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.

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

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.