Differences between patients expectations and satisfaction with nursing care in a private hospital in Jordanijn_

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1 International Journal of Nursing Practice 2012; 18: RESEARCH PAPER Differences between patients expectations and satisfaction with nursing care in a private hospital in Jordanijn_ Amal Samir Abdel Maqsood PhD Lecturer, Medical Surgical Nursing Department, Faculty of Nursing, Alexandria University, Alexandria, Egypt Arwa I Oweis RN DSNc Dean of Nursing and Associate Professor, Department of Maternal and Child Health Nursing, Jordan University of Science and Technology, Irbid, Jordan Fadia Shawqi Hasna PhD Dean of Nursing and Associate Professor, Faculty of Nursing, Philadelphia University, Jerash, Jordan Accepted for publication July 2011 Abdel Maqsood AS, Oweis AI, Hasna FS. International Journal of Nursing Practice 2012; 18: Differences between patients expectations and satisfaction with nursing care in a private hospital in Jordan A descriptive correlation study was conducted to describe the differences between patient expectations and satisfaction with nursing care, and to determine the relationships among patient s satisfaction with nursing care and selected sociodemographic variables. A convenience sample of 250 patients with different medical, surgical and gynaecologic diagnoses was recruited to participate in the study, which was carried out at a private hospital in Amman. Two research instruments and a sociodemographic data form were used for data collection: The Patient Expectations Questionnaire and Patient Satisfaction with Nursing Care Quality Questionnaire. The results indicated that patients were more satisfied with technical and ethical aspects of nursing care whereas they were less satisfied with nursing care during the night shift as well as with professional information provided by the nurses. The difference between patients expectations and satisfaction was statistically significant. Patients opinions regarding their expectations and their satisfaction with nursing care can be considered as an important opportunity for nurses to plan and implement appropriate strategies that improve the quality of nursing care. Key words: nursing care, patients expectations, patients satisfaction, quality of nursing care. BACKGROUND Since patient-centred care has become a major concern of health-care providers, patient satisfaction with nursing Correspondence: Amal Samir Abdel Maqsood, Medical Surgical Nursing Department; Faculty of Nursing, Alexandria University, Edmon Fermon Street, Smoha, Alexandria 21527, Egypt. amal_abdmaqsoud@yahoo.com care became a pivotal indicator of the quality of care provided in hospitals. 1,2 O Connell et al., 3 highlighted difficulties in dissociating patient s satisfaction with nursing care from their overall satisfaction with their hospital experience. Given the fact that nurses provide the primary service to patients, therefore they influence the overall level of patients satisfaction. Moreover, previous research showed that patients satisfaction with nursing doi: /j x x

2 Patients expectations and satisfaction 141 care reflect the increasing hospital accountability to the public 4 6 and to outcomes of their health-care experience. 7 Oleni et al. 8 explored the elements of patients satisfaction with nursing care using literature from Sweden, UK and the USA, and although no consensus regarding the factors that constitute patients satisfaction with nursing care could be reached in the literature, many sources relate patients satisfaction directly to quality of care. Satisfaction is widely recognized as a patient legitimate measure of health care, particularly managed care Eriksen 12 defined patients satisfaction as the patients subjective evaluation of the cognitive-emotional response resulting from the interaction between the expectations of nursing care and the perception of actual nurse behaviours/characteristic. In addition, patients opinions are important because they are the best source that can tell the providers of what is important, that is why this information can be used in health-care planning and evaluation. 2,13 On the other hand, patient s satisfaction has been associated with improved patient compliance with therapy that presumably leads to better health outcomes. Nurses and other health-care professionals play a key role in providing support and information. 5 Patients satisfaction is viewed as a mediator between patients perceptions of quality and their future intentions to reuse the service or recommend the hospital to family and friends. 1 In order to achieve patients satisfaction consistently, data about what the patient prefers should be obtained before care is delivered not at the end of a care episode in an attempt to bridge the gap between patients perceptions of quality of care and those of the nurses. Assessing patients preferences should be a major component of the nursing assessment. 