INTRODUCTION
Patient satisfaction is the patient’s perception of care received compared with the care expected. Patients base their expectations on their own encounters with behaviours of nurses (Aiello et al 2003). According to Eriksen (1995), critical attributes of patient satisfaction with quality nursing care are reliability, tangibles, responsiveness, empathy and information giving. Reliability is defined as being “dependable, accurate, timely, competently, done right the first time.” “Assurance includes “trust, problem is in good hands, credibility, security, and reassurance”. Tangibles are “physical appearance of facilities staff.” Responsiveness consists of “promptness, accessibility.” Empathy relates to ‘individualised attention, kind, courteous, understanding, friendly, able to listen, unhurried attention.” Information giving is “keeping patient informed” and “explaining to patient”. During hospitalisation, patient satisfaction represents a balance between the patient’s perception and expectation of their nursing care (Han et al 2003). The patient’s perception of quality nursing care also include caring, compassion, competence, confidence, conscience and commitment in the delivery of care (Gunther et al 2002). It is interpreted as a therapeutic response, which leads to speedy recovery among post-cardiac surgery patients (Doering et al 2002; William 1998).
The achievement of patient satisfaction among post cardiac surgery patients is specific to the interventions implemented by the nurse. The four domains of outcomes have been identified as technical competence, information giving, assurance and empathy (Larrabee et al 2001). The post cardiac surgery patients require constant vigilant nursing care, as their condition can be life threatening (Doering et al 2002). The types of cardiac surgeries include coronary artery bypass graft (CABG), valve surgery, correction of atrial septal defect (ASD), ventricle septal defect (VSD), tetralogy of Fallot (TOF), pulmonary atresia and aortic aneurysm. Post cardiac surgery patient satisfaction is pivotal to the achievement of optimum clinical outcomes, speedy recovery, reduced length of stay and avoidance of recurrent admission (Larrabee et al 2001). On the other hand, patient dissatisfaction would result in poor compliance with the treatment regimen, premature self-termination of care plan and seeking care outside the plan. Such patients would portray anger and verbal abuse (Jafar et al 2003). Achieving optimum patient satisfaction with quality nursing care has been the primary focus of nurses.
It is with this intent that the researcher conducted a study on post cardiac surgery patient satisfaction with quality nursing care in the surgical wards of IJN. The objective of this study was to identify factors in quality nursing care that determined patient satisfaction.
SUBJECTS AND METHODS
A descriptive study was undertaken at IJN. This study was conducted from January 2005 till March 2005. A conceptual framework was formulated for the purpose of having an overview of the critical attributes (Figure 1). Primary data were collected using NURSQUAL, a fully structured questionnaire, to measure the four domains in relation to technical competence, information giving, assurance and empathy (Larrabee et al 2001). There were two sets of questions; section A consisted of 33 items to measure quality nursing care and section B comprised six questions with regard to demographic data. In section A, the above questions were scored with a seven-point Likert-type scale. Scores were rated as follows: one-strongly disagree and seven-strongly agree, whereas section B used a nominal scale. Fifty two respondents who fulfilled the inclusion criteria were recruited from the surgical wards (Mawar and Cempaka) of IJN.
The inclusion criteria of the respondents were post cardiac patients more than 18 years old, elective cardiac surgery CABG and valve surgery and emergency cardiac surgery (CABG) and valve surgery without complication. The exclusion criteria of the respondents were those undergoing any emergency cardiac surgery (CABG) and valve surgery with complications, critically ill and nursed in high dependency unit.
The research instrument was a self-administered questionnaire. The questions relating to the four domains are listed in Figure 2, Figure 2A, and Figure 2B
Ethical approval was undertaken and permission obtained from the ethics committee of the Faculty of Medicine, University Kebangsaan Malaysia (UKM) and Institute Jantung Negara (IJN). The study was carried out in accordance with the ethical principles and guidelines of UKM and IJN. Confidentiality of the respondents were assured. Research questionnaires were given and collected by the researcher on the same day, to prevent respondents from discussing their answers among themselves or with others such as family members, nurses or visitors.
Statistical analysis was done using the statistical package for social science (SPSS) windows, version 11.5. Demographic data of respondents were analysed by descriptive statistics of frequency. Statistical methods included Pearson correlation coefficient, the differences of mean between patient satisfaction with technical competence, information giving, assurance and empathy. A multiple linear regression test was utilised to identify the attributes on patient satisfaction with quality nursing care (Burns & Bush 2003).
