Outpatient satisfaction with nursing care

Abstracts

OBJETIVO: Descrever a metodologia utilizada para mensurar a satisfação do cliente externo com relação aos cuidados de enfermagem e apresentar o índice de satisfação destes clientes quanto aos cuidados de enfermagem. MÉTODOS: Estudo descritivo, de corte transversal, retrospectivo e abordagem quantitativa. realizado em uma instituição hospitalar de grande porte localizada na cidade de São Paulo, no período de dezembro de 2003 a outubro de 2005. O estudo foi elaborado a partir de dados fornecidos pelo Departamento de Marketing da Instituição. RESULTADOS: Os resultados demonstraram que 99% dos clientes pesquisados (3.860) estão satisfeitos com os cuidados de enfermagem. CONCLUSÃO: A satisfação dos clientes é decorrente do atendimento às expectativas e necessidades atendidas pelos cuidados de enfermagem recebidos.

Cuidados de enfermagem; Indicadores de qualidade em assistência à saúde; Gerenciamento de prática profissional; Satisfação do paciente

ORIGINAL ARTICLE

Outpatient satisfaction with nursing care^*

Satisfacción de clientes sobre cuidados de enfermería en el contexto hospitalario

Juliana de Lima Lopes^I; Maria Lucia Alves Pereira Cardoso^II; Vera Lucia de Souza Alves^III; Maria D'Innocenzo^IV

^IMaster of Sciences, Assistant Nurse of the Instituto do Coração – São Paulo (SP), Brazil

^IIPost-graduation (PhD) student, Assistant at the Research and Studies Group for Evaluation of Health and Nursing – GEPAV-SE, Universidade Federal de São Paulo – UNIFESP – São Paulo (SP), Brazil

^IIIMaster of Sciences from the Universidade Federal de São Paulo – UNIFESP – São Paulo (SP), Brazil

^IVPhD, Leader of the Research and Studies Group for Evaluation of Health and Nursing – GEPAV-SE; Assistant Professor at the Nursing Department, Universidade Federal de São Paulo – UNIFESP – São Paulo (SP), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: To describe the methodology used to measure outpatient satisfaction with nursing care and to report their actual satisfaction scores.

METHODS: This was a descriptive retrospective cross-sectional study. Data were collected from December 2003 through October 2005 from a database provided by the department of marketing of a large hospital in São Paulo City.

RESULTS: The majority of outpatients (99%) were satisfied with nursing care.

CONCLUSION: Outpatients satisfaction was due to their expectation, needs, and nursing care received.

Keywords: Nursing care; Quality indicators, Health care; Practice management; Patient satisfaction

RESUMEN

OBJETIVO: Describir la metodología utilizada para medir la satisfacción del cliente externo con relación a los cuidados de enfermería y presentar el índice de satisfacción de estos clientes en cuanto a los cuidados de enfermería.

MÉTODOS: Se trata de un estudio descriptivo, de corte transversal, retrospectivo y abordaje cuantitativo, realizado en una institución hospitalaria de gran porte localizada en la ciudad de Sao Paulo, en el período de diciembre del 2003 a octubre del 2005. El estudio fue elaborado a partir de datos proporcionados por el Departamento de Marketing de la Institución.

RESULTADOS: Los resultados demostraron que el 99% de los clientes investigados (3.860) están satisfechos con los cuidados de enfermería.

CONCLUSIÓN: La satisfacción de los clientes es resultante de la atención a las expectativas y necesidades atendidas por los cuidados de enfermería recibidos.

Descriptores: Atención de enfermería; Indicadores de calidadde la atención de salud; Manejo práctico; Satisfacción del paciente

INTRODUCTION

Quality Programs developed in-company represent a process that involves people, activities and methods, and are synonyms of continuous improvement, seeking compliance to requirements and adequacy on its usage, and have increasingly evidenced focus on the human capital of organizations⁽¹⁾.

