Patients' satisfaction with nursing care in Jordan. Jafar A. Alasad. Assistant Professor, Clinical Nursing Department, Faculty of Nursing,. University of Jordan ...
Patients’ satisfaction with nursing care in Jordan
Jafar A. Alasad Assistant Professor, Clinical Nursing Department, Faculty of Nursing, University of Jordan, Amman, Jordan Muayyad M. Ahmad Assistant Professor, Clinical Nursing Department, Faculty of Nursing, University of Jordan, Amman, Jordan
According to the World Bank report (1999), improving the quality of health care delivery system is considered a major challenge that International Journal of Health faces health care providers in Jordan. This Care Quality Assurance
study, probably, is the first patient-centered study that identifies the satisfaction factors that are important to patients in Jordan. Despite the enormous number of studies in Western countries over the past decade on patient satisfaction, it seems that consensus on its definition remains a matter of stipulation (Wallin et al., 2000). Patient satisfaction is a term that can be interpreted differently by patients and its meaning can also differ for one patient at different times (Larson et al., 1996; Shikiar et al., 1999). The multidimensionality of patients’ satisfaction forms an obscurity in examining this concept. Through the extensive research that has been done in the medical care dimensions, many concepts have been used to examine patients satisfaction. It has been interpreted as art of care, technical quality of care, accessibility and convenience, efficacy of outcomes of care, cost of care, physical environment, and availability and continuity of care (Fakhoury, 1998). Furthermore, Patients’ satisfaction has been used as an indicator to measure the quality of health care provided by nurses (Lledo et al., 1999; Niedz, 1998). More specifically, the assessment of quality of health care from patient’s perspective has been operationalized as patient satisfaction (Dufrene, 2000). In this study, patient’s satisfaction with nursing care is defined as the patient’s opinion of the care received from nursing staff and is acknowledged as an outcome indicator of the quality of nursing care. Patients’ satisfaction has been advocated as an outcome measure of quality nursing care (Comley and DeMeyer, 2001; Donabedian, 1980). There are seven main dimensions that have been addressed in the literature as crucial in the measurement of patients’ satisfaction. These dimensions are:
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Keywords Patients care, Nurses, Teaching, Hospitals, Jordan
Abstract This exploratory study investigated patients’ satisfaction with nursing care at a major teaching hospital in Jordan. A total of 266 in-patients participated in the study. Patients were recruited from the medical, surgical, and gynecological wards. Pearson correlation, one-way analysis of variance, and logistic regression analyses were used. The findings showed that patients in surgical wards had lower levels of satisfaction than patients in medical or gynecological wards. Gender, educational level, and having other diseases were significant predictors for patients’ satisfaction with nursing care. Methodological challenges, implications to nursing practice, and recommendations to nursing research are discussed.
The authors are grateful for the University of Jordan for funding this study. Thanks also extend to the hospital administration who granted access to the clinical settings. We also would like to thank the following research assistants: Hamza Ratrout, Maysoon Al-Otoum, Mohannad Abualruz, Muna Hammash, Reem Al-Qasem, and Wadah Da’meh.
Introduction There has been increasing interest in patients’ satisfaction with nursing care in the past few decades (Comley and DeMeyer, 2001; Shikiar et al., 1999). Patient satisfaction with nursing care is considered an important factor in explaining patients’ perceptions of service quality. Satisfaction is the psychological state that results from confirmation or disconfirmation of expectations with reality (Jackson et al., 2001; Weingarten, 1995). Consequently, a dissatisfied patient is not considered psychologically or socially well and thus the goal of nursing has not been attained (Dufrene, 2000; Ottoson et al., 1997). It is important for nurses to let patients express their views of care and incorporate these views in the provided care (Petersen, 1988). Health care providers in developing countries seem to be ignoring the importance of patients’ perceptions regarding health services (Andaleeb, 2001). Thus, a scarcity of literature made it difficult to find research examining patients’ satisfaction with nursing care in developing countries. Quality of health care in developing countries usually is defined by health care providers from technical perspective. Recent literature however, emphasizes the importance of patient’s perspective in assessing quality of health care (Andaleeb, 2001). According to O’Connor et al. (1994, p. 32): It’s the patient’s perspective that increasingly is being viewed as a meaningful indicator of health services quality and may, in fact, represent the most important perspective.
