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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.38 no.2 Porto Alegre  2017  Epub July 13, 2017

http://dx.doi.org/10.1590/1983-1447.2017.02.58962 

Original Articles

Satisfaction with nursing care in drug users: the evolution of a scale

Paulo Rosário Carvalho Seabraa 

Luis Octávio Sáa 

José Joaquim Penedos Amendoeirab 

Ana Leonor Ribeiroc 

a Universidade Católica Portuguesa, Instituto de Ciências da Saúde, Centro de Investigação Interdisciplinar em Saúde (CIIC). Lisboa, Portugal

b Instituto Politécnico de Santarém, Escola Superior de Saúde, Centro de Investigação Interdisciplinar em Saúde (CIIC), Santarém, Portugal.

c Escola Superior de Enfermagem do Porto. Porto, Portugal.

ABSTRACT

Objectives

To identify the degree of satisfaction with nursing care, the significant variables and contribute to the evolution of the scale.

Methods

Descriptive, correlational, cross study, with 180 drug users. Data collected using the scale called “Satisfaction of users with the Nursing Health Center26”, between February and December 2012 in three treatment units in the region of Lisbon and Vale do Tejo, Portugal.

Results

Users indicated 83.3% satisfaction. The dimension “Information individualization” was the most marked (98.5%). The more stability in the programs, abstinence from stimulants and benzodiazepines and more nursing interventions, the greater the satisfaction. Better working conditions, specializing in mental health, younger ages and less experience of nurses also contributed to satisfaction. Four items of the scale were extracted, assuming new SUCECS22 designation.

Conclusions

Satisfaction was high, influenced by structural variables of users, nurses and working conditions. The scale has proved suitable for assessment in this population.

Key words: Substance-related disorders; Nursing; Patient satisfaction; Mental health; Working conditions

INTRODUCTION

In the substance dependent population, difficulties in social and family life, emotional distress and other indicators that may influence the relationship with health professionals on who they rely have been described. This population has the particularity of having a high prevalence of physical and psychological co-morbidities, responsible for the increase in disabilities associated with substance abuse. These problems identified by users, imply high consumption of nursing care, leading to their satisfaction with health care and particularly nursing care, being an area of interest in the research.

One of the therapeutic responses for opiate addiction have been pharmacological assistance therapeutic programs. Different maintenance programs with methadone (opioid agonist), are offered to users based on personal characteristics, their goals and intervention strategies outlined in multidisciplinary teams. User satisfaction with health care is a key variable for the success of the programs, as they are characterized by years of participation and membership, and important factors of quality of life1. The escalating growth of dependence on opiates and new relapses of users who had previously successfully completed treatment programs, correspond to a greater interest in the scientific community to study the issue.

Satisfaction with health care has been investigated by various disciplines as a quality indicator, related to the health of users2. Studying satisfaction with nursing care is an effective way to evaluate the results of independent intervention, especially when the instrument used in this assessment is directly related to nursing care3 and when the indicators of the results obtained by users are sensitive to care. It can also be better evaluated when the tool creates a relation between the care provided and the needs and expectations of the beneficiaries4-5.

“Satisfaction with nursing care” is an attitude towards nursing care from someone who was the beneficiary in their own health/disease process3,5-6, i.e., as a subjective evaluation of cognitive and emotional control resulting from the interaction between user expectations about nursing care and their perception of the real behavior and characteristics of nurses. It is defined as a series of reactions by people to the experience of health care, and the distance between what one expects of care and their perception of the care received.

There has been some research relating satisfaction to care, and accession, as behavior of patients that coincides with professional advice. Satisfaction can be considered as a good indicator to assess the quality of care3,7, and is considered a result sensitive to nursing care6. The evidence that the research seeks to prove attempts to demonstrate the need to effectively assess this dimension in a complex environment for which reliable and well adapted measurements to each cultural context are needed3,8.

