Inpatients satisfaction with nursing services at king khalid university hospital, riyadh, saudi arabia.

UNLABELLED: Recent development and changes in health care services in Saudi Arabia have encouraged a search a search for comprehensive and established measurements of the quality of care. Patient satisfaction with nursing care in particular has ferquently been used as a sensitive and objective measure of quality of hosiptal services.
OBJECTIVES: THE OBJECTIVES OF THIS STUDY ARE: (1) to assess the level of inpatient satisfaction with nursing care (PSWC) in the various wards of the hospital; (2) to assess the socio-demographic determinants of PSWC in addition to the effects of duration of hospital stay and type of wards on the level of satisfaction.
METHODS: The sample consisted of randomly selected 450 inpatients with probability proportion to the size of the wards. The data was collected by personal interviews using a 21-item structured questionnaire pertaining to nursing services.
RESULTS: The results revealed that the instrument of measurement was valid and reliable. The overall mean satisfaction score was 2.4 (77%) and the highest mean satisfaction was for items on skillfulness and the lowest score was for communication items. Multiple regression analysis indicated that sex, age, marital status and duration of stay are the most imortant predictors of PSWC; female, young, married and short duration of hospital stay have the highest satisfaction score.
CONCLUSION: In conclusion, this study has highlighted the aspects of nursing care at King Khalid University Hospital (KKUH) which need re-examination by the management. The most importance findings have been that there is: (1) a shortage of nurses at the hospital; (2) limited communication between nurses and patients: most probably due to cultural and language barriers; (3) no proper oversight of patients personal hygiene; (4) dissatisfaction of male patients with most of the nursing care rendered. These results offer the hospial management the opportunity to work out stategies to connect the deficiencies highlighted.

INTRODUCTION

As care delivery institutions hospitals are always faced with the challenge of providing the quality of care that meets the expectation of its clients. As a service industry, it is expected to provide its customers with quality of care they need. Patient satisfaction is an important component of the quality of care. Satisfaction is a function of the discrepency between what is expected and what is perceived to be actually occurring.1 Therefore, it is imperative for hospital managers and administrators to identify patients’ perceptions and expectations of the quality of care, from time to time and to asess the extent to which these ideals are met by their institutions. Various studies have concluded that satisfied patients are more likely to continue using the medical care service, to maintain the relationship with a specified provider and to comply with medical regimen.2

Patients’ expectations as a set of preconceived notions about type of care anticipated, tend to be formulated around a variety of dimensions among which are the hospital environment, admission and discharge procedures, nutrition and housekeeping services and physician and nursing care. Out of these, nursing care occupies a critical position in molding patients’ perception of quality of care.34 Indeed, several research findings have pointed out that patients’ perceptions of the quality of care tend to be related to their interpersonal interaction with the care givers.4–8

In the provision of health care, nurse-patients interactions predominate over those with either physicians or other hospital personnel. A study by Cleary et al4 found nursing care to be the most important factor for evaluation of patients’ satisfaction with care. Cleary's finding was supported by results from a survey conducted by Koska7 where 97.3% of 663 chief executives interviewed ranked nursing care as the top factor in quality of patient care.

Because quality patient care is considered essential to instiutional survival, it is an attribute sought after by hospitals and emphasized by administrators.9–13 A study comparing patient perception of quality care and patient satisfaction with quality care found that failing to meet the expectations of quality was synonymous with poor quality and resulted in patient dissatisfaction.14 Patient satisfaction with nursing care was found to be an important predictor of overall satisfaction with hospital care.15

A recent study on quality improvement, compared nurses’ and pateints’ definitions of quality and the values each placed on different aspects of care.13 The values held by patients were found to be different from the values health professionals thought were held by pateints. Young and colleagues13 suggested that the organizational culture of the unit, driven by the values of the nurse manager and unit staff, may have reinforced differences between patient and caregiver values. As a result of this study, there was an effort to transform the unit culture to support aspects of care valued by the patients.