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Jafar A. Alasad and Muayyad M. Ahmad Patients’ satisfaction with nursing care in Jordan International Journal of Health Care Quality Assurance 16/6 [2003] 279-285
respect for patients’ values, preference and expressed needs; coordination, integration and information flow; information and education; physical comfort; emotional support and alleviation of fear and anxiety; involvement of family and friends; and transition and continuity (Ryden et al., 2000). Accordingly, patients’ satisfaction measurement tools should consider the aforementioned dimensions. Various studies have presented controversy in the results concerning possible relationships between patient characteristics and their satisfaction with nursing care (Minnick et al., 1997; Williams and Calnan, 1991). Satisfaction with nursing care was found to increase when patients become older in their age, having better functional health status, being in private rooms, and being hospitalized in surgical wards (Crooker and Near, 1998; Jackson et al., 2001; Thi et al., 2002; Williams and Calnan, 1991). On the other hand, no correlations were found between patients satisfaction and age, gender, or education (Arnetz and Arnetz, 1996; LoÈvgren et al., 1998; Wallin et al., 2000). Moreover, patients’ ability to evaluate the care they receive is reduced when they do not have enough knowledge about their condition (Donabedian, 1980; Vuoei, 1991). The study aims to: 1 examine patients’ satisfaction with nursing care at a major teaching hospital in Jordan; 2 assess the quality of nursing care that is provided at this particular hospital as indicated by patients’ satisfaction; and 3 compare patient’s satisfaction with nursing care at major areas within the hospital.
(medical, surgical, and gynecological) was obtained from the appropriate tables (Cohen) for an alpha of 0.05, and a power of 0.80. The study sample (n = 266) constituted all patients who were admitted to the study wards and met the inclusion criteria, that is, being: 18 years or older in the ward for two nights or more; and not disorientated. The participants’ characteristics can be seen in Table I. A total of 267 in-patients were invited to participate and 266 agreed. Participants were recruited from medical (two wards), surgical (three wards), and gynecological (one ward) wards. The median age for participants was 37 years (range 18 to 87); 54 per cent were women. The mean duration for the length of stay was seven nights (SD = 8.4).
Procedure Participation in the study was voluntary and based on patient’s ability to give informed consent. The relevant Institutional Review Board approved the study. Inguanzo (1992) pointed out that patients tend to be reluctant to be honest when they feel they might be identified and or their care may be jeopardized. McColl et al. (1996) recommend that administration of patients’ satisfaction instruments should be carried out by a neutral individual not involved in patient care. Accordingly, research assistants from outside the hospital were recruited and trained to collect data. Research assistants’ roles were to recruit patients who meet the inclusion criteria, obtain informed consent, and deliver and collect the completed questionnaires. Data was collected from the relevant wards in two months, simultaneously. Participants were guaranteed confidentiality.