Assessing satisfaction with nursing care implies that the user is aware of the nursing practices exercised. It is necessary to combine what both nurses and users, consider as a result of nursing care, for if the nurses mostly value the emotional support, studies show that more users value the technical and educational aspects6.

Satisfaction with nursing care is influenced by the perception of quality, personal aspects of users, structural aspects of professionals – job satisfaction and its conditions, environment, workload, type of management, among others6. Satisfaction with nursing care despite not being controlled by nurses, improves adherence and increases the functionality of users8. The results of this evaluation should be carefully considered when the vulnerability of users is very high and when the instrument does not assess the true essence of nursing care6.

Regarding the importance of the characteristics of health facilities and their relationship with the process of care, it appears that the time for indirect care, from the perspective of care at the outpatient clinic, can be crucial to ensure the quality of direct care. The perception of time for the care relates to the support and justice that professionals sense from their organizations, which in turn, contributes to meeting their needs as professionals, helping them identify more with the work, improve their performance and increase job satisfaction9.

Several researches address the concern with nursing care satisfaction in two perspectives, outpatient and hospital care3-4,10, however, internationally research on drug users satisfaction with nursing care is unknown. The relationship between satisfaction with care and the structural variables of nurses, units and users is also still unknown. Thus, based on existing knowledge, the following objectives were established for this research: To identify the degree of satisfaction with nursing care, the significant variables and contribute to the evolution of the scale.

METHODS

A quantitative, descriptive, correlation study with a lateral approach was developed. The study population were 180 individuals that were dependent on illicit substances integrated in methadone maintenance programs. Data collection took place between February and December 2012 in three outpatient monitoring units in the region of Lisbon and Vale do Tejo, Portugal. This study is part of a doctoral study in nursing11.

A systematic random probability sampling was used, sequentially requesting participation (n + 2) during the medical care programs. Inclusion criteria: a) Being of age (18 or older); b) Being integrated into the program for at least 1 month. Exclusion criteria were as follows: a) Being a minor; b) Participating in a methadone program for under a month; c) Change in level of consciousness.

The data collection instrument consisted of a questionnaire that allowed to obtain demographic, clinical and behavioral data related to drug use and the evaluation of characteristics of nurses and their working conditions. An instrument was selected to measure satisfaction with nursing care in outpatient units, built and validated for the Portuguese population, knowing that such instrument had never been used in a monitoring unit for dependents of illegal substances. The scale “Satisfaction of users with nursing care at the health center (SUCECS26)” was used3. The original scale consists of 26 items in which participants assign a value to a Likert 4-point scale (0-3). Higher values correspond to better satisfaction with care (0-78). Six subscales comprise this scale: formalization of information (2 items), quality of care (9 items), individualization of information (6 items), involvement of the patient (3 items), information of available resources (3 items), promotion of a bond (3 items). It should become a percentage grouping dimensions: dividing the value obtained for each dimension by the maximum points possible in the set of items of said dimension multiplied by 100.

The use of the scale with this study’s population occurred differently from the original study in which the interview was conducted after patient discharge via telephone3. For this research, the instrument was applied in person with users who were still in the treatment program. This scale is well proven in other contexts of care, with a clear indication for use in different outpatient populations10,12.

In the SUCECS26 care satisfaction evaluation, good internal consistency was verified (Cronbach’s alpha 0.89)3 in the validation research for the Portuguese population (n = 225) in 2003, as in a more recent study (n = 200) (0.81 alpha)10.

The Job Diagnostic Survey (JDS) was used to characterize working conditions13. It is a scale that assesses five dimensions that are characteristics of the work: variety of skills, work identity, meaning of work, autonomy and feedback. Regarding fidelity, a Cronbach’s alpha of 0.70 was found. On this scale, the items (3 items for 5 factors each) can be classified in a 1-7 interval and values in the interval between 15-105 may be ascertained, with higher values corresponding to better work conditions.