RESULTS
Respondents’ demographics data consisted of gender, age, ethnicity, marital status, highest education level and occupation, as shown in Table 1.
Eighty three percent of patients agreed that the nurses were technically competent, 83% that they gave adequate information, 87% that they provided assurance, and 94% that they showed empathy (Table 2).
There was a strong correlation between technical competence, information giving, assurance and empathy with questions on “how would you rate your satisfaction with overall nursing care received during stay in hospital?”, “would you comply to the nurses advise regarding your care at home?”, “would you come back to this hospital to seek treatment if needed?” and “do you have intention of recommending this hospital to your family member, relatives and friends?”. (Table 3)
The strongest predictors of patient satisfaction were assurance (beta coefficient of 0.557) and technical competence (beta coefficient of 0.280) (Table 4)
DISCUSSION
The findings from this study were consistent with those previously published. Patient satisfaction with regards to the four domains of quality nursing care may vary but they are interrelated to one another (Aiello et al 2003; Jafar et al 2003; Uzun et al 2001). The results of this study highlighted the importance of technical competence, information giving, assurance and empathy in the holistic management of the post cardiac surgery patient during hospitalisation.
The study found a significant association between gender and the elements of assurance and empathy. Men were found to be more satisfied than women. The reason for this gender differences in our study was not specifically explored in-depth. According to Lumby et al (2000), women possessed negative perceptions of assurance than men. Valentin et al (2005) concluded similar findings in relation to gender which may be true for our population.
According to Uzun (2001), patients’ aged ≥ 50 years gave high scores for nursing care compared to patients aged <50 years. The results of the present study support this finding and that of another study where older patients were found to be more compromising and contented (Staniszewska et al 1999), particularly with regards to the domains of technical competence, assurance and empathy.
The results of this study also showed a significant positive correlation between the elements of technical competence, information giving, assurance and empathy, and the overall satisfaction with nursing care, willingness to comply with nurses advice regarding their care at home, willingness to come back to the hospital to seek treatment if needed and intention of recommending the hospital to family members, relatives and friends (p value < 0.01 and 0.05). Jacox et al (1997) found a strong relation between technical skill and quality nursing care provided, which is in keeping with our findings.
For element of information giving, a positive association exist between patient compliance to the nurses advice regarding their care at home. Jafar et al (2003) also reported similar findings with respect to patient’s information, satisfaction and hospital revisits. Similarly, for element of empathy, a positive association was also noted. Lumby et al (2000) reported that empathy had a significant relationship with patient satisfaction. It is also unclear how the weighting of each dimension could be determined, since there will be differences in their relative importance for each patient as each person has a unique frame of reference and a set of personal norms for making judgments about nursing care (Valentin et al 2005). There will be differences based on patient’s attitudes to receiving care, their knowledge of the services available, their previous experience and reports that they obtained from others.
Indeed the most valuable element in our study was assurance provided by the nurses. “Assurance” made the strongest statistically significant unique contribution to the prediction of patient satisfaction. From an organization structure perspective, nurses who use rules, procedures and instructions positively would influence patient satisfaction (Lumby et al 2000). Since IJN has been established as a cardiac referencing hub,it has been used as a benchmark for other hospitals in Malaysia to emulate their own cardiac centre. The organization has experts in every sector of their management, including nursing. Post cardiac surgery patients are more satisfied with nurses who incorporate organisational and professional guidelines as their tool for implementing quality nursing care. Therefore, organisation must consistently include the latest guidelines and standards in their rules, procedures and instructions to meet the demands of globalisation and evolution in nursing care (Han et al 2003).
CONCLUSION
In conclusion, this study has demonstrated the importance of nurses being sensitive and knowledgeable of four major domains, which are technical competence, information giving, assurance and empathy among the post cardiac surgery patients. Of these, assurance from the nurses has been found to be of top priority and a crucial factor in determining patient satisfaction with quality nursing care.
ACKNOWLEDGMENTS
The authors thank Associate Professor Dr. Aliah Hanim M. Salleh (UKM, Bangi Campus) for her review of the research proposal.
The authors also extend their gratitude to the Management of IJN, post cardiac surgery patients and nurses for their cooperation in responding to the survey; without their help, this work could never have been done.
Heartfelt thanks to Prof. Dr. Lokman Saim, Dean Faculty of Medical UKM for giving permission for this study to be published.
We wish to extend our sincerest thanks to Puan Raiah Hj. A. Rahim Head of Nursing Department for her continuous support.