Assessment of adult patients ’ satisfaction and associated factors with nursing care in Black Lion Hospital , Ethiopia ; institutional based cross sectional study , 2012

Patient satisfaction has been used as an indicator to measure the quality of health care provided by nurses. Moreover, patient satisfaction is one of the ultimate validators of effectiveness and quality of care. The purpose of this study was to assess adult inpatient satisfaction and associated factors of nursing care in Black Lion Specialized Hospital, Addis Ababa, Ethiopia. An institutional based cross sectional study was conducted on a total of 374 adult patients admitted to Medical, Surgical and Gynecologic wards in Black Lion hospital. The data collection tool was modified from Newcastle Satisfaction with Nursing Scale (NSNS). Simple random sampling technique was used. Data were entered into EPI info version 3.5.1 and exported to SPSS version 16.0 for cleaning and analysis. Frequencies distribution, binary and multiple logistic regression were done. OR and 95% confidence interval was computed. The average mean (SD) of satisfaction was 3.93 (0.88). Participants in Gyn/Obs wards had a better satisfaction (mean= 4.02; SD=0.76) with nursing care when compared with participants in medical and surgical ward. Among all respondents females had “Moderate and High” level of satisfaction (95%) than males (86.21%). Being female (3.78 (1.35, 10.56)), Age>50 years (0.36(0.14, 0.93), never married patients (2.74(1.07,7.03)) and admitted in Medical or Gyn/Obs and number of nights spent in the ward were found to be independent predictors of patients satisfaction. Since the overall patient satisfaction was 90.1% in this study, the hospital could be a model for other hospitals.


INTRODUCTION
Patients' satisfaction is considered as an important outcome criterion in health services.In the past few decades, there has been increasing interest in patients' satisfaction with nursing care.Patients' satisfaction with nursing services gains even more hospitalized patients.According to American Nurses Association (2000), 'patient satisfaction with nursing care' is patients' opinion of care received from nursing staff importance as nursing care is the major supportive service provided to during their hospitalization'.(Teng and Norazliah, 2012) On the other hand, patients' satisfaction is also referred as an expression of patient's overall judgment on the quality of care particularly in the aspect of interpersonal process (Donabedian, 1988).Today interestingly, the organization perspective views patient satisfaction as the goal of health care delivery (Merkouris, 1999).Patient satisfaction with nursing care is the degree of convergence between the expectations patients have of ideal care and their perception of the care they really get (Crow et al., 2003, Risser N, 1975, Merkouris, 1999).However, evaluation of the quality of health care is a complex and challenging process.Though medical experts have argued that patient satisfaction is not the best indicator of quality of care (Roohan et al., 2003), it is a category that has received attention as a useful indicator of the quality of care in consumer-driven health care systems (Ganova-Iolovska et al., 2008;Johansson et al., 2002;Felesia, 2009).
Nurses spend more time with hospitalized patients than members of any other discipline and therefore have a significant impact upon patients' perceptions about their hospital experience (Crow et al., 2003).Patient's satisfaction will be determined by nurses' role in the hospital; because they are more acquainted bedside nursing care than any other health personnel in the hospital.Nurses are on shifts stay in the hospital twenty four hours, seven days per week and three hundred sixty five days in a year.Nurses stay longer with the patient than the attending physicians.Learning about what consumers want from their health care system and what quality care means to them offers decision-makers a better understanding of their expectations (Ganova-Iolovska et al., 2008).That is, satisfaction provides a meaningful focus for improving quality care, planning and evaluation of health care services (Felesia, 2009) and it will change the nur-sing service practice beyond medication administration, carrying out physicians order and measuring vital sign.Health care environments throughout the world are currently under enormous pressure to improve quality of care, while at the same time restraining the increasing costs.We should, however, not make the market for health care like the market for everything else (example, airplane journeys, restaurants and movies), where customer satisfaction can be almost like the whole story of running a busines (Tzeng, 2008).Patient satisfaction in Jordan and Ethiopia was 73% and 67% respectively (Felesia, 2009;Bekelle, 2005).Being a female and admitted to a Gynecological ward, the amount of time nurses spend with the patient and the type of information nurses gave to patients about their condition and treatment, lower income and education, longer period of admission and no history of admission were among factors adversely affecting satisfaction levels (Bekelle, 2005).
The issue of patient satisfaction has drawn much attention for research particularly in specialized areas such as emergency departments (Thrasher andPurc-Stephenson, 2008, Saiboon et al,. 2008) coronary care units (Ho et al., 2006), Orthopaedic wards (Teng and Norazliah, 2012) and psychiatric units (Kuosmanen et al.,2006).In contrast, patient satisfaction among the patients admitted to the medical, Surgical and obs/Gyn wards of government hospital settings, which usually comprise of the highest density of in-patient population of any countries are neglected and here is limited literature.
In view of the wide coverage of population in the medical wards, surgical wards and Obs/Gyn wards the evaluations on patient satisfaction would contribute to the knowledge of strategies in nursing care improvement.

