Comparison of patients' and nurses' viewpoints about responsiveness among a sample from public and private hospitals of Isfahan.

BACKGROUND: Health systems search for ways of making their services more responsive to patients and the public The new framework of the World Health Organization (WHO) for assessment of health system performance has determined health, responsiveness and fairness of financing as the main goals. This study aimed to compare patients' and nurses' view points about responsiveness among a sample of public and private hospitals of Isfahan, Iran.
METHODS: A descriptive study was conducted on 160 nurses and also equal number of patients. Data were collected by a valid and reliable questionnaire designed by WHO. Data were analyzed using SPSS software. Scores were reported as mean (standard deviation).
RESULTS: Mean score of responsiveness was 2.4(0.58) in nurses and 2.3(0.54) in patients but the difference was not statistically significant (out of a maximum of 4). The corresponding figures were significantly different (p = 0.009) regarding patients' viewpoints in public [2.2(0.4)] and private hospitals [2.3(0.5)].
CONCLUSIONS: Proper satisfaction about responsiveness was not provided in studied hospitals, based on the nurses' and patients' points of view. Public hospitals, in spite of their high costs, had a worse situation about responsiveness; the improvement of this situation necessitates managerial policies.

Responsiveness is one of the main goals of health systems which is very important to policymakers and managers. Therefore, health systems throughout the world are searching for the methods and ways in order to make their services more responsive to patients and public.1

Considering that the World Health Organization's (WHO's) new framework for health system performance assessment applies health, responsiveness and fairness of financing as three goals of the health system,2 these concepts are being increasingly more important. Responsiveness in the context of a system can be defined as the outcome that can be achieved when institutions and institutional relationships are designed in a way that they are cognizant and respond appropriately to the universally legitimate expectations of individuals.3 Indeed, responsiveness applies to the ability of health system to meet the individuals’ legitimate expectations for non-health aspects of the health system. “Legitimate” is defined as conforming to recognized principles or accepted rules and standards.3

Responsiveness also concerns satisfaction. In addition, patient satisfaction with non-medical aspects of care is often associated with better compliance with treatment instructions, prompt seeking of care and a better understanding and retention of medical information.4 Thus, it can be concluded that responsiveness includes two major components: (a) respect for persons including dignity, confidentiality and autonomy of individuals and their families to make decision about their own health; and (b) client orientation including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider.2

Responsiveness can be viewed with two different approaches: First, the user of health care system who is often portrayed as a consumer with greater responsiveness being perceived as a means of attracting consumers. Second, responsiveness is related to protecting patients’ rights in order to access adequacy and timely care.3

Responsiveness is not a measure of how health system responds to the health needs which shows up in health outcomes. Responsiveness is a measure of how the system performs relative to non-health aspects, meeting or not meeting a population's expectations of prevention, care or non personal services.5

The responsiveness model accepted by the WHO has 8 elements as non-medical aspects of health care which were picked through a review of the literature, examining surveys relating to patient satisfaction, and discussions with researchers from different disciplines involved in health sector research.3 These 8 elements are as follows:

Dignity: Being shown respect or having physical examinations conducted in privacy.

Autonomy: Being involved in deciding on your care or treatment if you want to. Providers ask for your permission before starting treatment or tests.

Confidentiality Having Conversations with health care providers where other people cannot overhear. Having your medical history kept confidential.

Communication: Having health care providers listen to you carefully, and explain things so you can understand.

Access to social support networks: Being able to have family and friends bring personally preferred foods, soaps and other things to the hospital during the patient's hospital stay. It also means to be able to observe social and religious practices during hospital stay.

Quality basic amenities: having enough space, seating, furniture, clean water and fresh air in the waiting room or wards. In general, it means to have a clean facility.

Choice of health care provider: Being able to get to see a health care provider you are happy with.

Prompt attention: Getting care as soon as wanted. Having short waiting times for tests being done.6

In a study conducted by Dickert and Kass, patients believed that respecting persons incorporates the following major elements: empathy, care, autonomy, provision of information, recognition of individuality, dignity, and attention to needs.7

The responsiveness level of health care systems of 191 members were estimated and compared based on the WHO tool. Scores obtained from the countries were also adjusted according to some characteristics such as the level of freedom and development, and also male/female ratio of the countries. In this report, the responsiveness level of Iran health care system was estimated as 5.10 and was ranked in the 100th place in the world health report (WHR) in 2000. This is the only estimation available about Iran.5 Although no research was found about hospitals responsiveness in Iran, the Ministry of Health has considered this issue in Iran health map according to third and fourth development plans.8

Considering the above mentioned facts, the WHO should encourage all its member states to regularly monitor their own health system performances. This way, it would help ensure their ownership and use of evaluation methods, the inclusion of national trend assessment and sub-national variations, and the formulation of policies which fit the local context. Furthermore, the health system is a set of several subsystem components such as human resources, hospitals and public health programmers. Understanding the performance of various key components will make policy recommendations more specific. For example, the performance of hospital sector, which takes up more than half of national health resources, should be rigorously assessed.9

Considering the importance of measuring responsiveness in health systems, this study was aimed to measure responsiveness in selected public and private hospitals of Isfahan based on patients’ and nurses’ viewpoints.

