan [cited 2013 Nov 4];13(1):244. Available
from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3543334&tool=pmcentrez&rendertype=abstract
27. Griffin JP, Koch K a, Nelson JE, Cooley ME. Palliative care consultation, quality‐of‐life measurements, and bereavement
for end‐of‐life care in patients with lung cancer: ACCP evidence‐based clinical practice guidelines. Chest J [Internet].
2007 Sep [cited 2014 Feb 11];132(3 Suppl):404S‐422S. Available from: http://www.ncbi.nlm.nih.gov/pubmed/
17873182
28. Boyer S, Protopopescu C, Marcellin F, et al. Performance of HIV care decentralization from the patient's perspective:
health‐related quality of life and perceived quality of services in Cameroon. Health Policy Plan. 2012;27(4):301‐315.
29. Thuemmler C, Morris C. Global case management: Scotland real‐time monitoring of patient flow as an instrument to
optimize quality of care in acute receiving units. Lippincotts Case Manag. 2005;10(5):254‐260.
30. Lee KH, Yang SBCM. The association between hospital ownership and technical efficiency in a managed care environ-
ment. J Med Syst. 2009;33(4):307‐315.
31. Gok MS, Sezen B. Analyzing the ambiguous relationship between efficiency, quality and patient satisfaction in healthcare
services: the case of public hospitals in Turkey. Health Policy (New York) [Internet]. Elsevier Ireland Ltd. 2013 Aug [cited
2014 Jan 13];111(3):290‐300. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23769176
32. Lanjananda P, Patterson PG. Determinants of customer‐oriented behavior in a health care context. J Serv Manag
[Internet]. 2009 [cited 2013 Oct 18];20(1):5‐32. Available from: http://www.emeraldinsight.com/10.1108/
09564230910936832
33. Frampton S, Charmel P. Putting patients first: best practices in patient‐centered care [Internet]. 2009 [cited 2015 Feb 3].
Available from: http://books.google.com/books?hl=en&lr=&id=XPiXhIcobPMC&oi=fnd&pg=PT11&dq=Putting+patients
+first+:+best+practices+in+patient‐centered+care&ots=4Mg4h‐a6Ut&sig=wo0jF4Ye7mj‐JLLmdePxpYQkRG0
34. Aiken LH, Clarke S, Sloane D. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. J Am
Med Assoc [Internet]. 2002 [cited 2015 Jan 1];288(16):1987‐1993. Available from: http://jama.jamanetwork.com/article.
aspx?articleid=195438
35. Coetzee SK, Klopper HC, Ellis SM, Aiken LH. A tale of two systems—nurses practice environment, well being, perceived
quality of care and patient safety in private and public hospitals in South Africa: a questionnaire survey. Int J Nurs Stud
[Internet]. Elsevier Ltd. 2013 Mar [cited 2014 Jan 31];50(2):162‐173. Available from: http://www.ncbi.nlm.nih.gov/
pubmed/23218020
36. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann D, Sharek PJ. Temporal trends in rates of patient harm
resulting from medical care. N Engl J Med [Internet]. 2010 Nov 25;363(22):2124‐2134. Available from: http://www.
ncbi.nlm.nih.gov/pubmed/21105794
37. Aiken LH, Sermeus W, Van den Heede K, et al. Patient safety , satisfaction , and quality of hospital care: cross sectional
surveys of nurses and patients in 12 countries in Europe and the United States. Br Med J. 2012;344(e1717):1‐14.
38. Hayes AF, Preacher KJ. Statistical mediation analysis with a multicategorical independent variable. Br J Math Stat Psychol
[Internet]. 2014 Nov 5 [cited 2014 Jul 10];67:451‐470. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24188158
39. Hayes AF. An Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression‐based Approach. 1st ed.
New York, NY: Guilford Press; 2013:527.
40. Zhao X, Lynch JG Jr, Chen Q. Reconsidering Baron and Kenny: myths and truths about mediation analysis. J Consum Res
[Internet]. 2010 Aug [cited 2014 Jul 12];37(2):197‐206. Available from: http://www.jstor.org/stable/10.1086/651257
41. Hardy M. Regression with Dummy Variables [Internet]. 1st ed. SAGE Publications Ltd; 1993 [cited 2014 Nov 23] Available
from: http://books.google.com/books?hl=en&lr=&id=EzLffJlYISEC&oi=fnd&pg=PR5&dq=Regression+with+Dummy+
variable&ots=R8lXjXqfSx&sig=lnNBq6o1hwewjSygDJeQDJSyJTw.
42. Cohen J, Cohen P, West S, Aiken L. Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences [Internet].
Lawrence Erlbaum Associates; 2003 [cited 2014 Nov 23] Available from: http://books.google.com/books?hl=en&lr=
10 JARRAR ET AL.

&id=gkalyqTMXNEC&oi=fnd&pg=PP1&dq=Applied+multiple+regression/+correlation+analysis+for+the+behavioral+
sciences&ots=tQCV02mbch&sig=kbtLMNFzquJwmyNgVxNV‐Owh07s.
43. West SG, Aiken LS, Krull JL. Experimental personality designs: analyzing categorical by continuous variable interactions.
J Pers. 1996;64(1):1‐48.

How to cite this article: Jarrar M't, Minai MS, Al‐Bsheish M, Meri A, Jaber M. Hospital nurse shift length,
patient‐centered care, and the perceived quality and patient safety. Int J Health Plann Mgmt. 2018;1–10.
https://doi.org/10.1002/hpm.2656