While analyzing the quality related to healthcare, Donabedian⁽²⁾ establishes seven attributes: efficacy, effectiveness, efficiency, optimization, acceptability, legitimacy and equity. Within such concepts, the acceptability and legitimacy are the ones directly connected to patients and families' expectations and aspirations. The concept of acceptability refers to adapting healthcare service to the patient/family's aspirations, expectations, and values. Regarding legitimacy, it is the acceptance of healthcare service according to the way it is perceived by the community or society in general.

Measuring quality and quantity of healthcare programs and services is crucial for planning, organizing, coordinating/leading and evaluating/controlling the developed activities⁽³⁾. In order to measure healthcare services and programs quality, indicators have to be elaborated and monitored.

Indicator is the unit to measure an activity, or yet, a quantitative measure which can be used as a guidance to monitor and evaluate the quality of important healthcare services provided to patients, and activities from the support services⁽³⁾.

The indicators adopted by the American Nurses Association-ANA⁽⁴⁾ are based on Donabedian's model and defined as Nursing sensitive indicators, reflecting the structure, process and results of nursing care. ANA has ten sensitive indicators, being one of them the patient satisfaction related to nursing care.

The patient satisfaction indicator on nursing care is the opinion measure related to the attention provided by the nursing team during the time a patient is admitted in a hospital⁽⁵⁾. Measuring client satisfaction level on healthcare services is not an easy task, given studies still have limitations, mainly referring to approaching methods, and gaps on standardization of tools for data gathering⁽⁶⁾. A good measurement and monitoring system of client satisfaction consists of a continuous process, which allows the organization to improve assistance through a periodical studies program.

Client satisfaction, as a result of healthcare services, is an important indicator of a hospital environment quality. In that context, a theoretical model of client satisfaction specific for nursing has been prepared, presenting three dimensions: the nurse (regarding personality characteristics, nursing service and ability); the patient (referring to patient's own expectations), and organizational installations (referring to facilities and hospital organization). Additionally, it is equally important to be aware of the patient expectations for the process of measuring the level of satisfaction, which will depend on the interaction of nurses and patients⁽⁷⁾.

Other authors reviewed the nursing literature regarding this matter and concluded that the most regularly used result is patient satisfaction; but, in spite of being largely used, there is no consensus about the concept of patient satisfaction. Further, five other result measurements have been identified, including the patients' ability for taking care of themselves, well being and stress levels, the period of time as an inpatient and the level of complications⁽⁸⁾.

Given those definitions, some issues emerge: what methodologies have been applied by health institutions to evaluate the level of client satisfaction and nursing services? What is the client satisfaction degree related to the quality of nursing services?

Attempting to explain some of those questions and to demonstrate its practices, the intention is to present the model utilized by institutions, study field, to measure the client satisfaction related to nursing services.

The research is periodically made by the Marketing Department – Customer Relationship Service, using a methodology that proposes to measure and evaluate the level of client satisfaction on services rendered while being both an inpatient and outpatient, while undergoing exams or being received in emergency rooms.

Customer Relationship Service assistants, through a tailored software, generate a database on patients/clients who have been discharged during the 10 previous days from units such as: Maternity, Hospital, Diagnosis Centers and Emergency Rooms. Through a random process, patients and clients are selected from the database to be called by the Customer Relationship Services staff; the sample base ranges from 100 to 200 clients.

The Customer Relationship Service assistants make phone calls – which are recorded – to the selected clients, giving a personal introduction, explaining the object of the call and proceeding with the research questions. If the client does not agree to collaborate, the Customer Relationship Service Assistant will be thankful and will randomly select a new client from the database.

If the client does not agree to participate at that very moment, a new scheduling time is suggested. In case the client agrees to contribute, the assistant starts the research by asking questions that are based on grades from 1 to 5, where: 1= very bad, 2= bad, 3= regular, 4= good, 5= excellent, according to the client's level of satisfaction with the services rendered.