The present study was initiated at King Khalid University Hospital (KKUH) to assess: (1) the level of inpatient satisfaction with nursing care (PSWC) in the various wards of the hospitals; (2) the socio-demographic determinants of PSWC in addition to the effects of duration of hospital stay and the type of ward on the level of satisfaction. To he best knowledge of the author, this is the first study in Saudi Arabia, that has focused on nursing care in appraising patient satisfaction.

MATERIAL AND METHODS

The study was conducted at King Khalid University Hospital (KKUH), Riyadh, during the period from October 1995 to March 1996 on various aspects of services rendered to inpatients admitted in the hospital. The hospital, established in 1982 provides free medical services to eligible patients. The average daily census is 547, average occupancy rate is 81, average turnover interval is 2, bed productivity is 4, average of length of stay is 5 and beds available are 701. There are six wards in the hospital (Medical male, Medical female, Surgical male, Surgical female, Obstetrics and Gynecology and Pediatric). The study population consisted of all patients admitted as inpatients. The criteria for inclusion were that (1) the patient should have been in admission for at least 3 days, (2) consent to be interviewed should be given. Since the establishment of KKUH, there has been no evaluation of the quality of care delivered by nurses to patients admitted to variuos wards in the hospital. The questionnaire used to collect information from inpatients included 83 questions relating to various aspects in the hospital, out of which 21 pertained to nursing services. These questions were compiled from several researches on patients’ perception of quality of care.7–12 For pediatric patients too young to be interviewed, the person attending to the patient, from his family, was interviewed. Informed consent was obtained from each respondent before the conduction of an interview, and assurance of the confidentiality of responses given. A simple random sample of 450 patients was selected from the different wards with probability proportional to size of a ward. The department of patient affairs collected the data.

The aim of the present study was to assess inpatients’ satisfaction with nursing services at KKUH based on the respondents’ replies to the 21 items pertaining to nursing care on a three-point scale of very satisfied, somewhat satisfied and dissatisfied.

Statistical Methods

The statistical methods used in the analysis of the data included the Chi-Square test to investigate the association between duration of stay in hospital and ward of admisison. Multiple regression analysis was undertaken, with the mean score of satisfaction being the dependent variable and sociodemograhic, wards and duration of stay as the dependent variables. Student's t-test and ANOVA were used for the comparisons of distributions of interval data for two or more than two independent groups, respectively. Data was analyzed using SPSS package.

RESULTS

Results relating to patients’ satisfaction with various nursing services are shown in Table 1. The highest mean satisfaction score was obtained for patient prepared for medical investigation (2.72) and for patient being placed in bed (2.67). The lowest mean satisfaction score was obtained for nurses’ attention to patients’ cleanliness (1.73) and for listening to and talking to patients (1.81).

Table 1

Patient satisfaction with nursing care at King Khalid University Hospital

Table 2 summarizes the mean level of satisfaction for socio-demographic variables. Females tended to be more satisfied (2.47) than males (2.16). Saudi and non-Saudi exhibited the same level of satisfaction. Education, marital status and age were significantly related to satisfaction with nursing services. Those with university degree reported higher levels of satisfaction (2.41), while patients with lower education level showed lwer level of satisfaction (2.21). Elderly patients showed lower level of satisfaction (2.14) than younger groups. The marrieed were more satisfied (2.41) than single individuals (2.25). Regarding duration of stay, patients who stayed for more than two weeks showed less satisfaction (2.19) compared to patients who stayed for less than 1 week (2.46). With regards to wards, the highest mean satisfaction score was obtained for Obstetrics (2.64) and the lowest was for Male Surgical Ward (2.10).

Table 2

Analysis of variance to identify the effects of different variables on patient satisfaction with nursing care

The influence of sociodemographic factors on patients’ satisfaction with the nursing services was also investigated further by regression analysis and the results are shown in Table 3. The strongest predictor variable that influenced mean satisfaction was sex. Females had a mean satisfaction score of 0.187 more than males. The second variable was marital status. Married patients reported higher satisfaction score than patients who were single (0.186). The third variable to influence mean satisfaction was age, with older patients rating their satisfaction lower than the younger. The fourth variable was duration of stay. The fifth variable was the type of ward. None of the other independent variables were significantly associated with nursing services. The set of independent varaiables included in this equation accounted for 53% of the variation in mean satisfaction in the led services.

