An evaluation of patients satisfaction with a physical education service at a rehabilitation centre: a quality activity. Kate Roberts B Sc, B App Sc (Physiotherapy), Allied Health Quality and Research Coordinator, Hampstead Rehabilitation Centre. Kathy Stiller B App Sc (Physio), Ph D, Research Advisor, Hampstead Rehabilitation Centre. George Dunstan Dip Liberal Studies (Human Movement), Senior Physical Educator, Hampstead Rehabilitation Centre. Corresponding author Kate Roberts Hampstead Rehabilitation Centre, 207-255 Hampstead Road, Northfield, Adelaide, South Australia, 5085, Australia. Phone number: 61 82221878. Email: kate.roberts@health.sa.gov.au Keywords: patient satisfaction, physical education and training, rehabilitation. ABSTRACT Purpose. Patient satisfaction is an important outcome in all healthcare settings, including rehabilitation centres. The purpose of this prospective study was to measure patients levels of satisfaction with the physical education service provided at a rehabilitation centre. Methods. Twenty-nine of 31 (94%) eligible patients receiving inpatient or outpatient physical education services completed a purpose-designed survey. Analyses were mainly descriptive in nature.
2 Results. Overall, a high level of satisfaction was reported by participants, with respect to the quality of, and access to, the physical education service and interaction with physical education staff. No frequent areas of dissatisfaction were reported. Conclusions. The survey was relatively easy to administer and the results obtained from the small sample indicated a high level of satisfaction with the physical education service provided to patients at the rehabilitation centre studied. These findings will be of interest to other providers of rehabilitation services services who wish to evaluate their patients level of satisfaction. Abstract word count: 155 Main text word count: 2,217
INTRODUCTION 3 Rehabilitation centres provide rehabilitation services for patients with a variety of injuries/conditions including spinal cord injury, brain injury, stroke, orthopaedic conditions, amputation, general medical conditions and burn injury. The broad aim of rehabilitation is to improve patients functional ability and independence so that they are able to return home or to a supported environment with optimised function and health-related quality of life. One of the most important aims of rehabilitation services is to maximise functional independence, hence, the assessment of functional outcomes is vital. However, evaluation of patients satisfaction is also an important outcome in its own right, particularly as patient satisfaction does not always correlate with functional outcomes [1-6]. Rehabilitation services are provided by a multidisciplinary team that includes medical and nursing staff, physiotherapists, occupational therapists, speech pathologists and social workers. Additionally, in some rehabilitation centres, physical educators may also be part of this multidisciplinary team and provide services that include fitness and strength training, wheelchair skills, driver education, and recreation and sporting activities. A literature search was undertaken to identify studies which had specifically evaluated patient satisfaction with physical education (PE) services within a healthcare setting. No relevant studies were found. The lack of research in this area is an important oversight given that patient satisfaction is a key outcome in the healthcare setting. In a general study regarding evaluation of patient satisfaction, White [7] suggested that patient satisfaction surveys should address three key areas: quality issues (i.e. is the patient satisfied with his/her medical care?), access issues (i.e. is it easy to make an appointment or get a referral?), and interpersonal issues (i.e. are the physicians and staff caring and compassionate?). Similar recommendations were made by the United States Department of Health and Human Services [8] regarding the need to include questions addressing patient satisfaction with respect to staff and the facility itself. This
4 organisation also suggested that if a patient is unable to complete a survey independently, they should seek help from non-healthcare people (e.g. family, friends, volunteers, non-clinical staff members) rather than healthcare providers. The aim of the current study was to measure patients levels of satisfaction with a PE service at a rehabilitation centre. It was hoped that this quality activity would provide valuable data to support the effectiveness of the PE service from the patients perspective and to identify areas where the service could be improved. Studies of this nature are particularly important to the staff of the PE service and also to the rehabilitation centre in terms of their commitment to quality activities and research. METHODS Study design A prospective survey was conducted. Inpatients (IPs) and outpatients (OPs) who received PE services were approached regarding participation in the study during the last 2 weeks of their IP admission to Hampstead Rehabilitation Centre (HRC) or their course of OP treatment. Initially, the PE staff screened each patient regarding whether or not he/she met the eligibility criteria. Any decision to exclude a patient was reviewed by another PE staff member to decrease the potential for bias. The names of eligible patients were passed onto a member of the HRC Volunteer Service who then approached the patient regarding participation in the study. If patients required assistance to complete the survey they were instructed to seek help from the HRC volunteer or their family/friends. Return of the completed survey indicated consent to participate. Patients who did not wish to participate were asked to return the survey in its blank format. Ethics approval was obtained from the Royal Adelaide Hospital Research Ethics Committee.