Measures
Method Sample and setting An exploratory approach utilizing cross-sectional survey design was used to examine patients’ satisfaction with nursing care at a 600-bed teaching hospital in Jordan. Sample size was estimated using Cohen’s technique (1988) for power analysis for F-test (ANOVA). Since data on the effect size of relationship between nursing care and satisfaction of patients were not available, and to be conservative in estimating the sample size, a medium effect size (0.25) for ANOVA was considered. A sample size of 44 for each of the three groups in the study
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Patients’ satisfaction with nursing care was assessed using the Newcastle Satisfaction with Nursing Scale (NSNS); (Thomas et al., 1996). The NSNS is considered parsimonious and empirically supported. Moreover, it covers most of the dimensions of patients’ satisfaction suggested in the literature such as quality of care and patients views of their care. The NSNS includes demographic information, satisfaction with nursing care scale, and one item-scale (seven point response scale) of overall patients satisfaction (Thomas et al., 1996). The satisfaction scale consists of 19-items. All items are scored on a five-point Likert scale (1 = not at all satisfied, 2 = barely
satisfied, 2 = quiet satisfied, 4 = very satisfied, and 5 = completely satisfied). Participants were asked to rate their satisfaction with various aspects of nursing care by selecting International Journal of Health only one number that best describes their Care Quality Assurance 16/6 [2003] 279-285 opinion in each item of the scale. The total score was transformed to yield an overall satisfaction score of 0 to 100, where 100 denotes complete satisfaction with all aspects of nursing care. The NSNS was found to be valid and reliable in previous studies (McColl et al., 1996; Preist et al., 1995; Walsh and Walsh, 1999). The Cronbach alpha of NSNS in the current study was 0.93. Jafar A. Alasad and Muayyad M. Ahmad Patients’ satisfaction with nursing care in Jordan
Data management All univariate descriptive statistics were computed using the Statistical Package for the Social Sciences/Personal Computer (SPSS/PC). Preliminary data analyses were conducted to describe the study sample via the mean, median, range, standard deviation, variance, and index skewness. The one-way analysis of variance (ANOVA) statistic was computed to compare total patients scores in
Table I Participants’ characteristics by area of admission (n = 266) M edic al n = 82
Su rgical n = 14 5
G yneco logical n = 39
To tal
A g e ye ars ) M (SD )
42 .1 (16 .6 )
3 6.9 (1 3.5)
37.1 (9 .7)
38 .5 (14 .2)
G en der M ale Fe m ale
43 39
73 72
0 39
116 150
C las s of adm is s ion P riva te First Se cond Th ird
2 9 32 39
2 13 51 79
5 1 13 20
9 23 96 138
26 19 11 26
40 38 24 43
12 8 8 11
78 65 43 80
O pe ration s tatus W aiting for opera tion O pe ration do ne N o operation
3 8 71
30 97 18
6 16 17
39 121 106
H ea lth ins ura nc e P resen t N ot prese nt
78 4
126 19
39 0
243 23
H aving other disea se(s)
37
55
10
102
C atego ry
E duc ation Less than nine grade H igh sch ool D iplom a B ac helor de gree and ab ove
Leng th o f s ta y nig hts ) M (SD ) Sa tisfaction M (SD )
8 .4 (10 .9 )
6.8 (7 .5)
7 8.3 (12 .2 )
74.7 (1 2)
4.9 (3 .9)
7 .1 (8.4)
83.6 (1 2.7)
77 .1 (12 .5)
satisfaction scale in the wards of the hospital. In addition, logistic regression was conducted to examine the effect of selected variables on the probability of patients’ satisfaction with nursing care (Polit, 1996).