Study design, population and sampling
An institution based cross sectional was conducted.The study participants were Adult inpatients in Medical, Surgical and Gynaecology wards of Black Lion Hospital; who stay for two or more days and who consented to participate in the study.The sample size for the study was calculated using single population proportion formula: 2 Using the assumption that the proportion of patient satisfaction was 67% (Bekelle, 2005), 95% CI, 5% marginal error, and 10% none response rate, a total of 374 admitted patients were required for the study.First the number of patients to be taken from each ward was determined based on the number of beds they had.Then, all patients who had been admitted during data collection period was interviewed until the required sample size from each ward was found.Accordingly, 111 patients from the medical ward, 176 from the surgical and 87 from the obstetrics and gynecology wards were taken.

Data collection tool
The data were collected according to the Newcastle Satisfaction with Nursing Care Scales (NSNSs) users' manual.Questionnaire was translated into Amharic and was re-translated back to English to check for consistency.The questionnaire contained both open and close-ended questions.Two non health professional data collectors and one supervisor was recruited and training was givento data collectors and supervisor for a day on the objective, relevance of the study, confidentiality of information, respondent's right, about pretest , informed consent and techniques of interview; after the investigators discussed in depth.Pretest was conducted in 20 patients in other hospitals found in the city.Data was collected by interviewing each patient.The data collectors interviewed the inpatient without wearing a gown in order to reduce bias.The quality, clarity and consistency of the data were checked every day.

Criteria for classification of satisfaction score
The maximum scores for patients' satisfaction were calculated out of 100.The scores were categorized into moderate and high level of satisfaction for those who answered more than 12 (>60%) questions and low level of satisfaction for those who answered 11 and less (≤ 60%) questions.

Data analysis, presentation and interpretation
Data were entered using EPI info version 3.5.1 statistical software.
Cleaning and analysis was done by using SPSS version 16.Univariate analysis was done to describe dependent and independent variables; percentages, frequency distributions and measures of central tendency and measures of dispersion were used for describing data.Open-ended questions were coded after data collection for analysis.Then binary logistic regression was made to see the crude significant relation of each variable with dependant variables.Finally, independent variables found significant (p≤0.05) were entered to multivariate logistic regressions to control the effect of confounding.Stepwise backward LR was used for multiple logistic regressions.Odds ratio with 95% confidence interval to ascertain association between independent and dependent variable was used.

Ethical considerations
Ethical clearance was obtained from IRB of AAU, CHS, department of nursing and midwifery.The permission letter was obtained from Black Lion hospital quality management team before the research commenced.Participation in the study was voluntary and informed verbal consent was obtained from each patient after a thorough explanation of the purpose of the study.Data collection was anonymous and guaranteed confidentiality of the information given and either participating or not participating would have a negative effect on their care.

