Chapter 2 Rrl
Transcript of Chapter 2 Rrl
CHAPTER 2
Review of Related Literature
A. Patient Satisfaction
Generally, patient satisfaction has been defined as the patient’s subjective
perception of care, which is usually an indicator of the “degree of congruency between a
patient's expectations of ideal care and his or her perception of the real care he or she
receives” (Ganova-Ioloska, et al., 2008). Most research has tried to correlate these with
socio-demographic variables, such as age, sex, the level of education, employment,
income, or marital status.
Patients are consumers, and what they purchase in a medical institution are both
products and services that are rendered primarily to keep them healthy and free of
harm. As consumers, one of the patient’s priorities is satisfaction with the purchase.
Among the services that patients evaluate is nursing care.
B. Nursing Care
Once, nursing mainly focused on keeping the body in a near homeostatic state
during illness. As innovation ushers more discoveries on the various aspects of health,
what was once the “humanitarian” act of nursing is now being transformed to a
“humane” profession. The idea that a purely physiologic nursing care is enough for a
patient is now replaced with the view that nursing care should be holistic, sensitive, and
meaningful. Nursing is inherently therapeutic and is differentiated from other medical
care by the personalization or individualization of care.
One of the oft-quoted nurse-theorists, Watson (1988), developed her own
checklist of nursing care components. These are: (1) Humanistic-altruistic system of
values; (2) Faith-hope; (3) Sensitivity to self and others; (4) Helping-trusting, human
care relationship; (5) Expressing positive and negative feelings; (6) Creative problem-
solving caring process; (7) Transpersonal teaching-learning; (8) Supportive, protective,
and/or corrective mental, physical, societal and spiritual environment; (9) Human needs
assistance; and (10) Existential-phenomenological-spiritual forces. Watson (2003)
concluded that what should define the nursing practice is the act of caring itself. Caring
can save the life of a patient, offer a death with dignity, and convey trust and
commitment to patients, families, and staff (Vance, 2003).
Studies have identified critical components of nursing care, which can be
categorized as: (1) tending to physiologic needs through technical skill (i.e., giving
medications, etc.), (2) nurse-patient interaction, including comforting, providing security,
and other psychosocial interventions, and (3) providing information.
Meade, et al. (2006) have found that smiles, humor, reassurance, kindness,
compassion, gentle touch, a nurse’s ability to anticipate the patient’s needs, and a
nurse’s physical presence are important considerations for the patient. Likewise, Wolf et
al. (1994) have found that respectful deference to others, assurance of human
presence, positive connectedness, and attentiveness to the other's experience were
also important elements.
On the Philippine front, the UP-PGH has provided a list of actual duties and
responsibilities of the nurse in terms of patient care, teaching, and research. These
items are as follows:
a) Accurately assess the nursing needs of patient through establishing rapport and
trust with the patients and significant others.
b) Obtain nursing history
c) Conduct a physical health exam
d) Be able to recognize the normal and abnormal findings from laboratory or
diagnostic exams.
e) Monitor and interpret vital signs.
f) Provide support measures like physical and psychosocial needs including dietary
regimen, comfort, hygiene, safety, and health teaching.
g) Maintain therapeutic environment.
h) Carry out doctor’s orders.
i) Formulate a nursing care plan through prioritization of health needs.
j) Evaluate the nursing care given and be able to make necessary revisions
through appropriate documentation of information relevant to patient are.
In addition, Laurente (1996) has defined, in her study of the effect of nursing care
in anxiety reduction, the following components of nursing care: presence (proximity,
active listening, therapeutic touch, verbal communication), concern (respectful attitude,
gentleness in handling, patience, various helping acts), and stimulation
(encouragement, guidance, smiling, compliment or praise).
C. Quality of Care
Azam, et al. (2008) have defined quality of care as “the degree to which health
services for individuals and populations increase the likelihood of desired health
outcomes and are consistent with current professional knowledge…the totality of
features and characteristics of a service that bear on its ability to satisfy a given need.”
