Nursing Care Component of Patient Satisfaction
Patient Satisfaction
Patient satisfaction has become increasingly popular as a critical component in the measurement of the quality of care.
Donabedian (1988) theorized that the quality of medical care could be evaluated from three perspectives: its process (how and what things are done), structure (the setting in which the care is administered), and outcomes (eg, the effects on health status and patient satisfaction).
Few studies of patient satisfaction existed prior to the 1970s. After that time, there was an increase in the research conducted in this area. The number of studies of patient satisfaction parallels the research on consumer satisfaction, which has historically been conducted by industries interested in maintaining and/or increasing their market share.
Research on patient satisfaction has continued to gain momentum with the Total
Quality Management (TQM) and "outcomes" movements of the 1980s and
1990s, and over the last decade as the health care marketplace has become more
competitive.
Dimensions of Patient Satisfaction
Patient satisfaction is a complex concept with several dimensions. Ware, Davies-Avery, and Stewart (1978) developed a detailed taxonomy of patient satisfaction from their review of 111 studies published over the 25-year period prior to 1975.
The taxonomy initially included the art of care, technical quality of care, accessibility/ convenience, finances, physical environment, availability, efficacy, and continuity.
After decades of continued research,
the dimensions of care were refined to include the following six dimensions:
nursing and daily care, hospital environment and ancillary staff, medical care,
information, admissions, and discharge and billing (Ware & Berwick, 1990).
Instrumental Measure of Patient Satisfaction
Risser (1975) developed an instrument to ascertain patient satisfaction that was specific to nursing care. The Risser Patient Satisfaction Scale (PSS) included 25 questions and three subscales:
Technical/Professional Area, Educational Relationship Area, and Trusting Relationship Area. The PSS was originally developed to measure the care of ambulatory patients and was later adapted to the hospital setting through minor rewording and a replication study (Hinshaw, AS, & Atwood, 1982).
La Monica, Oberst, Madea, and Wolf
(1986) further developed the PSS to reflect nursing behaviors in the acute care
setting and additional items were added and then. subjected to psychometric
testing to ensure reliability and validity (Munro, Jacobsen, & Brooten,
1994).
Patient Satisfaction With Nursing Care
Patient satisfaction with nursing care has consistently been found to be correlated with overall satisfaction with care, and has been defined as the “patient's subjective evaluation of the cognitive/emotional response that results from the interaction of the patient's expectations of nursing care and their perception of the actual nurse behaviors/characteristics” (Erikson, 1995, p. 71).
aMeasuring patient satisfaction with care is instrumental to the success
of providing patient centered care and allows consumers to participate in the
evaluation process.
Nursing Research on Patient Satisfaction
The majority of studies on patient satisfaction have been cross-sectional and descriptive in nature. Characteristics of providers or organizations that result in more “personal” care have been associated with higher levels of satisfaction (Cleary & McNeil, 1988).
The nurse work environment has been found to be both directly and indirectly (through nurse burnout) related to patient satisfaction (Vahey, Aiken, Sloane, Clarke, & Vargas, 2004).
aPatients cared for on units which nurses characterized as having adequate staff, good administrative support for nursing care, and good relations between doctors and nurses were more than twice as likely as other patients to report high satisfaction with their care; Additionally, their nurses reported significantly lower burnout.
Patient satisfaction has also been found to be
associated with patient adherence to care provider recommendations and intent
to return for or refer services (Hill, MH, & Doddato, 2002).
Implementations for Improvement in Satisfaction
It is clear that there are many important implications for assessing and improving patient satisfaction with nursing care.
The American Nurses Association (ANA), the Joint Commission on Accreditation of Health Care Organizations (JCAHO), and others have identified patient satisfaction as an important quality indicator (American Nurses Association, 1996, 2000a; Donabedian, 1988; Joint Commission on Accreditation of Healthcare Organizations, 2003a).
However, there are several challenges facing researchers
in the 21st century.
Challenges for Satisfaction Measure
A major challenge is the need for psychometrically sound, reliable, and valid measures (McDaniel & Nash, 1990). Patient satisfaction with nursing care is a multidimensional phenomenon and therefore a single item will not suffice.
However, researchers must consider the burden to patients and limit the number of items to only those that are essential. Additionally, a standardized approach to the measurement of patient satisfaction will allow care providers to benchmark their services and consumers to adequately compare across providers in order to make informed decisions about their care.
Currently, the ANA and the Centers for Medicare and Medicaid Services (CMS) are working towards this goal by developing multisite databases.
The ANA is sponsoring the National Database for Nursing Quality Indicators (NDNQI), which plans to collect data on patient satisfaction with pain management, educational information, nursing care, and over-all care (National Center for Nursing Quality, 2004).
The CMS has implemented a three-state pilot project to test and refine a standardized “Patient Experience of Care” (Centers for Medicare & Medicaid Services, 2003).
Another challenge is for health care researchers to refine the methodological strategies so that techniques with greater sensitivity can be achieved. Crosssectional studies limit the ability to identify causal relationships and generalize findings.
Results from mail and telephone surveys, which are the most common methodologies, can be biased because of the timing of these surveys and the rigor in which responses are obtained. Moreover, it is argued that patients tend to report “socially desirable” ratings, which result in data that are skewed and typically reported as high levels of satisfaction.
Some researchers therefore have recommended that health care providers focus only on areas of dissatisfaction or patient complaints. Future research should consider other methods for assessing patient satisfaction, which may include focus groups, observation, or qualitative studies.
These methods may help isolate “critical moments” such as specific episodes of care or interactions with care providers, or more clearly identify patient expectations prior to service and whether they are met-which is likely to be a more effective and efficient way to assess important dimensions of care and to make improvements.
Finally, one of the main indications for measuring patient satisfaction with nursing care is to identify areas for improvement; however, few studies have examined the effects of interventions. Recognizing the contributions of nursing to improved patient outcomes and the quality of care will lead to the provision of safe patient centered care.
Designing studies to evaluate interventions that
take into consideration increasing patient acuity, shorter lengths of stay, and
the cultural diversity of patients will provide for enduring changes resulting
in high-quality health care that benefits both patients and providers.
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