Setting and timelines 5 This quality activity was conducted at Hampstead Rehabilitation Centre (HRC), a 128-bed facility that provides clinical rehabilitation services for people suffering from spinal cord injury, traumatic brain injury, stroke, other neurological and medical disorders, orthopaedic conditions, amputation or burn injury. Recruitment to the study took place over a 6-month period (August 2009 to February 2010). Participants The PE Department at HRC predominantly provides services to patients of the South Australian Spinal Cord Injury Service. All IPs and OPs who received PE services at HRC were eligible for inclusion. As well as general OPs, who receive a short OP course of PE treatment, a small number of OPs also attend HRC on a regular, indefinite basis for ongoing maintenance PE. These maintenance OPs were also eligible for inclusion. Patients were excluded if they were unwilling to participate, had already participated in the study, were unable to understand written English (whether due to English as a second language or dysphasia) or had a mental disability that interfered with their ability to complete the survey. Interventions The interventions provided to patients were not altered as a result of participation in this study. From a PE perspective the interventions included strength/fitness training, instruction regarding wheelchair skills, driver education, and education/instruction regarding recreational and sporting activities. For IPs the interventions consisted of individual one-on-one sessions with a PE staff member for up to 60 minutes per day, 5 days a week. General OPs received a 60 minute session 2-3 times a week. Maintenance OPs attended the PE Department and undertook a 60-90 minute PE program 2-3 times a week, with limited input from the PE staff. The PE staff consisted of one senior and two basegrade staff members, all of whom had more than 20 years clinical experience at HRC.
6 Measurements As the literature review did not reveal any survey that was suitable for direct use or modification, the survey was based on one previously used to evaluate patient satisfaction with physiotherapy services at HRC [9]. The survey included an introductory section that explained the aims and format of the study. The survey items were deliberately worded to include a combination of positive and negative statements about the PE service. The survey items varied slightly between IPs and OPs and consisted of 12-15 closed statements that required responses using a Likert scale, and two open questions. An internal mail envelope was provided for return of the survey and addressed to a person who was independent from the PE service (KR). The patient s age, gender, primary diagnosis and service type (i.e. IP, general OP, maintenance OP) were recorded to allow the study sample to be described. No identifying personal information was recorded hence participant anonymity was preserved. Data analysis Raw data from the surveys were entered onto an Excel spreadsheet and imported into SPSS (version 11.0) for analysis. Analyses were mainly descriptive in nature. Additionally, the responses to each item were dichotomised into agree (i.e. strongly agree/agree) or disagree (i.e. strongly disagree/disagree), with neutral responses ignored, to enable statistical analyses using the Binomial Test. RESULTS Over the 6-month recruitment period, 32 patients were screened regarding participation, with 31 patients eligible for inclusion (see figure 1). Twenty-nine of the 31 (94%) eligible patients
7 returned a completed survey 19 IPs, two general OPs and eight maintenance OPs. The majority of participants were aged between 20 and 59 years (n = 20; 69%), male (n = 24; 83%) with a primary diagnosis of spinal cord injury (n = 25; 86%) (see table I). Screened regarding participation n = 32 Met inclusion criteria n = 31 Excluded from trial n = 1 No reason recorded: n = 1 Completed questionnaire n = 29 (94%) Figure 1. Recruitment of participants to study Table I. Characteristics of the 29 participants Characteristic Number (%) Age * < 20 years 1 (3) 20 39 years 9 (31) 40 59 years 11 (38) 60 79 years 7 (24) 80+ years 0 (0) Gender females males Diagnosis * spinal injury other medical condition Type of service inpatient general outpatient maintenance outpatient Some respondents did not reply to this item. 5 (17) 24 (83) 25 (86) 3 (10) 19 (66) 2 (7) 8 (28) Table II shows the frequency of responses to the survey items. Overall, a high level of satisfaction with the PE service was reported and for all but two survey items this achieved significance.