Likewise, Leino-Kilsi (1989) has defined quality of care as “comprehensive, based on
patient’s needs, oriented to the patient as an individual, conducive to a sense of security
in the patient, forms a complex process, involves self- care on the part of the patient, is
based on certain philosophical foundations and contains certain situational factors”
(Collado, 1993).
More specifically, the perceptions of hospitalized adult medical-surgical patients
(n = 268) have been explored (Larson & Ferketich, 1993). Using the Care Satisfaction
Questionnaire, these researchers defined caring as intentional actions conveying
physical care and emotional concern and promoting a sense of safety and security. The
CARE/SAT instrument combined the CARE-Q scale (developed previously by Larson)
items with visual analogue scales and 21 new items to measure overall satisfaction with
nurse caring behaviors. Instrument reliability and validity were established. This phase
of instrument development was necessary to focus on the quality care issue of patient
satisfaction which could ultimately assist nurses to assess whether hospitalized patients
experience nurse caring. Larson and Ferketich correlated the CARE/SAT with the
modified Risser Patient Questionnaire (Hinshaw & Atwood, 1981) establishing construct
validity. This established that the instrument measured the theoretical construct.
Many studies have posited that the quality of care, nursing or otherwise, can be
appraised through patient satisfaction measures. It is from this view that this study is
conducted.
D. Measuring Patient Satisfaction with Nursing Care
In the past, quality of care was measured based on practice standards. But in
recent years, there has been renewed emphasis on the involvement of patients in the
evaluation of health care as manifested by the measurement of their satisfaction.
Various methods and tools have been utilized to measure patient satisfaction. They
have explored components such as the art of care/ interpersonal manner, technical
quality of care, inaccessibility/ convenience, finances of how the service is paid for,
physical environment, availability of providers, and continuity and efficacy/ outcomes
(Buban, et al., 2003).
The WHO (2000) has warned that the method should be aligned with objectives.
When exactly should these studies be conducted? There are those more
concerned with specific interventions, and, as such, they assess satisfaction
immediately after an intervention is performed. There are others concerned with the
degree of satisfaction upon discharge. Sulit (2007) found it convenient in the Philippine
setting to conduct the interviews right before discharge, while papers and bills were still
being addressed by watchers.
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Researchers have utilized telephone surveys (DiPaula, et.al., 2002), self-
administered questionnaires, and even structured interviews, as in the case of Haqq, et
al. (1999) whose sample consisted of mostly lower socioeconomic status individuals at
local health centers.
Several examples of tools include: (1) the Care Satisfaction Questionnaire
developed by Larson & Ferketich (1993) that combines questions with visual analogue
scales; (2) the Quality of Nursing Care Scale by Mabel Wandett that measures patient
satisfaction with art of care, technical quality of care, safety and protection,
communication; (3) the Patient Satisfaction Scale by Risser (1995); and (4) the
SERVQUAL tool by Azam, et.al. (2008) which measures reliability, responsiveness,
assurance, empathy, and tangibility.
Sulit (2007) has surveyed the tools used by hospitals in the Manila area and has
found that they are more hospital-oriented, and not specific to nursing care or medical
care. Her survey of the tools is provided below:
Table 1. Patient Satisfaction Survey Instruments in the Hospital Setting in Metro
Manila as Compiled by Dr. Vanessa Villaruz- Sulit (2007)
Instrument Description of the Survey Instrument Number of items
and type of Scale
Used
The Philippine
General Hospital
Department of
Private Patient
Services
Satisfaction Survey
The satisfaction survey focuses on 6 areas
which include (1) admitting procedure –
Promptness, courtesy, information
provision, and orientation to payward
policies; (2) room - cleanliness of room and
toilet, ventilation, linens, janitorial staff
courtesy and efficiency, room equipment
maintenance; (3) medical care- availability
of physician when needed, regular visits by
physicians, treatment and care; (4) nursing
28 items with a yes
or no response
scale
1 open- ended item
care- promptness, friendliness/ warmth,
politeness/ courtesy), efficiency and overall
nursing care; (5) billing procedure- bill
prepared on time, computation easily
understandable, staff courtesy and
efficiency; (6) other health services-
courteous and prompt and efficiency from
dietary/ food service staff, x-ray and other
radiology staff, ECG/ EEG technician,
medical technologist/ laboratory services,
physical therapists/occupational therapists,
operating room staff, and ambulant
services. Additional comments and
suggestions are requested at the end of the
form and one can also write down the name
of the employee who gave a satisfactory
performance. A question on why the
hospital was chosen is placed at the end of
the form.
