Investigating admitted patients' satisfaction with ...

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ARTICLE DETAILS TITLE (PROVISIONAL) AUTHORS

Investigating admitted patients’ satisfaction with nursing care at Debre Berhan Referral Hospital in Ethiopia: a cross-sectional study Sharew, Nigussie; Teklegiorgis, Hailegiorgis; Ketema, Hilina; Habtewold, Tesfa

VERSION 1 – REVIEW

REVIEWER REVIEW RETURNED GENERAL COMMENTS

Ahtisham Younas Memorial University of Newfoundland, Canada 26-Jan-2018 Thank you for providing me with the opportunity to review this manuscript. I appreciate the amount of work that went into this research. However, there are several issues that need attention. Please find below some suggestions to improve this manuscript. 1. The manuscript has several grammatical errors. For example, on page 4, under "strengths and limitations of this study". The 1st point should be corrected as " use of a standardized patient satisfaction scale/instrument". The 2nd point should be " "Reasonably large sample size....." . The 3rd point should be "patients may feel frustrated that their responses negatively affect their relationship with nurses...". Several errors have been noted throughout the manuscript. 2. Page 5, under "Background" paragraph 2. "Risser first proposed definition". I could not find this reference in the reference list. Is it a spelling error? paragraph 3, please provide comprehensive discussion of the studies included in the review. Indicate the sample size used, strengths and limitations of these studies, and research gaps. The way these studies are discussed, the reader finds it difficult to understand the need for this study. In the same paragraph, three studies from Ethiopia have been mentioned, but later the authors' claimed that there is limited evidence on the very topic in Ethiopia. Put simply, the problem statement should be strengthen so that the reader may better understand the need for this research. 3. Page 8, under " sampling procedure and data collection". "The interviews were conducted using a semi-structured questionnaire...". As mentioned by the authors, a standardized scale (NSNS) was used, but here authors called it a semi-structured questionnaire. Please clarify. 4. Page 9, under "Variables". The authors wrote that " the mean satisfaction score was 63.9 and then the score was dichotomized..."

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BMJ Open: first published as 10.1136/bmjopen-2017-021107 on 17 May 2018. Downloaded from http://bmjopen.bmj.com/ on 17 May 2018 by guest. Protected by copyright.

PEER REVIEW HISTORY

5. Page 9, under " Data collection instrument". I believe the NSNS scale comprises two sub-scales: experiences of nursing care and satisfaction of care. The description of the scale provided by the authors is not correct. Please provide correct description of the scale and also provide a rationale for using the satisfaction scale only, as it may be confusing for some readers. 6. Page 12, under " Patient satisfaction with nursing care". Please elaborate how the score 49.2% patient satisfaction with nursing care was calculated. 7. Page 17, under " Discussion" paragraph 2, While comparing the findings of this study with previous studies, provide exact satisfaction rates of the previous studies and supply p-value to indicate if the differences were statistically significant. 8. Page 18, Under "conclusion". Since the study was conducted in a hospital, it is unclear why the authors have suggested "periodic community need assessment to improve satisfaction". Please clarify. 9. Ethical Considerations. I believe the Newcastle Satisfaction with Nursing Scale is freely available for use, yet it is a copyrighted scale. Please indicate if the permission to use the scale was sought from the scale's authors. REVIEWER REVIEW RETURNED GENERAL COMMENTS

Souraya Sidani Professor and Canada Research Chair, Ryerson University, Canada 28-Jan-2018 The research topic address in this paper is of interest, providing evidence on patient satisfaction with nursing care in an Ethiopian context, which can be useful for across-country comparison and for quality improvement initiative in Ethiopia. The following are points for the authors to consider, listed by section: 1. Introduction A few definitions of satisfaction and patient satisfaction with nursing care are presented. The definitions differ slightly in identifying the key characteristics of the concept. It is not quite clear which definition was adopted in this study and guided the selection of the measure. Consistency between the conceptual and operational definitions of concepts is essential for maintaining construct validity. Results of studies that investigated satisfaction with nursing care are nicely synthesized. The studies were conducted in selected countries, to the exclusion of others (e.g. European), which may be appropriate but should be justified. The implications of these findings for the current study are also not discussed. Some of the factors listed as affecting satisfaction have been considered by other researchers as domains or elements of satisfaction. Specifically, expectation, communication, participation, interpersonal relations, competence are usually included in multidimensional measures of satisfaction; as such, they cannot be posited as independent factors that contribute to satisfaction. The authors may have to clarify their perspectives. As shown by the evidence presented, the findings related to predictors of satisfaction are mixed. The authors may have to suggest possible explanations of this inconsistency and then to