Socio demographic characteristics of patients
A total of 374 adult in-patients who had spent two or more days in Black Lion Hospital were included in this study with 100% response rate.The mean age of participants was 40.3(SD=1.55)and the minimum age was 18 with the range of 68 (18, 86).Among the participants, 53.5% were females.The majority of the respondents were literate (80.7%) left only 12.8% who were employed.The vast majority of the respondents were Orthodox Christian in religion (65.8%) and 22.7% were Muslim.Of the total respondents 42% were Amharain Ethnicity and 63.9% were married and living together.
The median length of stays (nights) were 7 with interquartile range being 11 (Table 1).Among the given seven options, 48.7% rated nursing care they received in the ward as very good but 1.1% rated the care they received as dreadful (Figure 1).Almost all of the respondents 357 (95.5%) said nurses had good communication and interpersonal skill and 350 (93.6%) have said that the nurses keep their dignity, emotion and empathy.Among all respondents 354 (94.7%) felt that they would recommend this hospital to the people they know who may be seeking medical care in the future.

Patient satisfaction with nursing care
Patient satisfaction with nursing care, as measured using the PSNCS, is seen in  "Moderate and High level of satisfaction" than employed (83.33%) and those who spent 2 to 10 nights (95.74%) and those who spent ≥ 22 nights (85.71% were having more satisfaction than people who spent11 to 21 nights (81.44%) in the ward.Of all inpatients' interviewed, 90.9% had "Moderate and High" level of satisfaction the multivariate analysis result showed that female (95% CI, AOR: 3.78(1.35,10.56)) were more satisfied than male patients.Those whose Age ≥50 years (95% CI, AOR: 0.36(0.14,0.93)) were less likely to be satisfied than patients' whose age was <50 years of age.Among the wards, people who had been admitted in medical (95% CI, AOR (0.35(0.15, 0.83)) ward were less likely to be satisfied than surgical ward.From marital status, never married (95%CI,AOR:2.74(1.07,7.03))had a better satisfaction than those who were married and people who spent (11 to 21 nights) (95%CI,AOR:0.17(0.07,0.41)and ≥22 nights (95%CI,AOR:0.26(0.08,0.82)were less satisfied than those who spent <10 days in the ward (Table 3).

Patients' opinions and general comments about Black Lion Hospital
Among the 374 respondents 75(20%), 37(10%) and 262(70%) had negative, neutral and positive opinion respectively.Some of the opinions include; "Nurses must treat every individual equally, there is an interwoven problem in emergency department and card room, and the card room workers and the janitors must be a health professionals or they should be at least 12 grade completed or they should receive special training.There was also a problem of water, linen, toilet, food, sanitation in the hospital, laundry, laboratory, X-ray and pharmacy services and these services must be improved in order to increase patient satisfaction and experiences".The participants also provided general comments to the government bodies including: "The government should increase nurse's salary to make them happy/interested at their job, there should be supervision and controlling mechanism, and since there is a work overload in nurses, the government should recruit additional staff".The participants also provide comments to the hospital administrators to "give reward/ recognition / for those who perform well, information provider in every floor or direction indicator, providing adequate materials for nurses, and recruiting a multilingual person for those people who come from rural parts of Ethiopia/for peoples who cannot speak Amharic/ were among frequently provided recommendations".They also recommended the nurse's and other health professionals "to give a concern for the patient and for their relatives, to have patient station for those who are not admitted in the ward and waiting their appointment.Nurses are our families, they should be patient, transparent, open minded and well coming enough in their activity/service, like the nurses the doctors should also pay attention to the patients, Nurses must treat every individual equally, and the nurses and other health professionals must do that cooperatively".Generally, they witnessed as there was a big problem in the management area; and they recommended for continuous monitoring/ evaluation mechanism in other services than nursing care services.They also recommended before assessing the patient satisfaction, the researchers should also assess nurse's satisfaction and other factors, which affect patient satisfaction and experience other than nursing care.