The client's input for each attribute, as well as comments and suggestions provided, are registered in a proper electronic system which feeds the database. At the end of the research, the assistant analyzes its content and sends it through the intranet to the responsible area, which will also analyze and return it to the Customer Relationship Services area with follow up actions developed or with the pertinent comments. The area involved could still, if necessary, contact the client once more with the purpose of getting further explanations on inputs provided.

The closure and dissemination of the research results with client satisfaction rates are presented not after the 15^th day of each month. The final report is delivered to the president, directors, managers and supervisors of the areas involved in the process. Results represent a quality indicator, which is used to measure and monitor the fulfillment of each client requisites and expectations.

OBJECTIVE

Describe applied methodology to measure the level of external clients' satisfaction with regards to nursing services and present an index of satisfaction for those clients referring to nursing services

METHODS

It is a descriptive, field and retrospective study, with a quantitative approach.

As a descriptive research " the researcher acknowledges and translates the reality without interfering or changing its content. Describe is to narrate what happens, and so the descriptive research is drawn to discover and observe phenomena, in the attempt to describe, classify and interpret them. By studying the phenomenon, the descriptive research is willing to acknowledge its nature, composition, and inherent processes of which it is comprised" ⁽⁹⁾.

The field study is characterized as " unique field or community in terms of social structure, that is, one that emphasizes the interaction within their components. Basically, the research is developed through direct observation of the activities of the group being studied, and through interviews with informers to capture their insights and explanations on what happens in the group" ⁽¹⁰⁾.

Finally, the " quantitative research investigates facts through pre-determined variables previously measured and the results obtained are numerically expressed.

To express numerical value results the relative frequency was used. It is " the relation between the number of individuals presenting that attribute and the total of individuals being considered, reminding that the elements of the numerator are always included in the denominator" ⁽¹¹⁾.

The project was approved by the Committee of Ethics and Research from the referred institution under the number 186/2008.

The research was developed at a large, privately owned hospital, providing medical/hospital services in the South region of São Paulo city.

The hospital institution being studied is one of a 70-year-old historical hospital chain, dedicated to emergency and specialized services. Statistics concerning their services are representative, with an average of 100 surgical procedures per day, totaling approximately 3,000/month, besides 12,000 Emergency Room cases, and 15,000 exams in the Diagnosis Center.

There are 284 hospital beds for patients receiving high and medium complexity care, currently employing 1,500 professionals, from which 980 belong to the nursing team.

The population studied was comprised of 3.860 clients, using the hospital services from December 2003 to October 2005, who agreed to participate in the research being made by the Customer Relationship Services. Data were obtained from sources dedicating to satisfaction researches services.

The data evaluated in order to obtain the level of client satisfaction were based on the following factors: Nursing Team, Medical Team, Administrative Services (Scheduling/Admissions/Treasury), Hospitality Services, Nutrition Services and Maintenance Services. In spite of the several factors evaluated by the hospital, the objective of this study was to evaluate client satisfaction in respect to the Nursing Team. Thus, the following attributes were considered: triage, nursing services across all hospital sectors, efficacy at surgery preparation, pre-maternity, and labor room care, as well as newborn nursery room care.

RESULTS

Client satisfaction rate

A total of 144,542 clients used the hospital services from December 2003 to October 2005, and from that total 3,860 (2,6%) participated in the client satisfaction research interview by phone, from which 980 patients had used the Diagnostics Center, 980 had used the Maternity, 950, the General Hospital, and 950, the Emergency Room.

Regarding the client satisfaction rate on nursing services, the average of points reached 4.95, corresponding to 99,1% of clients satisfied. Table 1 shows the average of points and the percentage of clients satisfied in each area of the institution.

Clients evaluate their satisfaction on nursing services using some institution attributes and the results are listed on Tables 2 to 5.

DISCUSSÃO

The interview held at the studied hospital respects the clients' will to answer the questionnaire, and those who are not interested are automatically excluded. Two other positive factors in the system are the clients' random selection, which prevents results from being negatively or positively influenced; clients are interviewed in a maximum of 10 days after being discharged from the hospital, so that they can have an overview of all services rendered.