Items were adopted from other forms.
Reliability testing and further evaluation of
the form still to be conducted.
Philippine Heart’s
Center’s Patient
Satisfaction Survey
A patient satisfaction survey form that
focuses on facilities and services rendered
by the medical, nursing, paramedical,
admitting/ information, dietary, billing,
security, cashier, janitorial, engineering/
maintenance, social service and medical
records staff. Each member is graded with
following in mind: interaction with clients,
17 items with a 4-
point response
scale
DS- dissatisfied
S- satisfied
DL- delighted
SP- surprised
promptness of reception and services,
expertise of staff, accuracy of services.
Facilities are graded based on comfort/
cleanliness/ orderliness of the waiting
areas, patient’s room, laboratory and
procedure units, public restrooms and
cafeteria.
Questions on why the hospital was chosen
and who completed the form were included
as well as an open- ended comments and
suggestions portion.
Items were suggested by a group of
experts. Items were validated based on
expert’s assessment. No other
psychometric information was provided.
East Avenue
Medical Center’s
Patient Satisfaction
Survey
This patient satisfaction survey form looks
into 4 general categories in the
hospitalization experience: (1) attitude of
hospital staff- doctors, nurses, nursing
attendants, admitting staff, janitors and
security personnel; (2) services rendered by
hospital staff; (3) services rendered by the
different departments in the hospital-
dietary, housekeeping, radiology,
laboratory, social service, pharmacy,
emergency room and janitorial; and (4)
other comments regarding the hospital-
open- ended questions on other services
that were preferred, services that were not
provided, and suggestions. At the end of the
27 items with a yes
or no scale and 4-
open- ended items
form, one can write down the name of the
hospital employee/s who have provided the
best service.
Items were suggested by a group of
experts. No other information on
psychometric properties was provided.
The Medical City’s
Patient Satisfaction
Survey
This patient satisfaction form rates the
following areas: (1) quality of service
(patient care/ preparation/ orientation &
briefing/ promptness) in the ER admitting,
nursing unit, food service, janitorial service,
billing, cashier, security, diagnostic
departments and others; (2) room
accommodation such as amenities, toilet &
bathroom, ventilation system, lighting &
communication system; and (3) staff
behavior
(courtesy/concern/accommodating) in the
areas listed in ly (1). Comments are asked
in every section. Questions on why the
hospital was chosen and who completed
the form were included.
Doctors were assessed separately on
frequency of visits, courtesy, ability to
provide on information and personality.
Overall questions were asked regarding
satisfaction to services, facilities and staff
attitude as well as whether one will come
back to the hospital or recommend the
30 items with a 3-
point response
scale
E- excellent
F- fair
P- poor
5 overall times with
a yes or no
response scale
hospital to others. At the end of the form
one can write down the names of
employees who provided outstanding
service.
Items were suggested by a group of
experts. No other information on
psychometric properties was provided.
Makati Medical
Center’s Patient
Satisfaction Survey
The feedback and comment form for in-
patients assesses patient satisfaction in 6
areas: (1) room or bed- functioning of TV,
cleanliness, comfort, toilet facilities, quality/
availability of linen, sense of security and
quietness; (2) administration- courtesy of
admitting staff/credit and collection staff/
cashier, bills prepared on time and
medicare service; (3) nursing service-
concern for comfort, promptness of service,
adequate information about treatment,
courtesy of staff and efficiency of work; (4)
food service- tastefulness, timeliness,
temperature, courtesy of food personnel; (5)
waiting time- in x- ray, doctors’ offices, visits
by attending physician, emergency room,
visits by residents and interns as well as
staff in x- ray, laboratory, emergency room,
pharmacy, housekeeping, maintenance and
other units. Towards the ends of the form,
an overall question on how you rate the
personal is asked as well as an open-
ended question on how to make the
36 items and 1
overall item with a
3- point response
scale
1- Exceeded
Expectations
2- Met
expectations
3- Did not meet
expectations
1- open- ended
item
patient’s stay better. One can also write
down the name of the person or a area that
warrants commendation.