14,15 The aims of this study were to explore the relationship between patients expectations and satisfaction with nursing care received during hospitalization. Also to determine the relationship between patients sociodemographic variables and their expectations and satisfaction levels. Findings of this study could be transferable to other private hospital settings and might have similar implications for nursing care improvements. These findings can inform the planning and implementation of continuing education programs for nursing staff. Nursing management can also use these findings as one evidence-based indicator of nursing contribution to the patient care process. METHODOLOGY A convenience sample of 250 patients with different medical, surgical and gynaecologic diagnoses were recruited to participate in this descriptive correlation study, carried out at a private hospital in Amman. This hospital was selected because it has been accredited by the Joint Commission International in 2008; it was established in 2001, with a capacity of 100 beds and 24 comprehensive outpatient clinics including most of the medical specialties. The total number of hospital nurses at the time of data collection was 245 (120 registered nurses and 125 practical nurses). Registered nurses are usually holders of a Bachelor s degree in nursing (4-year university programs) or graduates from a 3-year diploma program whereas practical nurses are usually graduates from a 2-year diploma program or have a high school certificate from a nursing stream. Patients were selected from three departments of the hospital, the female medical surgical department which has 21 beds serviced by 13 nurses (7 registered nurses and 6 practical nurses). The male medical surgical department has 23 beds and 21 nurses (11 registered nurses and 10 practical nurses) and the obstetrics and gynaecology department which has 21 beds and 13 nurses (7 registered nurses and 6 practical nurses). The inclusion criteria for patients to be selected were being Jordanian, over 18 years of age, hospitalized for at least 2 nights at the time of data collection, able to communicate and agreeing to participate in the study, and being psychologically and physically willing to participate. INSTRUMENTS The Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ) developed by Laschinger and Hall 16 was mainly used for the purpose of this study; the questionnaire was modified after obtaining permission to use and modify it. The variables of this research instrument (PSNCQQ) were used to devise the Patient Expectation Questionnaire, which was given to patients upon admission to the hospital purely documenting their expectations of nursing care. Then just before discharge, these same patients were given the PSNCQQ that included the very same variables. In addition, a demographic data form was used in this study. The PSNCQQ was used after an extensive review of the literature since patient satisfaction with nursing care is a major indicator of the quality of hospitalization experience; although most instruments used in the literature did not have a framework and variables were

3 142 AS Abdel Maqsood et al. not measured in a tangible way that can be transferable to quality managers and be used by them; this instrument is largely based on the Patient Judgment of Hospital Quality used by Meterko et al. 17 in It included measurable standards of patient satisfaction. The researchers decided to use it upon admission and pre-discharge. Both questionnaires consist of 16 items scored on a Likert-type scale from 1 to 4 (1 being strongly disagree whereas 4 being strongly agree ). Each participant received a total score on the questionnaire ranging from 16 to 64; high scores indicated high expectations of nursing care. The PSNCQQ given pre-discharge had three additional questions that were excluded from the comparisons with the Patient Expectation Questionnaires; these additional questions tapped satisfaction with the overall quality of care received during the hospital stay, overall quality of nursing care, and intention to recommend the hospital to family and friends and these questions can only be answered after the hospitalization experience that is why they are not included in the expectations questionnaire. The 4-point Likert scale ranged from 4 very good to 1 poor was used for each item of the PSNCQQ. Each participant received a total score on the questionnaire ranging from 16 to 64. High scores on the PSNCQQ indicated high levels of patient satisfaction with nursing care. In addition, the sociodemographic data form was revised to include a 15-item self-reported scale developed by the researchers after a review of the literature. 