Table 3

Multiple regression analysis to identify the effects of different variables on patient satisfaction with nursing care

DISCUSSION

Recently, patient satisfaction with nursing care has become a subject of interest to many researchers and administrators. Moreover, it is an indicator of the hospital's accountability to the society and a marker of the quality of health services offered. Nurses have longer contact with inpatients compared to any oher health professionals. Therefore, patient desires and expectations for nursing care warrant scrutiny because of their potential influence on hospital care utilization, patient satisfaction and patient's perception of quality of care. This has urged researchers to develop reliable and valid scales for appraising patient satisfaction with nursing care (PSWC). Mc Donald and Nash reviewed 21 current PSNC instruments in a compendium, which provides information on the developer, the date of publication or first use, types of items and sub-scales, mode of administration, reliability, validity, formulas and availability.16 The most common used scales are the Newcastle Satisfaction Nursing Scale (NSNS)17 and La-Obert patient satisfaction scale.18 The selection of a scale for measuring PSNC depends on several factors among which are the underlying theoretical models and theories of patient satisfaction, local circumstances and cultural aspects, in addition to patient perception of, and quality of nursing care. Therefore, the self-administered questionnaire used in this study is a modified version of several validated scales of measuring PSNC. Oviously, the first logical step was to measure the quality of the scale in terms of reliability and validity. The content validity of the scale was reviewed by fiver experts in the field from the Department of Nursing, and the College of Applied Medical Sciences at King Saud University. It was found that the scale covered all the essential components of hospital nursing care in a Saudi context. Additionally, the reliability of the scale was measured. The internal consistency of the major sub-dimensions and the overall scale was high with Cronbach's alpha ranging from 0.81 to 0.91.

The overall mean PSNC was found to be 2.3 amounting to 77%. This figure is comparable to few studies and lower than other studies particularly in similar Arab cultures.19 This difference could be genuine and might be explained by the fact that the majority of nurses are fom non-Arabic speaking countries, which hinders fluent communication with patients. However, Sargeant20 stated that it was difficult to interpret this wide divergence in range without adequate iformation about such aspects as the methodology used, study population, the characteristics of the heal th systems and socio-cultural values and attitudes. Other authors argue that patient satisfaction with nursing care is determined by many other factors including job satisfaction of nurses, nursing care delivery models, organizational structures, supportive environment, patients’ perception of nurses, nurse-patient ratio and inability to discriminate nursing care from the rest of their overall patient experience. Based on this information, the authors question the accuracy of the measurement of patient satisfaction and raise issues that need to be considered, in order to further clarify the measurement of this concept.21–23

With all diverse theories, models of training and methods of nursing, two aspects of nursing remain constant: the need to care and the need to communicate. Both are essential to the process of nursing.24 The conduct of interpersonal communication must meet individual and social expectations whether these aid or hamper technical performance.25 In the present study, the perception of skill “skillfulness” with respect to nursing care was conceptualized in gentleness. The preparation of a patient for medical investigations and the placing of a patient in bed obtained the highest satisfaction score. This might be explained by the fact these skills rely heavily on manual and manipulation skills with minimal requirement of communcation skills.

On the other hand, the lowest satisfaction was with nurses’ attention to patients’ cleanliness and for listening to and conversing with patients. It is clear that longer interaction with patients in a two-way communication is required for these skills to be manifest. This is difficult for nurses in KKUH for whom language is a barrier. The vehicle for the implementation and success of technical care is nurse-patient communication. Findings from international studies have revealed that the highest satisfaction scores for nursing care were obtained for nurses’ interpersonal skills such as sense of humor and teaching behavior.26–28 This suggests that patients perceive these skills as an important indicator of the quality of nursing care. Therefore, the recruitment of nurses from Arab-speaking countries and the training of indigenous nurses in the long-term are strongly recommended. In the interim, foreign nurses must be given an intensive Arabic course and communication training. Additionally, the existing curricula must concentrate on communication and inter-personal skills training.

