CHAPTER 2 Review of Related Literature A.

Patient Satisfaction Generally, patient satisfaction has been defined as the patients 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 patients 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 problemsolving 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 nurses ability to anticipate the patients needs, and a nurses 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 doctors 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 knowledgethe 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 patients 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. 99999 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 The satisfaction survey focuses on 6 areas 28 items with a yes which include (1) admitting procedure or no response of Promptness, Patient provision, and courtesy, orientation information scale to payward

General Hospital Department Private Services Satisfaction Survey

policies; (2) room - cleanliness of room and 1 open- ended item 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 courtesy health easily and

understandable, efficiency; (6)

staff other

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 services. room staff, and ambulant and

Additional

comments

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 Centers Hearts A patient satisfaction survey form that 17 items with a 4response Patient focuses on facilities and services rendered point by the medical, nursing, paramedical, scale billing,

Satisfaction Survey

admitting/

information,

dietary,

security, cashier, janitorial, engineering/ DS- dissatisfied maintenance, social service and medical S- satisfied 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/ areas, orderliness room, of the waiting and patients

laboratory

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 experts assessment. No other

psychometric information was provided. East Medical Avenue This patient satisfaction survey form looks 27 items with a yes Centers into 4 general categories in the or no scale and 4-

Patient Satisfaction hospitalization experience: (1) attitude of open- ended items Survey hospital staff- doctors, nurses, nursing attendants, admitting staff, janitors and security personnel; (2) services rendered by hospital staff; (3) services rendered by the different dietary, laboratory, departments in the hospitalradiology, pharmacy,

housekeeping, social service,

emergency room and janitorial; and (4) other comments regarding the hospitalopen- 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 provided. The Medical Citys This patient satisfaction form rates the 30 items with a 3Patient Satisfaction following areas: (1) quality of service point Survey (patient care/ preparation/ orientation & scale briefing/ promptness) in the ER admitting, nursing unit, food service, janitorial service, E- excellent billing, cashier, and security, others; diagnostic F- fair (2) room P- poor response

departments

accommodation such as amenities, toilet & bathroom, ventilation system, lighting & 5 overall times with communication 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. system; and (3) staff a yes or no

response scale

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 who down the names of

employees service.

provided

outstanding

Items were suggested by a group of experts. No other information on

psychometric properties was provided. Makati Centers Medical The feedback and comment form for in- 36 items and 1 Patient patients assesses patient satisfaction in 6 overall item with a areas: (1) room or bed- functioning of TV, 3- point response cleanliness, comfort, toilet facilities, quality/ scale availability of linen, sense of security and quietness; (2) administration- courtesy of admitting staff/credit and collection staff/ cashier, medicare bills prepared (3) on time and 1- Exceeded Expectations 2- Met expectations 3- Did not meet expectations

Satisfaction Survey

service;

nursing

service-

concern for comfort, promptness of service, adequate information about treatment,

courtesy of staff and efficiency of work; (4) food servicetastefulness, timeliness, 1openended

temperature, courtesy of food personnel; (5) item 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 openended question on how to make the

patients 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 Hospitals This patient feedback form focuses on 3 43 items with a 5areas of hospital service: (1) point response

Patient Satisfaction major Survey

business/frontline- admission, billing, guest scale services desk and cashier; (2) clinical nursing care, laboratory, radiology, nutrition and dietary and doctors; and (3) support operationhousekeeping, security, 1- excellent 2- good 3- average 4- below average 5- needs big

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 1graded according to responsiveness of staff item to patient concern, communication of

improvement

open-

ended

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 treatment according to the medication/

they provide and relay of

information. Comments are requested at the end of the form on how to serve the patients 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. Eightysix 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 NUs, 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 & Englands (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 nations 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 Hospitals 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 masters 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.