Results Correlations between each item in NSNS and the medical, surgical, and gynecological wards were examined using Pearson product-moment correlation coefficient (Table II). While patients in medical wards had low satisfaction with the amount of information they received from nurses (r = ±0.17, p µ 0.01), they have high satisfaction with the nurses’ helpfulness (r = 0.13, p µ 0.05). A total of 14 items indicated low levels of satisfaction for patients in surgical wards. Mostly, patients had low levels of satisfaction with the speed of nurses’ response to their calls, the amount of freedom in the ward, nurses’ willingness to respond to requests, and in treating patients as individuals. In gynecological wards, patients had high levels of satisfaction at 11 items on NSNS. The highest correlation was with speed of nurses’ response to patients’ requests (r = 0.25, p µ 0.01). Table III summarizes the result of comparing the three main areas (medical, surgical, and gynecological wards) with respect to patients’ score on the satisfaction scale. The ANOVA results showed a significant difference in the total score across wards, F(2, 263) = 8.89, p < 0.001; therefore, it was followed by Scheffe’s multiple comparison tests to determine which specific pairs of areas were significantly different. The post hoc tests revealed that patients in gynecological ward were more satisfied than patients in surgical wards. There were no significant differences between medical wards and other wards. A dichotomous logistic regression model was used to estimate the probability of patients’ satisfaction with nursing care. There was significant correlation (0.70, p µ 0.01) between patients’ scores on the 19-item satisfaction scale and the one item-scale (seven point response scales) of overall patients satisfaction which reflects the internal consistency of the NSNS. Thus, the one item-scale of overall patients’ satisfaction was used in the logistic regression. As performed by Jackson et al. (2001), satisfaction was considered as either fully satisfied (i.e. rated their overall care as excellent or very good) or not fully satisfied (i.e. rated their overall care as less than very good). The process of selecting and entering
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Table II Correlations between wards and satisfaction items (n = 266)
Jafar A. Alasad and Muayyad M. Ahmad Patients’ satisfaction with nursing care in Jordan
M edical n = 82 Surgical n = 145 Gynecological n = 39
Item s
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1 2 3 4 5 6 7
The am ou nt of tim e nurses spent w ith you Ho w capa ble nu rses w ere at their jo b There a lw ays be ing a nurse aroun d if you need on e The am ou nt nurses knew a bout you r c are Ho w quickly nurse s ca m e w he n you called for them The w a y the nurses m ade you fee l at h om e The am ou nt of in form a tion n urses ga ve to you abou t co ndition and trea tm ent 8 Ho w often nurses che cked to see if you w ere O K 9 Nu rse s’ he lpfulne ss 10 The w ay the nurses exp lain ed things to you 11 H ow nurse s helped pu t yo ur re latives’ or friend s’ m inds at rest 12 N urses’ m an ner in going ab out their w o rk 13 The type o f inform a tion nurse s gave to yo u about your condition a nd tre atm en t 14 N urses’ treatm ent of yo u a s an individua l 15 H ow nurse s liste ned to your w orries and c oncerns 16 The am o unt of freedom you w e re given in the w ard 17 H ow w illing nurses w ere to respo nd to your requ ests 18 The am o unt of privacy nu rses gave you 19 N urses’ aw aren ess of your nee ds
0.0 6 0.0 8 0.0 7 ±0 .07 0.0 7 0.0 7
±0.12 ±0.12 ±0.14* ±0.04 ±0.24* * ±0.20* *
0.09 0.06 0.11 0.14* 0.25* * 0.19* *
±0 .17 ** 0.0 1 0.1 3* 0.0 6
0.03 ±0.14* ±0.15* ±0.15*
0.18* * 0.18* * 0.04 0.13*
0.1 1 0.1 0
±0.15* ±0.17* *
0.06 0.11
±0 .04 0.1 9** ±0 .02 0.0 9 0.0 6 0.0 8 0.0 2
±0.07 ±0.26* * ±0.13* ±0.22* * ±0.22* * ±0.15* ±0.15*
0.15* 0.11 0.21* * 0.19* * 0.23* * 0.10 0.18* *
No tes: * p µ0.05. ** p µ0.01
Discussion and conclusions
Table III Means of satisfaction scores in the study areas and F statistics Area M edic al w ards Fifth w a rd Six th w ard S u rg ic al w ards Sec ond w ard Third w ard Fou rth w ard G yne c olog ic al w ard A ll areas
n (M /F)* 82 (43/ 39) 38 (17/ 21) 44 (26/ 18) 145 (73/ 72) 48 (24/ 24) 49 (25/ 24) 48 (24/ 24) 3 9 (0/ 39) 2 66 (116/1 50)
M (S D) 7 8.2 7 8 0.1 4 7 6.6 5 7 4.6 8 7 1.5 1 7 5.2 5 7 7.2 6 8 3.6 4 7 7.1 0
(12.19) (10.87) (13.13) (12.02) (12.31) (8.1 9) (14.32) (12.65) (12.52)
F statistics
(8.8 9** ) a
N otes : * M = M ales, F = Fem ales; ** p µ0.001 ; a D iffere nce b etw ee n surgical w ards and gyne cologica l w ard
the variables to the logistic regression model was repeated with various orders of entry. The model that adequately fitted the data ( 2 Hosmer-Lemeshow = 3.32, eight degrees of freedom, p = 0.91) included eight predictor variables. The estimate of the variance accounted for in the patients satisfaction are 11.9 per cent (Cox and Snell) and 15.8 per cent (Nagelkerke). Three predictors were significant at p < 0.05. Female patients tended to be more satisfied than male patients. Less educated patients and those with no other diseases tended to have high satisfaction (Table IV).