Table II. Survey items and frequency (%) of responses 8 Entire sample (n = 29) a The PE staff gave you good advice and treatment Strongly agree Agree Unsure Disagree Strongly disagree p- value 25 (86) 3 (10) 1 (3) 0 0 0.00 You did not receive enough PE 2 (7) 1 (3) 2 (7) 9 (31) 15 (52) 0.00 The PE staff listened to your concerns * 19 (66) 8 (28) 1 (3) 0 0 0.00 The PE staff answered your questions in 18 (62) 10 (35) 1 (3) 0 0 0.00 a way you could understand The PE staff involved you in decisions 17 (59) 10 (35) 1 (3) 1 (3) 0 0.00 regarding your PE care The PE staff did not provide enough explanation or instructions to you regarding your treatment 1 (3) 0 2 (7) 8 (28) 18 (62) 0.00 The PE staff were kind, caring and courteous The area where you received PE was neat and clean Your privacy, dignity and comfort during PE were considered Overall, you found the PE service at HRC satisfactory Inpatients (n = 19) b The PE staff involved you in PE plans for when you leave hospital * The timing and location of the PE service was not convenient All outpatients (n = 10) c The appointment times were not convenient 19 (66) 9 (31) 1 (3) 0 0 0.00 19 (66) 10 (35) 0 0 0 0.00 21 (72) 8 (28) 0 0 0 0.00 23 (79) 5 (17) 0 1 (3) 0 0.00 5 (26) 7 (37) 3 (16) 0 1 (5) 0.00 0 1 (5) 0 7 (37) 11 (58) 0.00 1 (10) 0 0 5 (50) 4 (40) 0.02 The waiting time on the day of your 0 0 0 4 (40) 5 (50) 0.00 appointment was too long * The location of the OP service was 7 (70) 3 (30) 0 0 0 0.00 convenient There is not sufficient parking available * 0 3 (30) 1 (10) 4 (40) 1 (10) 0.73 Maintenance oupatients (n = 8) d The fee charged is too much * 0 1 (13) 1 (13) 2 (25) 4 (50) 0.13 a Percentages are calculated as a proportion of the entire sample (n = 29) b Percentages are calculated as a proportion of the inpatients (n = 19) c Percentages are calculated as a proportion of the general and maintenance outpatients (n = 10) d Percentages are calculated as a proportion of the maintenance outpatients (n = 8) * Some respondents did not reply to this statement. p-value represents results of analyses using the Binomial Test.