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This statement is confusing as in the later sections, patient satisfaction was reported to be 49.2%. Ensure consistency of the units used to report your findings.

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present a strong argument to support their decision to examine the association between the selected factors and satisfaction. The statement that patients want to know about their illness and treatment is correct. However, its linkage to the next point related to considering satisfaction as an established outcome is not clear or obvious. The description of the healthcare system in Sub-Sahara Africa and Ethiopia is very informative, providing the context for the study. However, the information presented seems to reflect the totality of the healthcare system, which may not be quire relevant to the acute care hospital setting in which the study was done. Could the information focus on the acute care sector? The statement of the study aim should reflect the 2 aims. In general, the background section presents different points; whereas the points are important and informative, they do not build on each other to make a logical and strong argument for the study. 2. Methods and Materials It would be useful to: 1) explain what the term “kebeles” means, as it may not be familiar to many readers; 2) describe the type of services and the skill mix of health professionals employed at the selected hospital; 3) explain in more detail, the cross-sectional design that is: who approached patients for recruitment, when; how was consent obtained and when; and in what context was the measure of satisfaction administered; 4) clarify if and how the sample size calculation took into consideration the regression analysis planned to address the second aim (i.e. identify factors affecting satisfaction); 5) clarify the rationale for selecting the three types of wards (i.e. what do the authors mean by “patient flow” and “organized nursing care”, and for lumping parents (of children admitted to pediatric ward) with adult patients – was there any difference in their level of satisfaction?; 6) explain what is meant by “history of admission” – is it having been admitted previously to any hospital for the same or different condition? The data collection instrument and variables subsections could be integrated to avoid redundancy, and to clearly identify the variables and their respective measures. Please, specify 1) what demographic and what medical history variables were assessed and how, 2) what are the aspects of nursing care that were assessed by the 19 items, 3) what are the subscales measuring these aspects, 4) what are the psychometric properties of the subscales, 5) whether or not the items translated to the local language or administered in English, and if translated, please describe the procedure used, and 6) the internal consistency reliability of the subscales and scale in the current study. The rationale for dichotomizing the scores on satisfaction is not made explicit. This practice is no longer recommended as it was found to contribute to loss of information and power. 3. Results If the measure has subscales, it would be important to compute the subscale scores and report relevant descriptive statistics to identify aspects of nursing care with which patients were most and least satisfied (rather than doing so at the item level). 4. Discussion There may be other factors that could account for the differences in the percent of patients satisfied with nursing care across countries, such as the characteristics of the samples, the hospitals, the types of services offered and the skill mix of nurses. These could be discussed. It is not quite clear how the measures of satisfaction used in the different studies can explain the differences in findings – do they

REVIEWER REVIEW RETURNED GENERAL COMMENTS

Cristina Arrigoni University of Pavia, Italy 05-Feb-2018 Many references are dated, in particular reference 36 is related to the Italian context, what about the validity of the NSNC in English? Moreover, is this the first time that NSNC was used in Ethiopia? If yes, you should discuss about this. • Sample description (e.g., can you better describe the exclusion criteria?) In the discussion you should better emphasize the role of this study in adding new knowledge related to this topic