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The aim of the study was to examine patients’ satisfaction with nursing care at a major teaching hospital in Jordan. Patients’ satisfaction was examined in the medical, surgical and gynecological wards of the hospital in relation to patient’s gender, age, class of admission, level of education, length of stay in the hospital, operation status, having other diseases, and health insurance. Patients’ response rate was almost 100 per cent. The problem of low response rate associated with postal questionnaires addressed in the literature was avoided in this study by having research assistants from outside the hospital to deliver and collect the questionnaires. Thus, from the 267 approached potential participants, 266 accepted to participate in the study. Completion of the questionnaire by the participant appeared to be simple and there was no systematic pattern of items being missed. The similarities in response rate in the different areas in the hospital make the comparison between these areas credible. Having nurses from the same ward to collect data imposed threat to patients’ which affected their responses (Weingarten et al., 1995). Therefore, having external data collectors is recommended to avoid imposing threat to patients’ satisfaction results, increase response rate, and minimize
systematic errors in completing questionnaires. The result of logistic regression analysis in this study was relatively consistent with the International Journal of Health findings of other studies (Jackson et al., 2001; Care Quality Assurance 16/6 [2003] 279-285 Ottosson et al., 1997; Thi et al., 2002; Wallin et al., 2000). In their logistic regression analysis, Thi et al. (2002) identified factors associated with in-patient satisfaction with nursing care. They reported that older age and higher general health perception were the strongest predictors of higher satisfaction. Jackson et al. (2001) emphasized the importance of functional health status as a predictor for patients’ satisfaction. In our study, being female, having less education, and having no other diseases were the significant predictors for higher satisfaction. Patients with no other diseases tended to have higher satisfaction than those with other diseases. This finding is consistent with Ottosson et al. (1997) who concluded that patients who are successfully treated, the state of their good general health will result in high satisfaction scores. Moreover, Greenfield et al. (1993) found that patients with co-morbid diseases may be sicker and have a worse outcome than other patients. Using a valid measure such as ``Charlson et al. (1987) index’’ to give weight for the co-morbid conditions among the study population could control for the effect of health status on the outcome measure While there was no correlation between gender and patient satisfaction in Wallin et al. (2000) study, Ottosson et al. (1997) reported higher satisfaction among males than among females. In the current study, female patients tended to have higher satisfaction than male patients. Further analysis revealed significant correlation (p < 0.01) between gender and education level. The logistic regression finding that patients with higher educational level were not satisfied with their care goes consistent with the findings of other studies (Minnick et al., 1997; Wallin Jafar A. Alasad and Muayyad M. Ahmad Patients’ satisfaction with nursing care in Jordan
Table IV Predictors of patients’ satisfaction among fully satisfied patients (n = 134) versus not fully satisfied patients (n = 132) Va riables G en der C lass of adm ission Age (ye ars) Area o f adm ission H aving other disea se E duc ation le vel N ights in hos pital O pe ration status
B
SE
W ald
O dd s ratio (C I 95 per cent)
0.66 0.02 0.01 0.27 ±1 .13 ±0 .29 0.02 0.21
0 .29 0 .18 0 .01 0 .24 0 .30 0 .12 0 .02 0 .21
5.28 0.01 0.29 1.28 14.03 5.79 1.37 1.01
1.93* 1.02 1.01 1.31 0.32** 0.75* 1.02 1.24
N otes : * p µ0.0 5;** p µ0.001