Concerning the methodology applied to identify the quantity of clients interviewed, a sample model of 100-200 interviews is used. This method could be modified by using the percentage method, for example 10% of patients from each sector. Such system would increase the number of clients interviewed and consequently, the results would be more accurate.

One of the main qualities of this system is the results it generates, either positive or negative, are communicated throughout all sectors and staff, from field staff to the directors of services that were evaluated. That system allows sustainable improvement for the institution as well as staff motivation.

The feedback to the client, on suggestions and complaints, is executed by the Customer Relationship Services department to avoid conflicts with the staff from the sector under evaluation; and this is extremely positive, showing concerns with regards to service suggestions and complaints and that actions have been taken to keep continuous improvement.

About the interviews, the sample varied from 20 to 120 interviewees, and was made across several units. In a couple of months only 20 interviews were generated due to the number of patients that were not interested in participating.

Concerning the number of clients interviewed on satisfaction, the Maternity Sector is responsible for more than 10% of the total of clients, and the lower participation rate goes to the Emergency Room (1.1%), considering that the institution great majority of clients is related to this sector (57%).

The majority of patients were satisfied with the nursing services level, and the average of client satisfaction is above 99%. The Sector registering the lower level of satisfaction is the Maternity (98.2%), and while analyzing the Sector is important to remember the mother & child binomial is being evaluated, and that the mother is not an inpatient with health problems, but her concerns lay on other nursing services, such as the response when the bell is rang, and the attention given to her child and family.

In relation to the evaluated attributes, the one clients scored the highest was the nursing service at the ICU sector, with 100% of patients satisfied. It is important to enhance that in many opportunities interviews were not made by the inpatients of that Sector, but by their family members, and those have the perspective of nursing services rendered during the time they were visiting the patient.

The evaluation process with focus on patients is an efficient strategy, because it conciliates efforts to understand their needs with systems to support continuous improvement on quality services, decreasing the physicians' hegemony, which frequently determines quality could only be understood and defined by this professionals⁽¹³⁾.

The nursing staff has to hear the opinion of patients on the quality of services rendered, using that strategy as a tool to implement new methods/best practices which adapt to their tasks and result in humanized and quality healthcare⁽¹⁴⁾.

Therefore, the continuous use of indicators could drive innovation and improvement on evaluation processes, and consequently, on planning, organization and management of services⁽¹⁵⁾.

Although patients are not prepared to evaluate services related to technical aspects and professional competence, when given the opportunity, they express opinions while inpatients regarding the health team and the impact of services rendered. Measuring client satisfaction is an important component, but it establishes only one of the indicators used for quality control, considering quality can only be confered when the analysis contemplates its global aspects⁽¹⁶⁾.

Quality and satisfaction can, therefore, demonstrate when services and results meet expectations, once what matters in any activity sector is how clients perceive services⁽¹⁷⁾.

Satisfaction on healthcare services is associated to the resolution of a problem that motivates a client to look for such service, evaluate and compare what was desired to what is experienced, and reflects what is expected and what is perceived as acceptable⁽¹⁸⁾.

CONCLUSION

When studying client satisfaction related to some attributes of nursing services rendered to clients using the targeted hospital, results show that more than 99% of them were satisfied.

It is considered that client satisfaction is driven by the process of fulfilling client expectations and needs regarding nursing services. Thus, it is evident that the methodology used can measure satisfaction results and contribute to continuous improvements. Such improvements are achieved through changes to the organizational culture, values and principles, generating a client base who becomes protagonist of the quality achievement process for healthcare services.

The results obtained in the present study were not conclusive, and still require new investigations about unsatisfied clients through qualitative analysis so as to identify the dissatisfaction roots and the impact it represents for the Nursing Department and for the organization as a whole.

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*

Estudo realizado em uma Instituição Hospitalar do Município de São Paulo - São Paulo (SP), Brasil.

Publication Dates

• Publication in this collection
  03 June 2009
• Date of issue
  2009

History

• Received
  06 June 2007
• Accepted
  05 Nov 2008