VERSION 1 – AUTHOR RESPONSE Editorial Requests - Please revise your title so that it includes your study's setting. This is the preferred format for the journal. Accepted and revised as recommended. Thank you! Page 1, line 1-3. - The quality of English is not at the requisite standard for publication in places (see examples below). Can you please thoroughly copy-edit the paper? We recommend consulting a native English speaker, if possible. Examples: “Further research should be conducted when the patients are discharged in order to get a better estimate of satisfaction”; the 3rd bullet point of the Strengths and Limitations section. This is relevant to ensure the readability of our article. We carefully revised and copy-edited the whole manuscript. In addition, we consulted senior researchers. Thank you! - Abstract >> Setting: please clarify where “North Shoa Zonal referral hospital” is. The study setting is clarified and revised in the main manuscript as well. Thank you! Page 2, Line 4-5. Reviewer: 1 Reviewer Name: Ahtisham Younas Institution and Country: Memorial University of Newfoundland, Canada Competing Interests: N/A Thank you for providing me with the opportunity to review this manuscript. I appreciate the amount of work that went into this research. However, there are several issues that need attention. Please find below some suggestions to improve this manuscript. We are grateful for your appreciation and investing your precious time to review our manuscript. All suggestions are very relevant and accepted. 1. The manuscript has several grammatical errors. For example, on page 4, under "strengths and limitations of this study". The 1st point should be corrected as " use of a standardized patient satisfaction scale/instrument". The 2nd point should be " "Reasonably large sample size....." . The 3rd point should be "patients may feel frustrated that their responses negatively affect their relationship with nurses...". Several errors have been noted throughout the manuscript.

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address different domains or aspects of satisfaction? Please explain. The explanation of the discrepancy in findings, given in the third paragraph, could be elaborated: what do patient flow, scarcity of bed screen and lack of knowledge mean and how could they contribute to satisfaction? The same applies for all explanations of the findings provided in the discussion section. The implications of the findings for future research and for quality improvement are not discussed in-depth.

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This is a valuable comment. It is also noted by the editor. Thus, we carefully revised and copy-edited the whole manuscript. In addition, we consulted senior researchers. Thank you! 2. Page 5, under "Background" - Paragraph 2. "Risser first proposed definition". I could not find this reference in the reference list. Is it a spelling error? You are correct. It was a mistake. We apologize for this unintentional mistake. Now, reference 4 is replaced by “Risser NL. Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nursing research. 1975.” and updated in the main manuscript. Page 21, Reference 5. - Paragraph 3, please provide comprehensive discussion of the studies included in the review. Indicate the sample size used, strengths and limitations of these studies, and research gaps. The way these studies are discussed, the reader finds it difficult to understand the need for this study. Accepted and revised as recommended. Thank you! Page 7, line 5-14. - In the same paragraph, three studies from Ethiopia have been mentioned, but later the authors' claimed that there is limited evidence on the very topic in Ethiopia. Put simply, the problem statement should be strengthen so that the reader may better understand the need for this research. Accepted and revised as recommended. We claimed the scarcity of evidence because there are at least 41 hospitals and 100 million people live in Ethiopia. Therefore, three studies fall short of to represent patient satisfaction with nursing care in Ethiopia. Thank you. 3. Page 8, under " sampling procedure and data collection". "The interviews were conducted using a semi-structured questionnaire...". As mentioned by the authors, a standardized scale (NSNS) was used, but here authors called it a semi-structured questionnaire. Please clarify. You are correct. NSNS is a standardized structured scale. Therefore, we rephrased it as “Five trained intern nursing students administered the questionnaire.” Thank you! Page 9, line 12. 4. Page 9, under "Variables". The authors wrote that " the mean satisfaction score was 63.9 and then the score was dichotomized..." This statement is confusing as in the later sections, patient satisfaction was reported to be 49.2%. Ensure consistency of the units used to report your findings. This is an important recommendation. Thank you!. As we stated in the manuscript the mean (63.9) was calculated from 19 items satisfaction sum score (page 10, line 1-6). 49.2% is the proportion of patients with a satisfaction sum score ≥ 63.9 (page 12, line 3-4). We revised in the manuscript to make it clearer. 5. Page 9, under " Data collection instrument". I believe the NSNS scale comprises two sub-scales: experiences of nursing care and satisfaction of care. The description of the scale provided by the authors is not correct. Please provide correct description of the scale and also provide a rationale for using the satisfaction scale only, as it may be confusing for some readers. Accepted and revised as you recommended (page 9, line 18-22). Thank you. Only the satisfaction scale was used because of feasibility issue; we included this as a limitation. Currently, we have planned to conduct a large-scale study assessing experience and satisfaction of nursing care in several hospitals. 6. Page 12, under " Patient satisfaction with nursing care". Please elaborate how the score 49.2% patient satisfaction with nursing care was calculated. Accepted and revised as recommended! Thank you. 49.2 is not a satisfaction score; it is the percentage of patients who presumed to be satisfied with nursing care (their satisfaction sum score ≥ 63.9). We hope it is now clear (page 10, line 1-6). 7. Page 17, under " Discussion" paragraph 2, While comparing the findings of this study with previous studies, provide exact satisfaction rates of the previous studies and supply p-value to indicate if the differences were statistically significant. Accepted and revised as recommended. Thank you (page 16, line 7-9; page 17, line 4-9 & 16-24). 8. Page 18, Under "conclusion". Since the study was conducted in a hospital, it is unclear why the authors have suggested "periodic community need assessment to improve satisfaction". Please clarify.

