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International Journal of Nursing Practice 2013; 19: 584–590
RESEARCH PAPER
Patients’ satisfaction with the quality of nursing care provided: The Saudi experience Mohammad A Atallah RN MSN PhD Associate Director of Nursing Education and Quality Improvement, Department of Nursing, King Khalid University Hospital-King Saud University, Riyadh, Kingdom of Saudi Arabia
Ayman M Hamdan-Mansour RN MSN PhD Associate Professor, Psychiatric and Mental Health Nursing, Department of Community Health Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
Mohammad M Al-Sayed RN MSN PhD Director of Nursing, Department of Nursing, King Khalid University Hospital-King Saud University, Riyadh, Kingdom of Saudi Arabia
Ahmad E Aboshaiqah BSHA BSN MS MHHA PhD Assistant Professor, Nursing Administration and Education Department, College of Nursing, King Saud University, Riyadh, Saudi Arabia
Accepted for publication October 2012 Atallah MA, Hamdan-Mansour AM, Al-Sayed MM, Aboshaiqah AE. International Journal of Nursing Practice 2013; 19: 584–590 Patients’ satisfaction with quality of nursing care provided: The Saudi experience Patient’s satisfaction has emerged as a central focus of health-care delivery during the last decades, and nursing care became one significant component of patient’s satisfaction. The purpose of this study is to examine patients’ satisfaction with quality of nursing care provided in Saudi Arabia. Cross-sectional descriptive correctional design was used to recruit 100 patients from one regional hospital in Saudi Arabia. Data collected using structured interview from patients related to six dimensions of nursing care. Patients had a high level of satisfaction with nursing care provided (86% agreement rate). Language (56% disagreement rate), discharge information (56% disagreement rate) and availability (20% disagreement rate) have been identified with the lowest rates of patients satisfaction. Nursing leaders and health-care administrators need to maintain quality nursing care and develop strategies for improving nursing care emphasizing language as barrier and strategies of information dissemination. Key words: patients’ satisfaction, quality of nursing care, Saudi Arabia.
INTRODUCTION
Correspondence: Ayman M Hamdan-Mansour, Psychiatric and Mental Health Nursing, Department of Community Health Nursing, Faculty of Nursing, University of Jordan, Amman 11942, Jordan. Email:
[email protected];
[email protected] © 2013 Wiley Publishing Asia Pty Ltd
Partnership between patients and health-care providers considered an essential part of quality of health care. Patients in different health-care settings want to assume more control and involvement in decision making.1 The emphasis on quality of care and outcome measurement led to an increased recognition to the role of patients’ doi:10.1111/ijn.12102
Patient satisfaction
perception of care in improving quality of care provided, and therefore, became a significant element in the modern health-care plan and management.2 Therefore, patients’ perceptions related to quality of care provided have been considered seriously in assessing and evaluating health-care services. Among is the patients’ satisfaction that has been assumed as an instrumental component in monitoring hospital’s quality of care. 3A very important aspect of patient’s satisfaction is nursing care. Nurses are involved in almost every aspect of patient’s care and interact with patients more often than any other healthcare professional in a hospital.4 The literature showed that a number of factors contribute to patient’s satisfaction that could be personal, institutional or environmental. Chapman and Purushotham5 emphasized the role of individualized care to enhance patient’s satisfaction, while others6,7 emphasized the role of physical needs, patient’s involvement in treatment plans and decision making, and competency of health-care professionals. In general, patients value nurses’ performance and expected to be treated with attentiveness, gentleness and respect.8 Previous international studies showed that patients had described nursing care as an individual behavior, focused on care and needs, lack caring manner, and attentive to patient’s needs.9 Moreover, patients did perceive nursing care as joyful, warm, tender, smiling, positive, polite and understanding.10 In summary, patient’s satisfaction with nursing care depends mainly on patients’ perception of quality of nursing care. Patients tend to perceive quality of nursing care as being individualized, having a professional manner and caring attitude which may explain variations in patients’ satisfaction if nursing care provided was different from what the patients expect. Although patient’s satisfaction has been examined thoroughly in the literature, there still a well-documented discrepancy between nurses’ and patients’ ratings of quality of nursing health care provided.11,12 In the developing countries especially in Saudi Arabia, research in nursing and patient’s satisfaction, while routinely conducted in the developed world to monitor and improve the quality of care, is neglected. The available information related to patient’s satisfaction in Saudi Arabia is either conducted as procedural function or as part of the routine periodic assessment that has never been published. In Saudi Arabia, about 80% of the nurses are non-Saudi and are coming from countries such as Philippines, India, South Africa and Malaysia.13 The cultural differences may have a role in patients’ perceptions and may influence
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patients’ satisfaction about nursing care considering the barriers of culture and language. This study came to address this issue and further to increase our knowledge about patients’ satisfaction related to quality of nursing care provided at one major public health-care institution in Saudi Arabia. Therefore, the purpose of this study was to investigate patient’s satisfaction with quality of nursing care provided at Saudi health-care settings. The specific aims were: To examine the patients’ satisfaction level about quality of nursing care provided To identify differences in patients’ satisfaction of quality of nursing care provided related to selected demographic characteristics
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METHODS Design This study utilized cross-sectional, descriptivecorrelational design to examine patients’ satisfaction of quality of nursing care provided. Data were collected using self-reported questionnaires from patients in one regional hospital in Riyadh, Saudi Arabia. Data were collected with regard to patient’s satisfaction of quality of nursing care provided.
