Patient Satisfaction RRL 3-28-09.doc

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					Patient Satisfaction

         Hinshaw and Atwood viewed patient satisfaction in 1981 as the patient’s opinion of the care
received from nursing staff working in hospitals. 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. Thus, one of the patient’s priorities is satisfaction with the services they purchase in a
medical institution.

        There are several theories made to explain to us what patient satisfaction truly is. Perneger TV
(2004) in an article in Adjustment for patient characteristics in satisfaction surveys, International Journal
for Quality in Health Care presented a theoretical model to understand patient views of satisfaction.
Such model is presented below:

         Oliver in 1993 on the other hand presented a theoretical model dealing with the cognitive,
affective, and attribute bases of the satisfaction response by patients.
        With these in mind, medical institutions are measuring the satisfaction of their patients with
various tools and methods. In addition, numerous researches are being made to determine what
influences, components and factors of patient satisfaction such as the one conducted by Buban, et al. in
2003. Their research has 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.

        Factors determined through these researches 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,, 1999);
            6. Staffing and continuity (Azam,, 2008; Stutts, 2001; Ambrose, 1998);
            7. Socio-demographic factors such as age and sex (DiPaula, 2002);
            8. Health status (DiPaula, 2002); and
            9. Direct care time (DiPaula, 2002; Macdonald, 2007).

        Interesting relationships were also found in these researches. For example, Haqq and
colleagues in 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 finding, which is that satisfaction increases with the perception that the wait time is shorter
than the actual wait time, was also seen in the study conducted by Di Paula and colleagues in 2002 that
aims to compare patient satisfaction in the Emergency Department (ED) and individual nursing units

         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,, 2002).

         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).

        Interestingly, there have also been studies that differentiate patient satisfaction by gender.
Ottoson in 1997 explored patient satisfaction in the surgical setting. The researcher 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.

        On the other hand, Ambrose in 1998 found several activities that are significant to each gender.
For example, the following were the 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.

         Several questions also came out when it comes to the administration of methods and tools that
will measure patient satisfaction - questions such as “When exactly should be these studies conducted
or how 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.
Some are concerned with the degree of satisfaction upon discharge. For example, Sulit in 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. Rafii on the otherhand in 2007 conducted the data
gathering while the patients are still hospitalized.

       Others such as DiPaula and colleagues on 2002 utilized telephone surveys and self-administered
questionnaires. Haqq and colleagues in 1999 used structured interviews at individuals in local health

        Through time, such researches resulted in the formulation of tools that could measure the
degree of patient satisfaction such as (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, (2008) which measures reliability, responsiveness, assurance, empathy,
and tangibility. These tools are able to measure patient satisfaction by evaluating patient’s perception
on the care provided to him in the hospital as a general.

          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.

         Nursing, a profession blooming in its critical analysis of its role among the health care
professions, is recently being considered as something that affects a patient’s satisfaction in a medical
institution. In an investigation of the relationship of patient satisfaction with nursing care, Mahon
(1996) concluded, “Quality of care as measured by patient satisfaction is most closely tied to patient
satisfaction with the quality of nursing care because most health care is nursing care”.

         To support the previous idea, Larson and Ferketich in 1993 explored the perceptions of
hospitalised adult medical-surgical patients with nurses’ care by using the Care Satisfaction. The results
implied that patients can respond objectively to questions about the caring dimensions of their nursing
care, but these responses do not necessarily translate into an indicator of patient satisfaction

         Valentine in 1997 reviewed professional nurse caring as a holistic nursing process and related it
to cost of services. Results indicated that patients were concerned about humane treatment as
compared to cost, convenience and time of care. Nursing services and nurse attitudes strongly
influenced patient satisfaction, leading Valentine to the conclusion that consumers’ choices of where to
seek health care were influenced by positive experiences with nurse caring behaviors.

        In the local scene, Sulit has surveyed the tools used by hospitals in the Manila area in her thesis
made last 2007. She found out that the tools used 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 The satisfaction survey focuses on 6 areas which           28 items with a yes or
Hospital                   include (1) admitting procedure – Promptness,          no response scale
Department of Private      courtesy, information provision, and orientation to
Patient Services           payward policies; (2) room - cleanliness of room and 1 open- ended item
Satisfaction Survey        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 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

                          Items were adopted from other forms. Reliability
                          testing and further evaluation of the form still to be
Philippine Heart’s         A patient satisfaction survey form that focuses on      17 items with a 4-
Center’s Patient          facilities and services rendered by the medical,         point response scale
Satisfaction Survey       nursing, paramedical, admitting/ information,
                          dietary, billing, security, cashier, janitorial,         DS- dissatisfied
                          engineering/ maintenance, social service and             S- satisfied
                          medical records staff. Each member is graded with        DL- delighted
                          following in mind: interaction with clients,             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    This patient satisfaction survey form looks into 4           27 items with a yes or
Center’s Patient       general categories in the hospitalization experience:        no scale and 4- open-
Satisfaction Survey    (1) attitude of hospital staff- doctors, nurses,             ended items
                       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 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
The Medical City’s     This patient satisfaction form rates the following           30 items with a 3-
Patient Satisfaction   areas: (1) quality of service (patient care/                 point response scale
Survey                 preparation/ orientation & briefing/ promptness) in
                       the ER admitting, nursing unit, food service,                E- excellent
                       janitorial service, billing, cashier, security, diagnostic   F- fair
                       departments and others; (2) room accommodation               P- poor
                       such as amenities, toilet & bathroom, ventilation
                       system, lighting & communication system; and (3)             5 overall times with a
                       staff behavior (courtesy/concern/accommodating)              yes or no response
                       in the areas listed in ly (1). Comments are asked in         scale
                       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 hospital to others.
                       At the end of the form one can write down the
                       names of employees who provided outstanding

                       Items were suggested by a group of experts. No
                       other information on psychometric properties was
Makati Medical             The feedback and comment form for in- patients           36 items and 1 overall
Center’s Patient           assesses patient satisfaction in 6 areas: (1) room or    item with a 3- point
Satisfaction Survey        bed- functioning of TV, cleanliness, comfort, toilet     response scale
                           facilities, quality/ availability of linen, sense of
                           security and quietness; (2) administration- courtesy      1- Exceeded
                           of admitting staff/credit and collection staff/                Expectations
                           cashier, bills prepared on time and medicare              2- Met expectations
                           service; (3) nursing service- concern for comfort,        3- Did not meet
                           promptness of service, adequate information about            expectations
                           treatment, courtesy of staff and efficiency of work;
                           (4) food service- tastefulness, timeliness,              1- open- ended item
                           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 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   This patient feedback form focuses on 3 major areas      43 items with a 5-
Satisfaction Survey        of hospital service: (1) business/frontline-             point response scale
                           admission, billing, guest services desk and cashier;
                           (2) clinical – nursing care, laboratory, radiology,       1-   excellent
                           nutrition and dietary and doctors; and (3) support        2-   good
                           operation- housekeeping, security, telephone              3-   average
                           services and plant operations. Each section is            4-   below average
                           graded according to courtesy of staff, timeliness of      5-   needs big
                           service and delivery of service except for laboratory,         improvement
                           nutrition/ dietary and doctors. Laboratory is graded
                           according to responsiveness of staff to patient          1- open- ended item
                           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 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.

         Also, 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).

        In our country, how can Filipino 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. However, patient satisfaction
was measured by using an instrument adapted from a foreign source. For example, 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 in 2002 explored
the effect of modular nursing on patient and staff satisfaction at the Davao Doctors Hospital.

        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.

         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.

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