Items were adopted from another
instrument and suggestions from a group of
experts were also included. No other
information on psychometric properties was
provided.
Asian Hospital’s
Patient Satisfaction
Survey
This patient feedback form focuses on 3
major areas of hospital service: (1)
business/frontline- admission, billing, guest
services desk and cashier; (2) clinical –
nursing care, laboratory, radiology, nutrition
and dietary and doctors; and (3) support
operation- housekeeping, security,
telephone services and plant operations.
Each section is graded according to
courtesy of staff, timeliness of service and
delivery of service except for laboratory,
nutrition/ dietary and doctors. Laboratory is
graded according to responsiveness of staff
to patient concern, communication of
relevant information, extraction of blood and
timeliness of result. Nutrition and dietary is
graded according to tastefulness of food,
timeliness, temperature of food, cleanliness
of utensils and courtesy of staff. Doctors
aside from courtesy and timeliness are
graded according to the medication/
treatment they provide and relay of
43 items with a 5-
point response
scale
1- excellent
2- good
3- average
4- below average
5- needs big
improvement
1- open- ended
item
information. Comments are requested at the
end of the form on how to serve the
patient’s better.
Items were adopted from instruments in the
US and suggestions from a group of experts
were also included. No information on
psychometric properties was provided.
E. Factors Affecting Patient Satisfaction with Nursing Care
The factors that affect patient satisfaction with nursing care can be categorized
as follows:
1. Quality of interpersonal relationship (i.e., communication, courtesy
and consideration, nurses' willingness to listen to patients'
explanations of problems, nurses' advice, smiles, humor,
reassurance, kindness, compassion, gentle touch, the ability to
anticipate needs, etc.) (Lange, 1999; Haqq et al. 1999; Meade, et
al., ?; Stutts, 2001; Dipaula, et al., 2002; Ambrose, 1998);
2. Skills and competence (Stutts, 2001);
3. Patient expectations and perception of fulfillment of these (Meade, et
al., 2006; Buban, et al., 2003);
4. Previous experiences (Buban, et al., 2003);
5. Waiting time (Haqq, et.al., 1999);
6. Staffing and continuity (Azam, et.al., 2008; Stutts, 2001; Ambrose,
1998);
7. Socio-demographic factors such as age and sex (DiPaula et.al.,
2002);
8. Health status (DiPaula et.al., 2002); and
9. Direct care time (DiPaula et.al., 2002; Macdonald, 2007).
Handelsman (1991) was able to determine what influences consumer satisfaction
with inpatient health care encounters. In this study, ninety inpatients were interviewed
and responded to 11 open-ended questions focused on consumer satisfaction with the
hospital stay. Four major themes were identified: consumer prepurchase attitudes
(previous past positive experiences and recommendations by physician, family, and
friends); consumer perceived consequences of health care (positive and negative
consequences of hospitalization); consumer perceptions of the health care provider
(provider behaviors that included caring behaviors and competency descriptions); and
consumer perceptions of the health care received (activities performed by providers that
made for satisfying encounters and included comfort measures, pain management, and
environmental factors [food service, housekeeping, etc]). Subjects accurately recalled
encounters with health care providers on follow-up interview. Handelsman pointed out
that consumer satisfaction could be influenced "at any time during or after an inpatient
health care encounter" (p. 122). In addition, Duffy (1990) conducted a correlational
study aimed at establishing relationships between nurse caring behaviors and patient
satisfaction, perceived health status, total length of stay, and nursing care costs. Eighty-
six randomly selected medical or surgical patients participated. The investigator
concluded that the more nurses exhibited caring behaviors, the more patients were
satisfied.
Greeneich developed a theoretical model inclusive of all these and further
categorized into three dimensions: (1) the nurse (inherent personality characteristics,
nursing care characteristics and nursing proficiency); (2) the patient (expectations); and
(3) the environment (nursing milieu) (Buban, et al., 2003).