Sample and sampling A convenience sample of 100 patients represented the sample of this study. About 250 patients approached and 100 of them agreed to participate with an agreement rate of 40%. Data collection took place at one regional hospital in Riyadh, Saudi Arabia. The hospital is considered a referral, tertiary, education and multi-specialty hospital with bed strength of 940 beds. Inclusion criteria include: (i) above the age of 18 years and (ii) admitted to general wards. Exclusion criteria include cognitive or physical disability that may contribute to understand or fill out the survey. For those who cannot read or write, a research assistant has been assigned to read the questions and transcribe the answers literally using the structured interview format.
Data collection procedure Prior to data collection, the principal investigator obtained ethical approval from ethical research committee at King Saud University and the targeted institution. Head of units served as liaisons to approach patients. A co-investigator was available during distributing and receiving the packages, so the patients returned them © 2013 Wiley Publishing Asia Pty Ltd
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directly to the co-investigator. The questionnaires were arranged in packages, and only those who express interest in participation were asked to fill out the questionnaires. The package had a cover letter that includes information about the purpose of the study, what is expected from them, where to return the packages, and that the study is anonymous. In addition, the cover letter included contact information of the principal investigator and co-investigators for any further information and for answering the questions related to the study. The cover letter included a statement informing the subjects that returning the questionnaire will be considered an approval to participate in the study. At the end of the cover letter, there was a statement included that their participation in the study is voluntarily and that their decision is of their own choice without any direct or indirect influence.
Instrumentation The data were collected using an Arabic version of the self-report questionnaire. After obtaining approval from the author to use the scale, a translation and validation back carried out by linguistic professionals. Pilot testing of the instrument carried out also to check for understanding, clarity and time required for filling the questionnaires. Numbers of procedures were used to determine the reliability and validity of the tool. The tool first translated into Arabic language by a researcher and back translated into English language by another independent researcher as described by Brislin13 and Chapman and Carter.14 The two English forms (the original and the translated) compared in terms of conceptual rather than literal meaning of the items. The translator and the back translator met to examine the difference in the two forms. Pilot testing was conducted using patients (n = 20) requesting their appraisals for the appropriateness of the tool. In addition, an author-develop profile was used to obtain demographic and personal information from patients. The instrument used was an adapted format of Patient Satisfaction Questionnaire.15 Six dimensions of patient satisfaction have been used. The original scale consists of 48 items referring to: (i) the importance of patients’ problem; (ii) patients’ admission and doctors’ care (behaviour, quality of communication with patients, informativeness and their availability); (iii) nurses’ care (behavior, quality of communication with patients, informativeness, their availability and their adequacy); (iv) assistant personnel care (orderly care, cleaning © 2013 Wiley Publishing Asia Pty Ltd
personnel, waiters); (v) accommodation aspects (hygiene, feeding and wards’ condition); and (vi) external environment (canteen’s service, canteen’s prices, information office, security, parking, access to hospital, piloting). In this study, 32 items were used referring to patient care orientation to the unit, communication, teaching, reassurance, professionalism, availability and attentiveness, and admission and discharge process. The patient’s responses are made on five-point Likert scale with responses ranging from strongly disagree (1) to strongly agree (5). The scale has a good internal consistency with Chronbach’s alpha of range 0.77–0.89.15 In this study, the scale showed good internal consistency with Chronbach’s alpha of 0.82 ranging 0.75 (admission and discharge)–0.84 (communication). Potential covariate includes patient’s age, gender, marital status, level of education, length of stay at the hospital, history of hospitalization, type of admission, number of admission, medical diagnoses and area of admission.
Data analysis The Statistical Package for Social Science (spss 18) software (IBM, Chicago, IL, USA) was considered as suitable software for data entry, storage and analysis. Descriptive statistical analysis such as frequency count, percentage, mean, median and standard deviation was employed to describe the research sample. The Pearson productmoment correlation coefficient was used to describe the association between variables. Chi-squared was used to compare means. Statistical significance was set at P ⱕ 0.05.