9 The first open question asked respondents whether there was anything particularly good about the PE service at HRC 24 (83%) indicated yes, three (10%) no and two (7%) did not respond. The comments that were provided for this question were mainly general in nature (n = 14; 48%), and consisted of comments such as all done well. Eight participants (28%) commented positively on the nature of the PE staff, for example wonderful people. Two participants (7%) made favourable comments about the range of equipment available and two participants (7%) reflected positively on the accessibility of the PE service. Further examples of the comments are as follows: my instructor uses a wheelchair and therefore has personal knowledge of what it is to go through the acute rehabilitation and postrehabilitation. I found it easy to speak to him about the horrors resulting from paraplegia. the treatment I was given was of the very best. you were always made to feel welcome, they help you to work hard if you are willing, they made it enjoyable. equipment meets my needs. The staff are very experienced in knowing how to use the equipment to meet my limitations so as to benefit me to the maximum. The second open question asked whether there was anything that could be improved with the PE service at HRC. Sixteen (55%) respondents answered no, 10 (34%) answered yes and three (10%) did not respond. Four respondents (14%) remarked on the need for increased staffing levels, two respondents (7%) noted that the equipment could be improved. One respondent each (3%) commented that the physical environment could be improved with better temperature control, that the program should be less hard physically, that fees charged for maintenance OPs should be higher and that a female wheelchair dependent staff member should be employed.
DISCUSSION 10 The aim of this quality activity was to evaluate patients levels of satisfaction with a PE service at a rehabilitation centre. Overall, a high level of satisfaction was found for the 29 participants. The majority of participants indicated they were satisfied with the quality of the PE service provided (e.g. received good advice and treatment, were involved in decision making regarding their care), the access to the service (e.g. timing and location of services) and interactions between staff and patients (e.g. staff were kind, caring and courteous; privacy, dignity and comfort were considered). There were no frequent or common areas of dissatisfaction with the PE service. The response rate found in the current study would be considered excellent [10] and was comparable to that found by Stiller et al [9]. There are no data concerning satisfaction with PE services with which the current results can be compared, but the overall high level of satisfaction seen in the current study compares favourably with other studies that have evaluated patient satisfaction in the rehabilitation setting [3,9,11]. In a recent study conducted at HRC, Stiller et al [9] evaluated 106 patients satisfaction with physiotherapy services at HRC using a similar survey and methodology. Frequency of responses were comparable for all survey items that were common between these two samples, suggesting similar levels of satisfaction with the PE and physiotherapy services at HRC. The two items in the current study where no significant difference was found between agree/disagree responses related to parking availability for OPs and the fee charged for maintenance OPs. However, even for these two items, the majority of respondents expressed satisfaction. Although the overall responses were predominantly favourable concerning the PE service at HRC, a few specific areas were noted by minority of participants where the service could be improved, with the need for more PE staff and better equipment suggested.
Limitations 11 There were a number of limitations with the current study, the main one being the small sample size despite a relatively long recruitment period. However, despite the small sample size, the characteristics of the sample were typical of those who receive PE services at HRC, being relatively young, predominantly male and having sustained a spinal cord injury. Furthermore, as only one patient was excluded from participation, the sample should be representative of the broader patient population who receive PE services at HRC. It is acknowledged that participants may have been unwilling to make unfavourable comments about the PE service. To minimise this, we ensured that patients were recruited to the study by an independent HRC volunteer and that surveys were returned to a staff member who was independent from the PE Department. Nevertheless, it is possible that participants answered survey items in a manner that did not reflect their true feelings. We also acknowledge that attempting to measure patient satisfaction with a simple survey is simplistic given the complexity of assessing patient satisfaction [3] and that qualitative research may provide more in-depth data regarding this topic. Finally, while patient satisfaction with the PE service was high, it is acknowledged that its actual effectiveness, in terms of its influence on functional outcomes, was not assessed. Clinical implications Despite the small sample size, this study has a number of important clinical implications for our rehabilitation centre and also for healthcare providers at other rehabilitation centres. Firstly, the study provides valuable feedback for staff of the HRC PE Department that their patients were highly satisfied with the PE service they received with respect to the quality of the service, its accessibility and interaction with staff. Secondly, although the results cannot be generalised, the findings may still be of interest and relevance to healthcare providers at other rehabilitation centres. Furthermore, as evaluation of patient satisfaction is an important outcome in its own right, other healthcare providers could adapt the methodology and survey used in the current study to evaluate their patients satisfaction.
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