et al., 2000). In the current study, of the 143 patients who have less than high school education, 63 per cent were females. On the other hand, 44 per cent of the 80 patients who have baccalaureate degree and above education were females. This could contribute to the difference in satisfaction between males and females. In comparison between wards, gynecological ward had significantly higher percentage of satisfaction with nursing care than the surgical wards. Although gynecological ward includes only female patients, mostly the difference between gynecological and surgical wards would not be the contribution of gender effect only, as this difference did not appear between gynecological ward and medical wards. Inconsistency in the literature was found regarding the relationship between age and satisfaction. While Wallin et al. (2000) did not find a correlation between age and patient satisfaction, other studies found age to be a significant predictor for satisfaction (Jackson et al., 2001; Ottosson et al., 1997; Singh et al., 1999). In the current study; age was not found to be a significant predictor for patients’ satisfaction. In order to explore any potential factors in the settings of the studied areas that may alter patients’ responses in the NSNS, the researchers of this study made a follow up visit to the relevant wards. The main obvious landmark was that the gynecological ward is designed in a close to circle shape which could make the nursing’ station closer to all patients. However, if this factor contributed to the significant difference between gynecological ward and surgical wards, it should be also the same with medical wards. The director of nursing in the hospital commented that one of the three surgical wards involved in the study had high turnover during the period of data collection which could explain the differences. Examining individual items in the satisfaction scale revealed aspects of nursing care with which patients were most and least satisfied. Consistent with findings of previous studies (Larson et al., 1996; McColl et al., 1996), the aspects with which patients were least satisfied (regardless of admitting ward) were the amount and type of information they receive regarding their condition and treatment. The top aspects that patients scored highest for their satisfaction with nursing care were the feeling of privacy, nurses capability at their job, and nurses helpfulness. It is generally believed that elements of privacy, respect, and advocacy which nurses consider through their practice
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enhance patients’ satisfaction with the care (Walsh and Kowanko, 2002). Although that patients overall ratings of satisfaction in this study was 77 per cent, it is International Journal of Health considered relatively low in comparison to Care Quality Assurance 16/6 [2003] 279-285 other studies (Andaleeb, 2001; Ottosson et al., 1997; Walsh and Walsh, 1999). Nevertheless, examining the items with low patients’ satisfaction will enable nurses to identify the defects in nursing care and to institute appropriate changes. Items with high patients’ satisfaction need to be maintained and enhanced by nurses. The findings of this study are anticipated to be used for improving the quality of nursing care through comparisons of patients’ satisfaction between wards, or hospitals. In addition, a longitudinal comparison for the studied wards after a specific intervention being implemented will contribute to the quality of nursing care. Moreover, ward managers may set standards of a level of care to be attained; for example, they may aim for 90 per cent of patients having satisfaction score on specific items. Despite the generalizability of the findings are potentially limited as the sample derived from one hospital only, the study’s results are considered sensible. The researchers of this study found that going back to nurses in the clinical area where the study was conducted as a helpful strategy in communicating findings. Discussing results with involved nurses and administrators was found fruitful in evaluating the relevance of the results and in accepting the potential needs for changes in the clinical practice. In addition, this strategy has clarified some findings and provoked suggestions as to how certain problems might be resolved. Patients need for more information from nurses regarding their health problems was found to be a major defect in nursing care in many studies. Therefore, nurses have to consider the importance of this issue on improving the quality of care and try to find out strategies to be more efficient on the quality and quantity of information provided to patients. The potential benefits of assessing patients’ satisfaction with nursing care make further studies a major priority in order to monitor care over time and evaluate nursing innovations. Jafar A. Alasad and Muayyad M. Ahmad Patients’ satisfaction with nursing care in Jordan
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