Reviewer: 2 Reviewer Name: Souraya Sidani Institution and Country: Professor and Canada Research Chair, Ryerson University, Canada Competing Interests: None declared The research topic address in this paper is of interest, providing evidence on patient satisfaction with nursing care in an Ethiopian context, which can be useful for across-country comparison and for quality improvement initiative in Ethiopia. We are grateful for investing your precious time to review our manuscript. All suggestions, questions and comments are very relevant and accepted. The following are points for the authors to consider, listed by section: 1. Introduction A few definitions of satisfaction and patient satisfaction with nursing care are presented. The definitions differ slightly in identifying the key characteristics of the concept. It is not quite clear which definition was adopted in this study and guided the selection of the measure. Consistency between the conceptual and operational definitions of concepts is essential for maintaining construct validity. This comment is very relevant. Thank you very much. In this study, the American Nurses Association of ‘patient satisfaction with nursing care’ was adopted. This explanation also included in the methodsmeasurement and instrument section. (page 5, line 13) Results of studies that investigated satisfaction with nursing care are nicely synthesized. The studies were conducted in selected countries, to the exclusion of others (e.g. European), which may be appropriate but should be justified. The implications of these findings for the current study are also not discussed. Evidence from European or other western countries was not intentionally excluded. We just tried to summarize evidence from developing countries which is close to the context of Ethiopia and make it concise. Now, we believe it is also important for readers to add a few evidence from western countries; therefore, we added a few literatures. Actually, evidence on the associated factors was obtained from different country studies. Thank you for your comment. This is relevant. (page 5, line 20-24; page 6, line 1-9; page 7, line 5-14) Some of the factors listed as affecting satisfaction have been considered by other researchers as domains or elements of satisfaction. Specifically, expectation, communication, participation, interpersonal relations, competence are usually included in multi-dimensional measures of satisfaction; as such, they cannot be posited as independent factors that contribute to satisfaction. The authors may have to clarify their perspectives. We totally agree with you; in fact, the article we cited considered as independent factors but it is confusing. Therefore, we revised in the manuscript. (page 5, line 13-16; page 6, line 1-9) As shown by the evidence presented, the findings related to predictors of satisfaction are mixed. The authors may have to suggest possible explanations of this inconsistency and then to present a strong argument to support their decision to examine the association between the selected factors and satisfaction. Accepted and implemented as recommended. Thank you. (page 7, line 5-14)

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Thank you for your question. Even though hospitals have their own nursing care standard, patients expectation play a substantial role and an important component of satisfaction. Therefore, community need assessment helps to identify individuals expectation and create awareness (page 18, line 2024). 9. Ethical Considerations. I believe the Newcastle Satisfaction with Nursing Scale is freely available for use, yet it is a copyrighted scale. Please indicate if the permission to use the scale was sought from the scale's authors. Yes indeed we emailed authors but they couldn’t reply. Since it is freely available, we used it and properly cited the tool. This is a very relevant comment. Thank you!