Demographic variable and patient satisfaction
In this study, the overall participants' satisfaction with nursing care was 90.1%, which is higher when it is compared with the previous research done in Ethiopia, which was 67% (Bekelle, 2005) and Jordan (72.9%) (Alasad and Ahmed, 2003).This change was most probably due to the implementation of BPR (Business Processing and Reengineering) reform, due to continuous monitoring and evaluation by Federal Ministry of Health about quality of care for the patients, upgrading different nurses to the next level and may be due to the beginning of nursing process implementation.Of the six independent variables that were entered into both regression models, the type of ward, sex, age, and marital status affected the SNCS.Among hospitalized patients the female patients who had been treated in a surgical ward surgical ward and had a higher educational level gave lower SNCS scores than the other categories of patient.
In this study females (95%CI, AOR: 3.78(1.35,10.56) had higher satisfaction than males.This finding was consistent with the studies done in Jordan and Ethiopia (Alasad andAhmed, 2003, Bekelle, 2005).This result might be due to females' ability to have a free discussion with female nurses because majority of the nurses on those study wards were females.Nevertheless, a study done in Turkey (Thomas et al,. 1996) indicated that males were more satisfied with nursing care than females.The study done in Ethiopia (Bekelle, 2005) indicated that age(18 to 30) had more satisfaction than older age group which was similar with the research done in Turkey (Ummu Yildiz et al,. 2010), but in this research middle aged groups were found to be higher than those of younger aged groups.Similar to those studies (Bekelle, 2005, Ummu Yildiz et al,. 2010) the findings of this study indicated that older people (Age>50 years (95%CI, AOR: 0.36(0.14,0.93)) are less likely to be satisfied than patients whose age is <50 yrs.This finding is incongruent with a study done in Japan, Jordan (Tokunaga J et al., 2002;Ummu Yildiz et al., 2010).The reason for this might be as the patient's age increase their demand or need for nursing care will increase due to many physiological changes; and this could be the reason for the less satisfaction.People who were admitted in Medical ward (Medical (95%CI, AOR (0.35(0.15, 0.83)) were less likely to be satisfied than Obs/Gyn ward admitted patients.This finding was similar with the study in Ethiopia, Jordan, and Japan (Bekelle, 2005, Alasad and Ahmed, 2003, and Alhusban and Abualrub, 2009).The reason for this may be due to the presence of specialized Midwife professionals in this ward.In contrast to this study, the study done in Turkey (Ummu Yildiz et al,. 2010) patients who were in surgical ward (43%) had more satisfaction than people who were in medical ward (57%).In this study never married (95%CI, AOR: 2.74(1.07,7.03)) people had higher satisfaction than married.It might be because of never married peoples' lesser expectation.However, there was no association in other studies (Ahmed and Alasad, 2004, Akin and Erdogan, 2007, Alasad and Ahmed, 2003, Alhusban and Abualrub, 2009, Bekelle, 2005;Ummu Yildiz et al., 2010;Vincent et al., 2004).Patients' number of nights spent in the ward had also an association with patients' satisfaction.In this study those (11 to 21 nights) (95%CI, AOR: 0.17(0.07,0.41) and ≥22 nights (95%CI, AOR: 0.26(0.08,0.82) had lesser satisfaction than those who had been <10 days.It may because those who spent (11 to 21 nights) and ≥22 nights might have a higher demand and they might have some other hospital acquired infections as they spent more time in the hospital.It was incongruent with the study in Japan (Tokunaga J et al., 2002).However, it was similar with the study in Jordan (Alhusban and Abualrub, 2009).Other factors like educational status were identified as they do have relation with patients' satisfaction.Study (Bekelle, 2005, Ummu Yildiz et al,. 2010) found lesser-educated individuals had higher satisfaction.This could be explained by people who are highly educated might expect a higher standard of care than lower education status people.Such inconsistent results in regard to the associations between the demographic variables of patients and the level of satisfaction calls for further research that controls other variables such as the demographic variables of nurses who provide care for those patients and other organizational variables such like nurses' satisfaction (Alhusban and Abualrub, 2009).It will be also better to add other variables in organizational variables like organizational infrastructure.Since the overall satisfaction level of the patient is 90.1% the rumors of the community was not related to the nursing care service they receive in the hospital.Even though there were some factors which would decrease the patient satisfaction related to nursing care, the majority of patients' dissatisfaction was related to other hospital services.Moreover, as the patients witnessed the community's rumor was not directly related to the nursing care they received in the hospital instead it was the problems of other services including "pharmacy, laboratory, catering, X-ray, medical and other services".