RESULTS Demographic characteristics About 250 patients approached and 100 of them agreed to participate with a response rate of 40%. Among these, 45% (n = 45) were males and 55% (n = 55) were females. The mean age of the participants was 45.5 years (standard deviation (SD) = 13.5) ranging 18–70 years of age. About 60% (n = 61) were above the age of 46 years. About 72% (n = 72) were married, 24% (n = 24) were single and 4% (n = 4) were widowed. Half of the sample had some education (50%, n = 50), while 40% (n = 40) had education higher than secondary school, and 10% (n = 10) were illiterate. Regarding hospitalization, 44% (n = 44) were at their first time admission, 20% (n = 20) have been admitted more than three times and 34%
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(n = 34) have been admitted one to two times. Moreover, 36% (n = 36) of the patents were admitted to medical units, 46% (n = 46) were admitted to general surgery units and 18% (n = 18) were admitted to obstetrics and gynaecology unit.
Patient satisfaction Six aspects of nursing care have been investigated in terms of patient satisfaction. As shown in Table 1, about 86% (n = 86) of the patients showed an overall satisfaction about the quality of nursing care provided. The
Table 1 Dimensions of patients’ satisfaction with nursing care provided (n = 100) Item
Nurse’s professionalism Respect to culture Maintained privacy Kind and pleasant Respectful Friendly and helpful Checked me frequently Nurse’s communication Dressed well Communication in Arabic Comfortable to call nurses Answers questions Explains plan of care Explains procedure Teaching Information provided for complication prevention Good at enforcing information Information provided about operation/procedure Nurse’s availability and attentiveness Responds to call bell promptly Responds to request for pain medication Informs about doctors visibility Explains pain medication availability Courteous Admission Admission staff was helpful It was easy to get to the unit Pre-admission instructions provided Discharge Process Nurse knows clinic appointment date Discharge handled in a timely manner Nurse taught me how to take my discharge medication Discharged medication was received timely I was given information regarding my wound care Overall satisfaction
Response Strongly agree to agree
Neutral
Strongly disagree to disagree
n
%
n
%
n
%
93 84 86 88 82 84
93.0 84.0 86.0 88.0 82.0 84.0
4 5 9 5 6 4
4.0 5.0 9.0 5.0 6.0 4.0
3 11 5 7 12 12
3.0 11.0 5.0 7.0 12.0 12.0
94 34 84 79 72 82
94.0 34.0 84.0 79.0 72.0 82.0
0 10 5 9 11 5
0.0 10.0 5.0 9.0 11.0 5.0
6 56 11 12 17 13
6.0 56.0 11.0 12.0 17.0 13.0
75 75 83
75.0 75.0 83.0
8 10 10
8.0 10.0 10.0
16 15 7
16.0 15.0 7.0
81 80 72 74 92
81.0 80.0 72.0 74.0 92.0
2 8 8 11 0
2.0 8.0 8.0 11.0 0.0
17 12 20 15 8
17.0 12.0 20.0 15.0 8.0
85 85 60
85.0 85.0 60.0
6 3 7
6.0 3.0 7.0
9 12 33
9.0 12.0 33.0
80 60 76 65 79 86
80.0 60.0 76.0 65.0 79.0 86.0
17 22 22 25 24 7
17.0 22.0 22.0 25.0 24.0 7.0
3 18 2 10 7 7
3.0 18.0 2.0 10.0 7.0 7.0
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analysis also showed that nursing professional domain had the highest patients’ satisfaction rate (86.2% agreement rate), while nursing communication domain had the lowest reported average of agreement rate of patients’ satisfaction (59.2%). The other four domains showed moderate agreement rates of patients’ satisfaction ranging 74.3 (discharge process)–79.8% (nurses availability and attentiveness). Regarding item analysis, the results showed that the least reported items of satisfaction were ‘communication in Arabic’ as 56% of the patients reported strong disagreement, ‘pre-admission instructions provided’ as 33% reported disagreement and ‘inform about doctors visibility’ as 20% reported strong disagreement. All other items showed lower level of disagreement. The results also showed that 11% or less of patients had no opinion about the quality of nursing care provided except for discharge domain in which about 22–25% of patients showed no opinion about the quality of care provided. Moreover, the highest reported items among the patients were ‘dressed well’ (94% agreement rate), ‘respect to culture’ (93% agreement rate), ‘respond to call bell promptly’ (92% agreement rate) and ‘courteous’ (92% agreement rate). The results, in general, showed high level of satisfaction among patients related to nursing care provided.