Haqq, et.al. (1999) found that, in terms of courtesy and consideration, as
educational level increased, percentage of satisfied patients declined. In terms of skills
and competence, willingness to listen, nurses' advice, waiting time, satisfaction
increased with age. In terms of waiting time, satisfaction decreased with longer waiting
time
A study by Di Paula, et al. (2002), conducted to compare patient satisfaction in
the Emergency Department (ED) and individual nursing units (NU), corroborated with
the finding that satisfaction increases with the perception that the wait time is shorter
than the actual wait time.
In addition, they found that, in ED, satisfaction was affected by care and concern
shown by ED nurses, how quickly ED nurses responded after assistance requested,
and the ability of ED nurses to answer questions. In the NU’s, satisfaction was
influenced by care and concern shown by nursing staff, nurses' ability to answer
questions, how quickly nurses responded after assistance request, respect for privacy
shown by the nursing staff, how quickly nurses responded after pain medication
request, and instructions given by nurses about care at home (DiPaula, et.al., 2002).
Interestingly, there have also been studies that differentiate patient satisfaction
by gender. Ottoson (1997) on patient satisfaction in the surgical setting, noted that men
receive more information spontaneously from nurses compared with women, indicating
that there are also gender differences in satisfaction with men rating more positively.
While some studies, men tend to score higher than women, other studies showed an
opposite conclusion.
Ambrose (1998) on the other hand found the following as most significant to
female patients: (1) listening; (2) responding to the patient's uniqueness; (3) being
perceptive and supportive of the patient's concerns; (4) being physically present; (5)
having attitudes and displaying behaviors that made the patient feel valued as a human
being not as an inanimate object or a thing on display; (6) returning to the patient
voluntarily without being asked; (7) showing concern that is comforting and relaxing; (8)
using a soft gentle voice and mannerisms; (9) invoking feelings of security; and (10)
evoking patient feelings of wanting to reciprocate. For male patients, being physically
present so the patient felt concern as a valued person, returning voluntarily without
solicitation, making the patient feel comfortable, relaxed, and secure, attending to the
comfort and needs of the patient before doing tasks, and, using a kind, soft, pleasant,
gentle voice and attitude were important.
Thus, gender differences in rating satisfaction may still be existent but may not
be a strong determinant of satisfaction.
One study customized for patient satisfaction with peri-operative nursing is
Lumby & England’s (2000) “Patient satisfaction with nursing care in a colorectal surgical
population”. They used the SERVQUAL tool, originally designed for the manufacturing
industry, was customized in the US for the health care industry, and is now utilized
internationally as a valid measure of patient satisfaction. Dimensions included: (1)
tangibles (physical appearance of facilities, personnel, and materials), (2) reliability, (3)
responsiveness (willing to help customers/patients and to provide prompt service), (4)
assurance (knowledge, courtesy of employers and their ability to convey trust and
confidence), (5) empathy (provision of caring, individualized attention to
customers/patients). They utilized a triangulated method with in-depth interviews after
the initial questionnaire, thus gathering insight into the results of the questionnaire and
enabling clearer feedback. They found that age, sex and education levels were major
influences on individual perceptions of nursing care. Patients whose surgery resulted in
stomas were also less satisfied with health-care delivery. From the in-depth interview,
they found that, while the initial comment was generally that of satisfaction, the deeper
the interview delved, the greater was the expressed dissatisfaction across all the
service dimensions.
Leinonen, Leino-Kilpi, & Jouko (1996) conducted a study on the perspective of
patients on quality of intra-operative nursing care, and found that problems occurred
mainly in cognitive and experiential perspectives, such as the need for continuous
access to information and coping with the anxiety related to the impending surgery.
They also found that special attention must be paid to thermoregulation, emergency
patients, younger patients, and patients who only remain in the operating department for
a short period of time. Interestingly, they also found that patients' evaluations changed a
few weeks after discharge and were more critical.