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The statement that patients want to know about their illness and treatment is correct. However, its linkage to the next point related to considering satisfaction as an established outcome is not clear or obvious. You are correct. This is a relevant comment. The idea in this paragraph is fragmented. Therefore, we deleted the first sentence and the other sentences moved to the first paragraph of the background. The description of the healthcare system in Sub-Sahara Africa and Ethiopia is very informative, providing the context for the study. However, the information presented seems to reflect the totality of the healthcare system, which may not be quire relevant to the acute care hospital setting in which the study was done. Could the information focus on the acute care sector? We don’t understand this question. The hospital providing both chronic and acute care. We believe focusing on the acute care sector not representing the hospital(s) services. Instead, we added a description of the healthcare context and nursing staff complement, training, role and responsibilities in Ethiopia. If your question is still not addressed correctly, elaborate it in the next version and we will provide the answer. Thank you. (page 6, line 10-24; page 7, line 1-4) The statement of the study aim should reflect the 2 aims. Accepted and revised as recommended. Thank you. (page 7, line 12-14) In general, the background section presents different points; whereas the points are important and informative, they do not build on each other to make a logical and strong argument for the study. This is a relevant comment. Thank you very much. In the current version, we rearranged the background section and a few sentences that destruct the logical flow of idea are left out. The background section organized using the following framework: (1)conceptual definition of satisfaction and patients satisfaction; (2)patient satisfaction with nursing care; (3)summering evidence on level of patient satisfaction with nursing care and factors influencing satisfaction; (4)healthcare system in SubSahara Africa and Ethiopia; (5)gaps in previous studies and inconsistencies; and concluded by objectives. (page 5-7) 2. Methods and Materials It would be useful to: 1) explain what the term “kebeles” means, as it may not be familiar to many readers. Accepted and defined in the manuscript. Thank you. Kebele is the smallest administrative unit in Ethiopia. (page 7, line 18) 2) describe the type of services and the skill mix of health professionals employed at the selected hospital. Accepted and described as recommended. Thank you! (page 7, line 17-23; page 8, line 1-11) 3) explain in more detail, the cross-sectional design that is: who approached patients for recruitment, when; how was consent obtained and when; and in what context was the measure of satisfaction administered. These all questions are very relevant to make our methodology clear and replicable. We revised the manuscript as recommended. Thank you.(page 9, line 10-18) 4) clarify if and how the sample size calculation took into consideration the regression analysis planned to address the second aim (i.e. identify factors affecting satisfaction). We did not consider the regression analysis to address the second aim. We awfully sorry. Currently, we have planned to conduct a large-scale study assessing experience and satisfaction of nursing care in several hospitals by including additional variables. We will consider your recommendation for our next project. In the meantime, we mentioned as a limitation (page 18, lin 10-11). Thank you very much. 5) clarify the rationale for selecting the three types of wards (i.e. what do the authors mean by “patient flow” and “organized nursing care”, and for lumping parents (of children admitted to pediatric ward) with adult patients – was there any difference in their level of satisfaction? Thank you for your question. “Patient flow” means the number of patients admitted in the respective wards; to get sufficient participants, we considered this criterion. As we all know, implementation of the nursing process in required to provide organized and optimal nursing care. Thus, currently only these three wards are providing nursing care based on nursing process; we considered this criterion