Difference in patients’ satisfaction related to patients’ demographic characteristic Regarding the differences in patient satisfaction of nurses’ quality of care provided in relation to demographic characteristics, the analysis using Kruskal–Wallis and chisquared tests to examine the difference showed that there were no significant differences between patients’ satisfaction (overall satisfaction) with regard to age, gender and marital status (P > 0.05), whereas there was a significant difference in overall patients’ satisfaction level related to educational level (c2 = 4.2, P = 0.02) and number of admissions to hospital (c2 = 5.9, P = 0.03). To examine the difference in items of patients’ satisfaction, Kruskal–Wallis and chi-squared tests were used to examine the difference with regard to age, gender, number of admission and length of stay. The analysis showed that male and female patients were significantly different in ‘respect to culture’ (c2 = 6.2, P = 0.007), ‘friendly and helpful’ (c2 = 2.7, P = 0.04), ‘explains plan of care’ (c2 = 8.3, P = 0.001), ‘pre-admission instructions provided’ (c2 = 12.4, P > 0.001) and ‘discharged © 2013 Wiley Publishing Asia Pty Ltd
medication was received timely’ (c2 = 1.5, P = 0.04). Regarding the difference in patients’ satisfaction related to number of admission, there were significant differences in ‘inform about doctors visibility’ (c2 = 11.2, P > 0.001), whereas there were no significant differences in patient’s satisfaction related to age and length of stay at the hospital. In general, results showed that patients’ satisfaction level is influenced mostly by patient’s age and number of admissions to hospital.
DISCUSSION Patients’ satisfaction surveys are used as tools through which patients provide health-care providers with their perception of quality of care provided. Patients’ satisfaction is also considered a feedback and used as part of quality assessment process to identify potential areas for improvement.16 This study aimed at exploring patients’ satisfaction level related to a particular and significant aspect of quality of health-care services, and that is nursing care. The results showed, in general, that patients had moderate to high level of satisfaction about nursing care provided with regard to patient care orientation to the unit, communication, teaching, reassurance, professionalism, availability and attentiveness, and admission and discharge process. The results correspond with previous international reports that patients perceived quality of nursing care as being individualized, focusing on care and needs, attentive and have excellent communication skills.9,10 However, other studies17 reported that patients estimated quality of care as fairly good and that there are areas in need of improvement. In addition, patients reported that nurses did not show an interest in their life situation, and they did not receive useful information on self-care.17 In this study, what patients had significant dissatisfaction reports related to nurses’ ability are using Arabic language for communication, quantity and quality of information provided prior admission, and availability of their physicians. This infers that language formed a barrier for patients’ communication with their nurses, and this may also interfere with patients’ ability to understand information provided at pre- and postadmission phases. In Saudi Arabia where the majority of nurses are non-Arabic native speakers, language appears as one major barrier for quality of nursing care provided. According to Aldossary and colleagues,13 the number of Saudi nurses increased from 9% in 1996 to 22% in 2008, which means that about 80% of nurses are non-Saudi. Most of migrant nurses in
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Saudi Arabia are coming from South Africa, Malaysia, India and the Philippines, and few are coming from the neighbouring Arabic states such as Jordan.18 This study did provide evidence that language as barrier has affected negatively the patient’s perception of quality of nursing care provided, although patients’ communication with their health-care providers at Saudi health-care settings is facilitated through assigning professional translators and through assigning native Arabic speaker to take the responsibility for the admission and discharge education. Language is also considered a barrier that poses difficulties in communication not only in admission and discharge phases, but also during providing routine and daily nursing care. Moreover, the patients were dissatisfied about the lack of availability of their physicians. The results agree with previous international study that found that patients were dissatisfied about not being able to locate doctors and about the admission process.19 The study also showed that patient’s demographic characteristics have minor influence on patient’s satisfaction with nursing care provided. The results support previous studies that patients’ satisfaction is multi-faceted factors, and a number of factors contributed to patients’ satisfaction that may include individual, institutional or environmental ones.5–7 One limitation of this study is that the sample has been recruited from regional hospital in which a multi-centre sample may provide more informative results.
CONCLUSION Many of the identified areas for quality improvement are related to nursing care. Therefore, nursing care should be recognized as an important element in patients’ perception of quality of care provided. This study showed that patients have high level of satisfaction with nursing care provided, although certain aspects of nursing care such as language, information giving and attentiveness were identified with lower rates. Language as a barrier should also be addressed, and decision makers should need to consider such barrier that affects patients’ perception of the quality of nursing care provided. There should be programmes and assessment tool that have to be used to reveal problems and issues related to language as barrier to quality nursing care. The study has an implication for nurses, health-care providers and administrators. Nurse leaders and health-care administrators need to maintain quality nursing care through periodic assessment and evaluation of all aspects of nursing care process. Moreover,
the results of this study suggest that nurse leaders and health-care administrators need to develop strategies to improve nursing care emphasizing teaching and information dissemination. Interventions should also emphasize attentiveness and importance of procedural nursing activities such as admission and discharge planning.
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