Very appropriate to the Philippine setting and an area as yet unexplored is the
association between the experience of the surrogate (or watcher) and the level of
satisfaction. Sagert (1991) explored surrogates’ perceptions of their experience as well
as reactions/attitudes, and responded to six satisfaction questions on: RN Care, RN
Communication, Doctor Management, Doctor Communication, Waiting Room, and
Treatment as a Relative. The greatest degree of satisfaction was with RN Care (92%)
and the least was with Doctor Communication (59%). There was no association
between extent of patient recovery (full, partial, very limited) and surrogate satisfaction
(p $>$.20).
Ever the vigilant standard-bearer, the WHO (2000) warned that “client
satisfaction with treatment processes may both influence, and be influenced by,
treatment outcomes.” “Clients who are not satisfied with a service may have worse
outcomes than others because they miss more appointments, leave against advice or
fail to follow through on treatment plans. On the other hand, clients who do not do well
after treatment may have less than favorable attitudes towards a treatment service,
even if it was of high quality by other criteria.”
F. Limitations/Issues in Measuring Patient Satisfaction
The WHO (2000) advised, “Your strategy for selecting clients for a satisfaction
survey can influence the kinds of results you obtain. If the surveys are limited to clients
who complete treatment, the results will probably differ from those obtained in surveys
that include people who have dropped out of the program. If the objective is to learn
about client satisfaction among those who complete treatment then there will be no
need to involve treatment dropouts. However, if the aim is to find how, in general, clients
feel about the programme, a representative sample of all clients completing the intake
process would be more appropriate.”
Other issues can be summed as follows:
1. first impressions or the carry-over effect among staff and units, i.e. a
bad encounter with one nurse may influence the perception of
nursing care in general (DiPaula, et.al., 2002);
2. unrealistic expectations of patients (WHO, 2000);
3. the problem with constructs or the "chameleon effect", in which the
exact meaning and interpretation of satisfaction differs for each
situation (L&Cote, 2000);
4. that satisfaction in and of itself does not necessarily result in
improved health status (Ervin, 2006); and
5. that surveys conducted at the end of care do not allow for
individualization, i.e. satisfaction should be measured before care is
completed in order to tailor to the needs of the patient instead of
generalizing results for future patients (Ervin, 2006).
G. Patient Satisfaction with Nursing Care in the Philippines
How can Philippine nurses assure quality of care, despite the nation’s dwindling
budget for health care and the rising costs of almost every necessity?
Several Patient satisfaction studies have been conducted locally. A local study
on the assessment of patient satisfaction at the OPD of Far Eastern University –
Nicanor Reyes Medical Foundation Hospital used a patient satisfaction questionnaire
patterned from the Patient Satisfaction Questionnaire III by Ware et al. and translated
into Filipino. This study however, was more concerned with the satisfaction of patients
with care provided by doctors than by nurses. Pedres (2002) explored the effect of
modular nursing on patient and staff satisfaction at the Davao Doctors Hospital.
However, patient satisfaction was measured by using an instrument adapted from a
foreign source.
In the Philippine General Hospital, several departments have attempted to
measure or rather evaluate nursing care and measure patient satisfaction. The
Philippine General Hospital’s Nursing Service has been developing its own evaluation
system for nursing care. They measure performance of nurses through a performance
evaluation report that is accomplished through self-assessment and assessment by
other nursing colleagues and the head nurse. The PGH Department of Pay Patient
Services on the other hand has come up with a survey form to measure pay patients
satisfaction with hospital services.
Most of the studies in the past have measured patient satisfaction by using an
instrument adapted from a foreign source.
No local tool has been made in the past to measure patient satisfaction until in
her master’s thesis, Sulit (2007) constructed a tool to measure the satisfaction of
Filipino patients at the Philippine General Hospital (PGH). In Phase One, she conducted
a qualitative review of nine patients and their respective watchers to find themes in
patient satisfaction. She pre-tested with 186 patients in phase two and then conducted
the actual survey with 236 patients in phase three. She found the four following roles of
the nurse as influential to patient satisfaction: (1) the nurse as a member of the health
care team; (2) the nurse as a caring person; (3) the nurse as a competent and skilled
health care provider; and (4) the nurse as an information provider.