The data collected were analyzed statistically using SPSS 22 using descriptive and inferential statistical procedures. The use of the tests was determined from the analysis of the data. We use parametric statistics, assuming the “central limit theorem” supported by distribution that is close to normal. To study the association between variables, the values were calculated by the Pearson correlation coefficient. To study the average difference between the samples according to the set number of categories, the ANOVA test was used with post-hoc Bonferroni contrast in some situations and in others, the T-Student test. The minimum acceptable confidence interval was of 95%. For the study of the scale construct validity, exploratory factor analysis was applied first and after, the confirmatory analysis by the Principal Components Analysis methods (PCA). Orthogonal factor rotation (varimax) was used, to interpret the solution of each analysis, ensuring data was adjusted to factor analysis using the Kaiser-Meyer-Olkin (KMO) test.

The participation of users was solicited through a free and informed consent form. This study received a positive opinion from the Ethics Committee of the Instituto de Ciências da Saúde da Universidade Católica Portuguesa.

RESULTS

The sample (n = 180), obtained from a population of 1183 users in the program was essentially male (n = 132; 73.3%). The average age was set at 41.06 [24-69]; sd = 7.58. As for education, 3 (1.7%) participants had ≤ 4th grade; 25 (13.95%) completed 4th grade; 63 (35%) completed the 6th grade; 58 (32.2%) completed the 9th grade; 26 (14.4%) completed the 12th grade and 5 (2.8%) completed higher education. Regarding marital status: 100 (55.6%) were unmarried; 18 (10%) were married; 36 (20%) in a common-law marriage; 22 (12.2%) were divorced and 4 (2.2%) were widows. Regarding being parents: 95 (52.8%) had children.

As for employment status: 55 (30.6%) were employed; 87 (48.3%) unemployed; 17 (9.4%) had sporadic work; 17 (9.4%) were retired and 4 (2.2%) were in subsidized professional training.

On the substance use (possibility of providing multiple responses), we found that 25 (13.9%) reported consumption of heroin, 46 (25.6%) consumption of stimulants; 52 (28.9%) cannabis; 55 (30.6%) alcohol and 33 (18.3%) consumed benzodiazepines. We found that 52 users (28.9% of the total sample) consumed no substances other than the methadone prescribed.

The comorbidities were very present, 45 (25%) were HIV positive, 106 (58.9%) were positive for HCV; 43 (23.9%) had at least one mental disorder as double diagnosis (particularly anxiety, depression and schizophrenia); 80 (44.4%) had physical diseases (except viral infection) and 27 (15%) had no comorbidities. The average age for the onset of consumption was 18.2 years (sd = 5.5) and a mean age of 16.7 years (SD = 7.6) of substance abuse was established. The average length of stay in the program was 52.8 months (sd = 43.3) i.e., slightly more than four years.

The fidelity of the SUCECS26 satisfaction assessment performed, re-evaluating its psychometric properties, revealed a α = ,838. We checked the scale’s total-item correlation and this analysis forced the need to remove three items (10, 14 and 21) by correlation of item-scale total <0.200, as it is the value pointed to the possibility of eliminating items with the intention of improving the overall performance of the scale. All commonalities had values> 0.40. The suitability of data to factor analysis revealed a KMO 0.780 (p <.001). Factor analysis by the method of principal components, showed 63.87% of the variance explained by a number of 8 factors which differed form 6 factors presented by the authors in the original scale.

When items 10, 14, 21 are extracted, all items showed a total-item correlation> 0.200; increasing the fidelity (α = ,857) and a KMO of 0.797 maintaining the stability of Bartlett’s test; the commonalities remained above 0.400. Conducting a new exploratory factor analysis, given the data had already been better adjusted, a variance of 64.67% was found, but with 7 factors. This presentation of the scale with seven factors differed from the theoretical matrix of the original instrument with six, related to the spectrum of dimensions of “quality” that it mattered to maintain. It was immediately decided to seek another solution, in addition to 3 items weighing in more than one factor with a difference <0.10.