Views of inpatients were uncertain about the adequacy of the number of nurses allocated to the various wards. Some (29%) felt there were not enough nurses at the hospital but the remaining 36.4% believed there were enough. Only those in the pediatric and obstetrics and gynecology wards were satisfied with number of nurses attending to them. The almost equal split of opinions among inpatients interviewed about the adequacy of the number of nursing staff assigned to the various wards may be a clue to the management, for a need to review the number of nurses available and institute better allocation between the wards. However, if the number for some wards is found to be inadequate a nursing recruitment drive could be undertaken to allevaiate the shortage.

Results in Table 2 have highlighted that patients in male wards have the least mean satisfaction score while obstetrics and gynecology and pediatric patients tended to have the highest mean satisfaction score with nursing services rendered to them. A number of factors might be responsible for the above phenomenon. First of all, Saudi culture restricts communication between males and females except for spouses, and close relatives. Secondly, since the majority of nurses at KKUH are females, and can be assigned to either female or male wards, it is likely that male patient would be able to communicate freely with or relate to female nurses, ad this could be interpreted as dissatisfaction. Furthermore, the inability of many nurses to communicate effectively in Arabic might have further worsened the patient-nurse interaction.

It is likely that the duration of stay in hospital influenced patients’ attitudes about quality of nursing care. As revealed in Table 2, inpatients who stayed longer in hospital, were more dissatisfied. Patients admitted to the female surgical ward and the obstetrics and gynecology ward had the shortest stay of 3-7 days while those admitted to the pediatric, the male surgical and medical wards tended to stay longer than one week. The lack of satisfaction here could be attributed to the psychological impact of the disease itself, adoption of the “sick role”, shortage of nursing staff in those wards or the reflected negative attitude of nurses towards longer stays, or chronic cases.29

As shown in Table 2, the results of this study appear to reveal a consistent pattern of association between the overall satisfaction and the studied socio-demographic variables except for nationality. Females tended to be more satisfied with nursing care then males. A literature review revealed contradictory findings. One study states that males were more satisfied,24 while other studies as the present one revealed that females were more satisfied.30–32 Further studies found that there was no association between sex and satisfaction with nursing care.33 This finding could be explained by cultural reasons in the lack of interaction between male patients and female nurses as discussed earlier. Married women reported higher satisfaction score than single women. This finding is comparable to a previous study in Riyadh which measured overall patient satisfaction.34 Older subjects are generally more conservative and les demanding than younger people.35 In contrast, our study found that older patients were less satisfied with their nursing care. This might be explained by the fact that older patients were too conservative to interact with female nurses in the Saudi culture. Other studies found similar association.3233 There was also an association betwee education and patient satisfaction. Those with university degrees reported higher levels of satisfaction compared to those with a lower level of education. This might be explained by the ability of educated patients to communicate with nurses in English. Findings from some studies revealed the reverse,36 while other studies did not find any association between education and satisfaction with nursing care.3233 Multiple regression analysis suggests that a short hospital stay, being female, married and young were the strongest predictors of patient satisfaction with nursing care. In this study, these variables contributed to 53% of the total variation. Tucker reported only 5% of the variability.33

In conclusion, this study has highlighted the aspects of nursing care at KKUH which need to re-examined by the management. The most important findings have been that: (1) there is a shortage of nurses at the hospital; (2) there is a limited communication between nurses and patients: most probably due to cultural and language barriers; (3) the personal hygiene of individual patients was not supervised; (4) male patients were dissatisfied with most of the nursing care rendered. Short hospital stay, being a female, married, young were the most predictors of patient satisfaction with nursing care. These results offer the hospital management the opportunity to work out strategies for improvement.