4,18 Sociodemographic variables included age, education and social status as well as hospital variables such as type of lodging, duration of stay in days and types of treatment received in the hospital that are proposed to influence the patient expectations and satisfaction. The patient was asked to respond to all questions included in the sociodemographic data form. Translation of the instruments was done using the back translation method for each instrument. INSTRUMENTS VALIDITY AND RELIABILITY Laschinger and Hall 16 reports that PSNCQQ instrument reliability for item correlations ranges from 0.61 to 0.89; the reported Cronbach s alpha coefficient is In the current study, the Cronbach s alpha coefficient was 0.81 for PSNCQQ and 0.82 for Patient Expectation Questionnaire indicating that the questionnaires were reliable. Laschinger and Hall 16 states that the predictive validity of this instrument for expected outcomes has been established as valid for the purposes of health services research. Content validity of these instruments was assessed by a panel of three experts specialized in adult health nursing for clarity, validity and comprehensiveness of the questionnaire items. A pilot study with 15 participants, who were then excluded from the study, was conducted to determine the clarity of the instrument and the time required from each participant to complete the questionnaire; based on the pilot study the length of patient s stay was decreased from at least 5 days of hospitalization to at least 2 nights. DATA COLLECTION PROCEDURE The research protocol was reviewed and approved by the scientific research committee at Philadelphia University. Permission to conduct the study was obtained from the director of the hospital; following that, the researcher scheduled a meeting with the head nurse and nursing staff of each unit to discuss the nature of the study and the data collection process. Data were collected by one of the researchers from December 2009 to February The researcher explained the nature and the purpose of the study to eligible participants who were reassured that their participation is voluntary, that they can withdraw from the study at any time, and that their names will not be identified; hence, their privacy, anonymity as well as confidentiality was protected. Furthermore, they were assured that their participation will not affect the quality of care they would be receiving. Written consent forms were signed by the participants before data collection. The patients were given their copy of the Patient Expectation Questionnaire and were asked to complete it on admission. On the other hand, the PSNCQQ questionnaire was completed just before they were discharged. DATA ANALYSIS Data were analyzed using the Statistical Package for the Social Sciences version 10 (SPSS) computer program (SPSS Inc, Chicago, IL, USA). Descriptive and inferential statistics were performed on the expectation and satisfaction questionnaires as well as the demographic data section. Frequencies, means and standard deviations were used to describe the characteristics of participants; t-test was used to examine the differences between patients expectations and satisfaction. Finally, correlations were

4 Patients expectations and satisfaction 143 used to determine associations between patient s satisfaction and demographic variables; values of P < 0.05 were considered significant. RESULTS Table 1 shows the sociodemographic characteristics of the patients where the mean age was (43.7 years and SD 19.4) with male patients representing 54% of the sample; the majority of participants were married (60%) whereas the highest portions for education were holders of a secondary school certificate and higher education (34%, 38.4%, respectively; the findings also revealed that more than half of the patients (50.8%) were admitted to the medical department. The largest portion of the patients was hospitalized for 5 days or less (67.6%). The findings of this study indicated that the mean expectation score was , whereas mean satisfaction score was Findings of this study showed that in general the patients were highly satisfied Table 1 Sociodemographic characteristics of the patients n = (250) Variables N % Age (years) Mean = 43.7 (SD) 19.4 Gender Male Female Marital status Single Married Educational level Secondary school Higher education (diploma and bachelor) Department Medical Surgical Type of lodging Private Semi = private Length of hospitalization Less than 5 days days More than 5 days SD, standard deviation. with overall quality of hospital care, nursing care and reported that they would recommend this hospital to their families and friends. Furthermore, a paired sample t-test was conducted to evaluate the impact of patient s expectations and satisfaction. The results revealed a significant increase from expectations to satisfaction (M = to M = ) with a P-value less than 0.05 (t =-6.814, d.f. = 245). The mean decrease was 2.14 with 95% CI ranging from 4.77 to Table 2 illustrates only the items with significant difference between patients expectations and satisfaction for the highest scoring items whereby nurses skills and competence had the highest score in terms of satisfaction (3.71); and the second high scoring item in terms of satisfaction was for maintaining privacy (3.71). In