By confirmatory analysis (excluding items 10,14,21) forcing the 6 original factors of the scale, it was found that all the commonalities remained above 0.300. The total variance explained after rotation fell to 60.31% and 4 items weighed by more than one factor with a difference <0.10. Later, all hypotheses were tested extracting 4 items from each, but considering its theoretical importance for each subscale and the dimensions of quality. It was decided that only item 9 would be extracted, as it was the most theoretically irrelevant (related to the provision of written information). The KMO rose to 0,801 and the total variance explained by the six factors increased to 62.04%. All commonalities settled above the 0,400 and the internal consistency remained (α =, 857) higher than the initial alpha value of the first evaluation with all items. Thus, the most stable structure was determined by 6 unique factors, it being possible to determine the items that most weighed on each factor, using the guidance of the author itself, attributing them to the factor which had a higher factor load. An exception was made to this criterion keeping item 18 in the factor related to the role played by nurses in interdisciplinary articulation, and not as the data suggests, in the satisfaction with user involvement (Table 1).

Table 1 – Factor loads and variance per factor (continue) 

Factors

1 2 3 4 5 6
31 Do you feel that nurses show themselves as up to date and knowledgeable professionals? .790
30 In relation to how nurses are rendering care .755
28 Do nurses regard your opinion in the nursing care they provide to you? .603
32 Are you relatively satisfied with the nursing care in TT? .555 .479 .374
24 Do you feel that nurses provide care in a sympathetic way? .439 .322 .351
26 Do you think the nurses demonstrate patience when providing care? .428 .380 .396
1 Regarding the information that you think is necessary to deal with your needs in nursing care, do the nurses provide you with this information? .771
2 Do you feel that the nurses worry about teaching what is needed to deal with your needs during the care that is provided? .708
25 Do you feel that nurses give importance to your problems? .310 .605
29 Are you satisfied with the knowledge that nurses have about the care you need? .442 .499
13 Are nurses worried about explaining your rights and obligations as a user of TT? .780
12 Are nurses concerned with reporting on the operation of the TT (Opening hours, type of consults, the location of nursing rooms, treatment rooms, vaccine rooms ...)? .701
6 Are you satisfied regarding how nurses explain things (language used, the concern of repeating if the information was not understood)? .304 .645
27 Do you feel that nurses put you at ease to ask your questions? .796
11 Are you satisfied regarding the way you are cared for by nurses in TT? .575
18 When needed, is it easy to contact the TT nurses (to make an appointment, to ask questions)? (.598) .522
22 Are you satisfied with the availability of nurses (to listen to your, or even remedy a situation related to the care provided) .311 .332 .490
4 Do nurses worry about providing you information about the services at your disposal (e.g. homes, social services ...)? .843
5 Are nurses concerned about informing you of how you can use the health services available (how and when to use them)? .375 .806
3 Regarding information, are nurses concerned about involving your relatives or the people closest to you (explaining your situation and how they can help you when you need it)? .718
8 Do nurses ask if you have understood or if it is necessary to repeat the information? .871
7 Do nurses try to explain things in an understandable way? .807

Current variance explained 27.80% 10.57% 6.90 % 6.24% 5.73% 4.78%

Source: Seabra, 2014(11)

TT: Treatment Team

The factors were maintained respecting the original model (spectrum of quality dimensions) but changing or exchanging some of the items between factors and reordering the very factors considering their weight. It was found that some items were not completely independent because they saturate in more than a factor, but it was decided they would be kept for their theoretical importance for the assessment of satisfaction. Factor analysis suggests a scale with 22 items, which was used in this study. Evaluating the internal consistency, the coefficients of the subscales were acceptable (Table 2).

Table 2 – Factor structure of the SUCECS22 form and internal consistency of the subscales 

Name of factor Number of items Alpha
1 – Quality in assistance 6 .761
2 – User involvement 4 .768
3 – Information formalization 3 .617
4 – Bond promotion 4 .611
5 – Resource information 3 .777
6 – Information individualization 2 .715

Source: Seabra, 2014(11)

To assess the validity of the tool and its robustness, the study of the association between the different domains and the full scale was further deepened, where it was found that all Pearson correlation values were significantly moderate or strong and that the dimension with the greatest association with the total scale was the subscale “Patient involvement” (r = 827). Among the subscales, moderate associations occurred in almost all correlations between, the most significant being the subscale “Involvement of the patient” and the subscale “Bond promotion” (r = 514).