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to get an unbiased estimation of patients satisfaction. There was no difference in their level of satisfaction between parents and patients (see table 2- ‘admission ward’ variable). To make it clear, we revised in the manuscript as well. 6) explain what is meant by “history of admission” – is it having been admitted previously to any hospital for the same or different condition? It is about previous admission in the same hospital. Thank you. We included this explanation in the manuscript as well. (page 9, line 4-5) The data collection instrument and variables subsections could be integrated to avoid redundancy, and to clearly identify the variables and their respective measures. Accepted and revised as recommended. We merged the data collection instrument and variables subsections. (page 9 and page 10, line 1-6) Please, specify 1) what demographic and what medical history variables were assessed and how, Sociodemographic characteristics include age, sex, religion, occupational status, educational status, marital status and monthly family income and assessed by interviewing patients. We considered the history of admission (i.e. having been admitted previously to any hospital for the same or different condition), hospital length of stay and admission ward as a medical history which assessed by medical record review but to avoid confusion, we left out “medical history”. Thank you for your question. (page 9, line 2-7) 2) what are the aspects of nursing care that were assessed by the 19 items, NSNS can assess all aspects of nursing scale, for example, nurses professional ethics, communication skill and knowledge. Thank you for your question. 3) what are the subscales measuring these aspects, We tried searching studies on NSNS based on factor analysis (principal component analysis). To the best of our knowledge, the 19 items satisfaction scale has no subscales and it measures only one construct-satisfaction. 4) what are the psychometric properties of the subscales, Given NSNS satisfaction scale has no subscales, the psychometric properties are not yet known. 5) whether or not the items translated to the local language or administered in English, and if translated, please describe the procedure used, and NSNS was administered in Amharic local language. The translation was done in consultation with professionals fluent in English and Amharic local language. (page 9, line 12-14) 6) the internal consistency reliability of the subscales and scale in the current study. Given NSNS satisfaction scale has no subscales, the internal consistency reliability of subscales in the current study was not checked. The internal consistency reliability of the NSNS satisfaction scale in the current study was excellent (Cronbach's α was 0.98 and intraclass correlation was 0.97). Thank you very much for your questions. (page 9, line 23-24) The rationale for dichotomizing the scores on satisfaction is not made explicit. This practice is no longer recommended as it was found to contribute to loss of information and power. We totally agree with you. From the statistical point of view, dichotomizing scores leads to loss of information and power. However, from the clinical point of view, dichotomization is easy to translate into practice. In fact, it is possible to analyze it using an independent t-test or linear regression using satisfaction score as an outcome variable. Given satisfaction is a difficult concept, interpreting results based on the mean change in satisfaction score (regression coefficient) is difficult to translate into clinical practice. Before analyzing the data, we also consulted clinicians and they recommended dichotomization. In addition, we believe there are distinct groups of individuals and interested in group differences rather than individual differences. To minimize loss of information for readers we also presented the frequency distribution of individual item as rated by patients (see table 2). Despite aforementioned, we included in the limitation section that readers should interpret the result cautiously (page 18, line 8-10). Thank you very much. 3. Results

The explanation of the discrepancy in findings, given in the third paragraph, could be elaborated: what do patient flow, scarcity of bed screen and lack of knowledge mean and how could they contribute to satisfaction? The same applies for all explanations of the findings provided in the discussion section. Accepted and revised as recommended. Thank you! (page 16-19 (line 1-6)) The implications of the findings for future research and for quality improvement are not discussed indepth. Accepted and revised as recommended. Thank you! (page 18, line 15-24) Reviewer: 3 Reviewer Name: Cristina Arrigoni Institution and Country: University of Pavia, Italy Competing Interests: None - Many references are dated We totally agree with you. We have used these articles intentionally because we would like to use the original definition of some concepts and NSNS tool. In addition, we couldn’t find some valuable information in recent articles. Despite all this, we updated some of the literature in current submitted version. - Reference 36 is related to the Italian context, what about the validity of the NSNC in English? Thank you for your question. The tool has been validated in different countries. We cited Reference 36 as an example and a recent validation study. The reliability and validity of NSNS are also excellent in English and other countries where validation study was done. - Moreover, is this the first time that NSNC was used in Ethiopia? If yes, you should discuss about this. Thank you for your question. NSNS is used for the first time in current study setting but there are other studies in Ethiopia that used NSNS as mentioned in the background section. - Sample description (e.g., can you better describe the exclusion criteria?) Accepted and revised as recommended. Thank you. (page 8, line 14-16) - In the discussion you should better emphasize the role of this study in adding new knowledge related to this topic

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If the measure has subscales, it would be important to compute the subscale scores and report relevant descriptive statistics to identify aspects of nursing care with which patients were most and least satisfied (rather than doing so at the item level). This is a very important comment. Thank you. NSNS comprises two sub-scales: experiences of nursing care assessed using 26 items and satisfaction of care assessed using 19 items. Experiences of nursing care were not assessed in this study because of feasibility issue (this also noted by reviewer 1). To the best of our knowledge, satisfaction scale has no subscale/subdomain based on factor analysis or principal component analysis. Our item level report has also been supported by previous literature. 4. Discussion There may be other factors that could account for the differences in the percent of patients satisfied with nursing care across countries, such as the characteristics of the samples, the hospitals, the types of services offered and the skill mix of nurses. These could be discussed. Accepted and revised as recommended. Thank you! (page 17, line 1-3) It is not quite clear how the measures of satisfaction used in the different studies can explain the differences in findings – do they address different domains or aspects of satisfaction? Please explain. Thank you for your question. First of all, we would like to make it clear about the phrase measure of satisfaction; we meant to indicate “satisfaction scale”. Nowadays, numerous satisfaction scale have been developed. Even though these scales measure the same construct, they are different in terms of the number of items included and components/domains included are slightly different. Therefore, this could create a variation in results.