all items in Table 2, patients satisfaction was significantly higher than patients expectations. Table 3 illustrates the items only with significant difference between patients expectations and satisfaction for the least scoring items whereby information provided to patients was the least scoring item for both patients expectation (3.31) and satisfaction of patients (3.55); this relationship was statistically significant for all items included in this table. The results also indicated that there were no significant relationships between patients sociodemographic characteristics and satisfaction with nursing care. DISCUSSION Findings of this study indicated that the patients were satisfied with the overall nursing care and their satisfaction level exceeded their expectations. The results also indicated that patients were more satisfied with technical and ethical aspects of nursing care including nurses skills and competencies, maintaining privacy, being sympathetic and having respectful communication whereas they were less satisfied with the professional information provided by the nurses about their disease, health status, investigations and prognosis of their condition. This finding reflects some idea about the status of the nurses in private hospitals in the sense that they shied away from providing information to the patients as this was mostly viewed as the doctors responsibility. This role of information giver expected by the public from the nurses is instrumental to the empowerment of nurses by playing the roles of advocates to their patients. Indeed, Taylor and Ferszt 19 stressed the importance of nurses releasing information to the

5 144 AS Abdel Maqsood et al. Table 2 Difference between patient expectations and satisfaction on items where patients were mostly satisfied Patient mostly satisfied with Mean Mean P t d.f. Expectation Satisfaction Nurses maintained my privacy Nurses provide skilled and competent care Nurses were sympathetic with me Nurses responded to my call promptly Nurses communicated respectfully d.f., degrees of freedom. Table 3 Difference between patient expectations and satisfaction on items where patients were least satisfied Patient least satisfied with Mean Mean P t d.f. Expectation Satisfaction Nurses gave information about my health status and progress Nurses gave clear and complete explanation about the investigations and treatments Nurses provided care for me at night d.f., degrees of freedom. patients re their condition, treatment protocols and even prognosis as part of the advocacy for human rights and informed decisions regarding their care; whereas Martin 20 explained all the barriers nurses faced in assuming their roles as advocates because of the ritualized nurse-doctor relationship (p. 191) of power hierarchy with the doctors. He used his analysis to discuss how nurses were pressured to accept the status quo (p. 192); this situation results in a serious dilemma for the nurses whereby they are expected to have empathy but at the same time must comply with doctors regimen of disclosure of information as well as distancing themselves from the patient. In this context, Schmalenberg and Kramer 21 mentioned that good relationships between nurses and physicians are important to high-quality patient care. By allowing the nurses to assume their roles as information givers, since they spend most of the time with the patients in the hospital, a culture of inter-professionalism between doctors and nurses would be encouraged; staying away from authority struggles and territorialism and looking at the larger picture that is the benefit of the patient and quality of care of the hospital would be strongly recommended. The findings of this study also indicated that the patients were less satisfied with nursing care during the night shift; this might be explained by the underresourcing hence heavier nursing workload during the night shift in comparison with the day shift. Similar findings were reported in the literature. 22,23 Moreover, Abdalkader and Hayajneh 24 in a study about staffing of nurses in Jordanian hospitals reported that there were fewer nurses working at night; in addition, 73% of the nurses stated that the ratios of the nurses to patients during night shift were not appropriate. This study also showed that 67% of the nurses did not feel energetic when working on night shift: Tiredness may be due to insomnia, change in sleeping patterns, and circadian rhythms (p. 80). On the other hand the above-mentioned findings showed that patients were satisfied with the ethical aspects of nursing care; this is in harmony with the strong cultural values of the nursing profession in Jordan. The fact of not releasing information might be explained by the fear of releasing bad news especially in patients with terminal conditions which is a trend highly affected by the Jordanian cultural context and the fatalism that results in the belief that patients prognosis is in God s hands; a similar situation is related in the literature by Martin; 20 furthermore, these findings are contextualized and validated by