Regarding the satisfaction results calculated, with the scale adapted to 22 items (response range 0-66) the average x = 55.4 [33-66]; sd = 6.43 was found, which was equivalent to 83.29% of satisfaction. Regarding the values of each subscale, results found in descending order were as follows: In the subscale “Information individualization” the value of 5.91 (98.5%); subscale “Information formalization” 8.14 (93.4%); “Quality in care” 16.74 (88.8%); “Bond promotion” 10.64 (88.6%); “Patient involvement” 9.41 (78.41%); and lastly, with the lowest value, the subscale “Resource information” 4.57 (50.7%). It was noted that the satisfaction with nursing care in the units where the study was conducted was generally very good in all subscales, except when referring to availability to inform the users about resources that were at their disposal. Users were more satisfied with the nurses in the aspects related to the information related to their monitoring (individualization and formalization).

As for the relationship between the values of satisfaction with the care and some structural variables of users, no significant differences regarding age, gender, the fact of if they were in a conjugal relationship, whether they had children or not, literary qualifications, type of occupation, employment status, type of income. When it came to clinical and behavioral variables on consumption, there were no significant relationships between the number of comorbidities, type of comorbidity, the number of substances consumed, means of consumption and satisfaction with care. Regarding the variables related to technical monitoring, there were no relations between the period for which the user was in the program and satisfaction; between the dose of methadone and satisfaction.

Statistically significant differences: The higher the number of nursing interventions that participants were subjected to, the greater the satisfaction with nursing care (F = 17.096, p <.05); The greater the number of entries in the program, the lower the satisfaction (r = – 220; p <.001). As for the difference in perceived satisfaction, given the type of substance consumed, it was found that satisfaction was lower in those that consumed stimulants x = 53.63; SD = 7.06 compared to those that did not consume them x = 56.01; SD = 6.10 (t = 2.192, p <.05). It was even lower in those who consumed benzodiazepines x= 52.03; sd = 7.60, compared to those who did not consume them x = 56.16; sd = 5.90 (t = 3.434, p <.05).

Looking for the influence of structural variables of nurses and working conditions in satisfaction with care, it was found that the variables that contribute to a higher level of satisfaction were: A lower age in nurses (F = 13.454, p = .004); higher professional qualifications, including specialization in mental health nursing (t = 5.434, p <.01); better working conditions (r = 410, p = <.001); lower nurse/user ratio (r = – 190; p = 011); more hours for indirect care (r = 220, p = .003). It was also found that less work experience (F = 17.09, p <.01) and less experience with dependents (F = 17.09, p <.01) were associated with greater satisfaction with care.

DISCUSSION

Satisfaction with care, perceived and expressed by users, resulted in the quality of care, according to this study4,14. Satisfaction with nursing care emerged as high (83.3%), higher than the satisfaction expressed in more general nursing care settings such as permanent service centers10 and nursing consultations with diabetic patients12. There are dimensions of satisfaction that were most valued by users: attention to individualization (the dimension with more satisfaction – 98.5%), information formalization, demonstration of quality in care, user involvement and action by nurses as bonding. The data suggest that the difficulty or lack of answers to the many needs, caused by socio-economic conditions and comorbidities of users, imply lower satisfaction with the role played by nurses when informing them about resources that can meet their needs. The ability of nurses to solve the problems of users, contributes to the satisfaction with care15 . The data reinforce the idea that the training of nurses, in this case specialization in mental health, acts as a key pillar for the quality of care 6,16-17.