Methods

This research was done by means of a questionnaire to measure score of responsiveness in 8 selected public and private hospitals of Isfahan in 2009. The validity and reliability of this questionnaire was confirmed by the WHO. The validity of the translated version of the questionnaire was confirmed by the experts and its reliability was evaluated (alpha = 0.89). A Likert scale from 0-4 was used for ranking. This questionnaire had 32 questions in 8 parts including dignity (8 questions), autonomy (4 questions), confidentiality (2 questions), prompt attention (3 questions), access to social support networks during care (2 questions), communication (8 questions), quality of basic amenities (3 questions) and choice of care provider (2 questions). The study population consists of 160 nurses and 160 patients (totally 320 people) who were selected through stratified randomized sampling. Only nurses and inpatients participated in the study and all other staff and outpatients were excluded. Data were analyzed by means of SPSS software. Student's t-test was used to compare numerical values.

Results

This study included 320 respondents, i.e. 160 (50%) nurses and 160 (50%) patients. The mean score of responsiveness was 2.3 (0.54) among nurses and 2.4 (0.58) among patients. No significant differences were shown between their viewpoints (f = 0.97, p = 0.3).

Analyzing responsiveness elements scores showed that except for “choice of health care provider”, scores of all elements in patients group were higher than nurses group. While the nurses gave the highest score to “confidentiality” and the lowest to “quality basic amenities”, “dignity” had the highest and “choice of health care provider” the lowest scores in the patients (Table 1). There was no significant difference between sex, education and responsiveness scores in the two studied groups (Tables 2 and 3).

Table 1

Elements scores for patients’ and nurses’ viewpoints in all hospitals

Table 2

Comparison of responsiveness scores of hospitals based on gender

Table 3

Comparison of responsiveness scores of hospitals based on education

There was a significant difference between responsiveness scores in public and private hospitals based on the patients’ viewpoints (f = 7.08, p = 0.009). However, no significant difference was found in nurses’ responsiveness scores in public and private hospitals (f = 0.6, p = 0.4) (Table 4).

Table 4

Total scores of responsiveness in public and private hospitals (out of 4)

Discussion

Health systems in many countries are searching for ways of making their services more responsive to patients and the public. Considering this fact that responsiveness is of a great importance, this study was designed to measure the level of responsiveness in selected hospitals of Isfahan. The nurses’ and patients’ opinions about responsiveness were 2.3 (0.54) and 2.4 (0.58) (from a maximum of 4), respectively.

In the WHR in 2000, the WHO estimated responsiveness level of different countries where Iran was ranked the 100th among 191 countries (with a score of 5.10 out of 10).5

Although no significant difference between nurses’ and patients’ views was found in our study, another study that conducted in China showed that there was a statistically significant difference between nurses’ and patients’ perceptions of quality of nursing care. Findings indicate that nurses and patients had different views about the quality of nursing care, because they may have had different standards and ways in which they viewed these characteristics of care.10

In the present study “confidentiality” and “dignity” scored the highest among nurses and patients, respectively. Similarly in a study including managers, hospital administrators and chief nurses as the study population in Turkey, “confidentiality” attained the highest score among the others.11

Based on the results of this study, patients assessed all responsiveness aspects higher than nurses except for “choice of health care provider” which is a challengeable issue and vary in different countries. In a study that was conducted in 8 European countries with the aim of addressing European people's views on responsiveness, it became clear that the majority of respondents desired to be able to choose their health care providers, while most of them felt like they did not have enough information to make an informed choice. The demand for choice of provider was very high everywhere except Sweden. However, it was not entirely cleared why the results were different in Sweden. Coulter and Jenkinson argued that Swedish people tend to go to hospitals administered by their local county council rather than further afield, and perhaps people are satisfied with this restriction.1

The scores of overall responsiveness by male and female respondents (nurses and patients) were not statistically different. On the contrary, a Turkish study showed that female respondents found Turkish health care system less responsive and gave lower scores compared to male respondents.11 In addition, the results from t-test in our study showed that overall responsiveness scores did not statistically differ by education.

Similar to the present study in which patients considered private hospitals more responsive, Pongsupap conducted a study in Bangkok and reported that private clinics, but not private hospitals, were significantly more patient-centered and responsive to patients.12 In another study performed by Taner, results indicated that inpatients in the private hospitals were more satisfied with service quality than those in the public hospitals. The results also suggest that inpatients in the private hospitals were more satisfied with doctors, nurses and supportive services than their counter-parts in the public hospitals.13

The authors declare no conflict of interest in this study.