VERSION 2 – REVIEW REVIEWER

REVIEW RETURNED

Souraya Sidani Professor and Canada Research Chair Ryerson University Canada 07-Mar-2018

GENERAL COMMENTS

There are still some concerns with the writing style; many points are confusing due to the English language. For clarity, the authors may want to state that 49.2% of participants were satisfied with nursing care, in the abstract and the text. p. 5, last sentence in the first paragraph - incomplete sentence: develop strategies for what? p. 6, line 25 5o 35, the sentence can be reworded to clarify what the percent actually reflects; suggested revision: "... shows variability in the percent of patients reporting satisfaction with nursing care: 73% in India... " p. 8, line 38-39: the sentence is incomplete - examine what? p.11: participants' inclusion criteria seem to have been omitted; these should be mentioned prior to listing the exclusion criteria

REVIEWER

Ahtisham Younas Memorial University of Newfoundland, Canada 10-Mar-2018

REVIEW RETURNED GENERAL COMMENTS

Thanks for providing me with another opportunity to review this manuscript. The revisions are well done and manuscript is much improved.

VERSION 2 – AUTHOR RESPONSE Reviewer: 1 Reviewer Name: Ahtisham Younas Institution and Country: Memorial University of Newfoundland, Canada Competing Interests: None declared Thanks for providing me with another opportunity to review this manuscript. The revisions are well done and manuscript is much improved. We are happy that all comments are successfully addressed and the manuscript is improved. Thank you very much. Reviewer: 2 Reviewer Name: Souraya Sidani Institution and Country: Professor and Canada Research Chair, Ryerson University, Canada Competing Interests: None declared There are still some concerns with the writing style; many points are confusing due to the English language. This is also noted by the editor. Thank you very much. This comment is essential and accepted. The whole manuscript has been copy-edited by native English speaker Dr Stephanie Grutzmacher

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Accepted and revised as recommended. It is also noted by reviewer 2. Thank you! (page 18, line 1524)

p. 5, last sentence in the first paragraph - incomplete sentence: develop strategies for what? This sentence is revised as “Patient satisfaction has become an established outcome indicator, a tool to analyze the quality of a healthcare system, and input to develop strategies for accessible, sustainable, affordable and acceptable patient care.” Page 5, line 7-9. p. 6, line 25 5o 35, the sentence can be reworded to clarify what the percent actually reflects; suggested revision: "... shows variability in the percent of patients reporting satisfaction with nursing care: 73% in India... " Accepted and revised as recommended. Thank you very much. Page 5, line 21-22. p. 8, line 38-39: the sentence is incomplete - examine what? This incomplete sentence is found in the ‘marked copy’ of the manuscript. In the ‘clean manuscript’ version, it has been stated as “….Thus, country-specific data is still required for providing evidence for cross-country/cross-cultural comparison in satisfaction level and factors affecting satisfaction using a standardized tool.” Page 7, line 11-13. p.11: participants' inclusion criteria seem to have been omitted; these should be mentioned prior to listing the exclusion criteria. Accepted and incorporated as recommended (Page 9, line 6-7). Thank you very much. The inclusion criteria were; a. Admitted in the three selected wards. b. Who stayed in hospital at least for two days. c. Capable of independent communication.

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(Oregon State University, College of Public Health and Human Science, USA; [email protected]). For clarity, the authors may want to state that 49.2% of participants were satisfied with nursing care, in the abstract and the text. Accepted and revised as suggested. Thank you very much. Page 2, line 17; page 13, line 3.