The behavior of some variables reinforces the literature consulted. The data shows that greater amount of hours for indirect care (essential for planning of care), and a larger number of interventions, are associated with greater user satisfaction with nursing care4. In some contexts, users primarily value the technical and educational aspects, others value the opportunity to participate in decisions and be informed about their health10, as in this study, the findings associate greater satisfaction in the dimensions related to information and the opportunity to participate in decisions. It is noted that, as in the literature, lower job satisfaction, uncomfortable and maladjusted environment, poor working conditions, more hours of care and overload, lower nurse/user ratio, were associated with lower user satisfaction with the nursing care17 as these factors can prevent the proper assessment of needs18.

With regard to the variables of users, age, gender, education and health status, which appear in the literature as determinants for satisfaction19, did not reveal to be significant. The study also found less satisfaction with nursing care in those who identified as having mental disorders, which reinforces the need for better evaluation of the users and better targeted interventions20. The findings in this study suggest that maintaining consumption, especially of stimulants and benzodiazepines, was significantly associated with lower satisfaction with nursing care. This information also meets the regulatory actions carried out by nurses, the rules of these programs and the emotional state that can be associated to these consumptions. It was shown that being subjected to more nursing interventions, as well as greater stability in the programs relate to better satisfaction with nursing care. This analysis can be associated with evidence that, being subjected to more nursing interventions promotes better satisfaction, which is manifested in improved adherence8, and that in this study may be considered for greater stability in the programs.

Regarding the re-evaluation of the psychometric characteristics of the scale, we can consider that, in this population, the data reinforced its reliability and consistency. The decisions made were based on the theoretical options of the analysis construct and statistical validity, but reinforce the need to consider the theoretical basis of the concept under study. The scale has been strengthened, losing four items and the researchers suggest the designation SUCECS22. No changes are suggested in the designation of the scale to enable a more universal coverage and multiple settings where nursing care is provided on an outpatient basis.

CONCLUSION

The variable satisfaction with care, a crucial pillar in the normative guidelines for health care, has been identified as one of the best ways to evaluate the contribution of each professional group for health results achieved by people. This research was intended to contribute to the consolidation of the continuous improvement of systems of quality in the practice of nurses. Several crucial indicators emerged for the quality of care, or that were key to better care and better health outcomes achieved by people: the need to invest in graduate training in mental health and the need for attention to the quality of working conditions, for when they are lower, they impact the quality of care that leads to lower patient satisfaction. Surprisingly, the older, more professional experience and working with dependents, were related to lower satisfaction with nursing care. The data showed that the variables associated with greater experience of nurses, were conditioned by the lower perception of working conditions and the lower nurse/user ratio. These data highlighted the importance of resource management and labor conditions for obtaining better health outcomes.

When users for some reason leave the medical programs, and seek them later, or reentrance in the program is proposed, they experience instability processes that are often associated with lower satisfaction with care. The continuity of nursing intervention is associated with more satisfaction with care, and impact on the quality of life of users by promoting better adherence. These empirical indicators could be deployed in providing care for greater effectiveness of interventions, better planning and monitoring of care. The permanence in the program and satisfaction with care received from nurses has emerged as an important recommendation. These are protective factors that reinforce the need for more flexible programs that meet every need, and that can prevent the discontinuance of users.

Regarding the evolution of the scale, in theory, it maintained the same number of sustainable factors in the quality framework, but when applied to a different population, it led to a reduction in the number of items and the reorganization of these items by other factors that have acquired a new expression of variance explained by each factor. This solution seemed more appropriate for this population, but it should be re-evaluated in future research. The study on satisfaction with nursing care should proceed, for which this research intended to contribute. In this sense, a challenge is posed to future research with the deepening experiences related to satisfaction with care as the encounter of subjects, something that a statistical approach does not allow. A limitation of this research is the fact that no studies were found on the satisfaction of dependent drug users, which affects data comparability. This study is a contribution to this comparative data.

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Received: December 02, 2015; Accepted: April 04, 2017

Corresponding author: Paulo Seabra. E-mail: pauloseabra@ics.lisboa.ucp.pt

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