6 Patients expectations and satisfaction 145 Mrayyan, 25 where she reported that nurses in the private sector of Jordan suffer many stressors such as nursing shortage, burnout and high turnover rates; this in her view is related to acute job dissatisfaction intensified by the hierarchy with the doctors and fear of confrontation with them because of this hierarchy; this might be an underlying reason for the lack of disclosure of information to patients that is considered a medical responsibility. This gamut of stressors seems global as pointed out by Scott et al., 26 Al-Ma aitah et al., 27 Lee et al. 28 cited in Mrayyan. 25 Moreover, Mrayyan 25 stressed the poor communication as well as lack of support from nurse managers in the role overlap with doctors leading to low autonomy levels in the profession. Finally, it seems important to note that the correlations between patients sociodemographic characteristics and satisfaction with nursing care were not significant although some studies in the literature found a significant association with race, gender, age and satisfaction with nursing care. 29 LIMITATIONS OF THE STUDY Since patients had a number of different nurses caring for them, they were hesitant in answering questions that referred to all nurses. In addition, nursing occurs within a multidisciplinary context; patients had difficulties to isolate the nursing care from the whole health-care experience. Finally, the investigation was conducted in only one private hospital in Jordan. Therefore, the results cannot be generalized to all private hospitals but might provide a flavour of the level of patient satisfaction in private settings; in the future, it would be interesting to compare private with public setting including more than one hospital in both sectors. CONCLUSIONS This study found that patients were satisfied with the overall nursing care and their satisfaction level exceeded their expectations. The results also indicated that patients were more satisfied with technical and ethical aspects of nursing care including nurses skills, competencies, maintaining privacy, being sympathetic and respectful communication. However, patients were less satisfied with nursing care during the night shift as well as with information provided by the nurses regarding their disease, health status, investigation and prognosis of their condition. Nurses should be aware of these comments and take them into account when providing care. Furthermore, as the nurse was regarded as the central figure in the patients health-care experience, it is particularly important that nurses are able to acknowledge and take into account patients expectations when they provide patientcentred care. IMPLICATIONS AND RECOMMENDATIONS The PSNCQQ can be incorporated into an existing hospital quality monitoring system focusing on patient satisfaction. The questionnaire could also be used as an outcome variable to evaluate the impact of unit or organizational change on patient satisfaction. Moreover, nurses can use the satisfaction with quality of nursing care in evaluating and improving the nursing care in clinical practice. This research study contributed knowledge to what makes the patient happy and satisfied from several aspects of nursing care that is why care should be tailored for the individual patient; and tailoring requires knowing what the patient prefers before care is given; hence assessing patients preferences should be a major component of the nursing assessment. The nursing assessment should also focus on identifying the needs for nursing care during the hospitalization and after discharge; this will be done by clinical nurse specialists; therefore advocating and legislating for clinical nurse specialist titles and posts to be initiated in all hospitals in Jordan in tune with the efforts of the Jordanian Nursing Council will presumably improve patient satisfaction and the image of the nursing profession at the national level. Finally, a follow-up monitoring of the results by filling the questionnaires by the patients a fortnight after their discharge is highly recommended as it might remedy any halo-effect bias from this study. REFERENCES 1 Peterson W, Charles C, DiCenso A, Sword W. The Newcastle satisfaction with nursing scales: A valid measure of maternal satisfaction with inpatient postpartum nursing care. Journal of Advanced Nursing 2005; 52: Wagner D, Bear M. Patient satisfaction with nursing care: A concept analysis within a nursing framework. Journal of Advanced Nursing 2009; 65: O Connell B, Young J, Twigg D. Patient satisfaction with nursing care: A measurement conundrum. International Journal of Nursing Practice 1999; 5: Larrabee JH, Ostrow CL, Withrow ML, Janney MA, Hobbs GR, Burant C. Predictors of a patient satisfaction with inpatient hospital nursing care. Research in Nursing & Health 2004; 27:

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