Conclusion
In this research, the overall patient satisfaction were 90.1% and this implies that the quality of nursing care service that was provided in Black Lion hospital was higher when it was compared with different literature findings.The causes of patient dissatisfaction with the hospital is not majorly due to nursing care instead it is the problems of other hospital services such as pharmacy, radiology, laboratory, catering and other services .In this study, the patients' satisfaction is affected by the amount and type of information they receive about their condition and treatment, and the time that they spent with the nurses have an influence on their satisfaction.The type of ward, age, sex, marital status and number of nights spent in the ward and the number of nights spent in the ward and occupation were found to affect patient satisfaction and experience with nursing care respectively.Surgical ward patients, female, <50-yrs-old patients, never married and those who spent 11 to 12 nights and ≥22 nights were lesser satisfied than those who spent 2 to 10 nights in the ward.Identifying the level of patients' satisfaction and experience with nursing care was a good indicator of quality in nursing care service provision.Based on the findings of the study, we give the following recommendations: 1. Since the overall patient satisfaction with nursing care was 90.1% in the Black Lion hospital, the nurses should continue their practices to give a better advocacy in nursing care for their patient's individual needs.Likewise nurses at Black Lion Hospital as stated by some of the patients' should practice equality and justice to all patients.2. Nurse administrators, managers, researchers and FMOH should; (i) give an emphasis on the importance of continuity of nursing care; (ii) hold workshops to foster effective time management and ethical issues among nurses.(iii) The hospital administrator should give reward and accreditation for those who perform well.3. Moreover; the future researchers should do an exit interview and qualitative study in order to minimize social desirability bias and to identify other confounders.In addition to this, researchers also shall do further research in general hospital services to uncover the major causes of patients' dissatisfaction.

Figure 1 .
Figure 1.Rating of nursing care received by inpatients in Black Lion Hospital from March to April, 2012.

Table 1
in medical ward was 3.78(M= 3.78; SD=0.98).Participants indicated that they had a better level of satisfaction with aspects such as the amount of freedom you were given on the ward (M=4.58;SD; 0.63).Conversely, participants indicted that they had "low" level of satisfaction with aspects such as 'the amount of information nurses gave to you about your condition and treatment (M=3.42;

Table 1 .
Socio-demographic characteristics of inpatients who had been admitted in Black Lion Hospital from March to April, 2012.
(M=3.90; SD=0.87), and the way nurses explained things to you (M=3.83;SD=0.92).'On the other hand, participants had the least level of satisfaction with aspects such as 'Nurses' manner in going about their work (M=4.34;SD=0.84)andthe amount of freedom you were given on the ward (M=4.43;SD=0.78)(Table2).Medical (25 %) wards.Of all interviewed people, 60% of Orthodox Christian had "Moderate and High" level of satisfaction than Muslim (20%) and others (Protestant and Catholic) (11%).Age ≤50 (92.36%) of people had "Moderate and High" level of satisfaction than Age ≥ 50(86.87).Those who were not employed (92.02%) had

Table 2 .
Mean and standard deviations for inpatients satisfaction with nursing care in Black Lion Hospital from March to April, 2012.

Table 3 .
Bivariate and multivariate analyses for factors affecting inpatients satisfaction in Black Lion Hospital from March to April, 2012.