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Patients’ satisfaction with nursing care in Jordan

Article  in  International Journal of Health Care Quality Assurance · November 2003

DOI: 10.1108/09526860310495660

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Jafar Alasad Alshraideh Muayyad Ahmad

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Patients’ satisfaction with nursing care in Jordan
Keywords
Patients care, Nurses, Teaching,
Hospitals, Jordan
Abstract
This exploratory study
investigated patients’ satisfaction
with nursing care at a major
teaching hospital in Jordan. A total
of 266 in-patients participated in
the study. Patients were recruited
from the medical, surgical, and
gynecological wards. Pearson
correlation, one-way analysis of
variance, and logistic regression
analyses were used. The findings
showed that patients in surgical
wards had lower levels of
satisfaction than patients in
medical or gynecological wards.
Gender, educational level, and
having other diseases were
significant predictors for patients’
satisfaction with nursing care.
Methodological challenges,
implications to nursing practice,
and recommendations to nursing
research are discussed.
The authors are grateful for
the University of Jordan for
funding this study. Thanks
also extend to the hospital
administration who granted
access to the clinical
settings. We also would like
to thank the following
research assistants: Hamza
Ratrout, Maysoon Al-Otoum,
Mohannad Abualruz, Muna
Hammash, Reem Al-Qasem,
and Wadah Da’meh.
According to the World Bank report (1999),
improving the quality of health care delivery
system is considered a major challenge that
International Journal of Health
Care Quality Assurance faces health care providers in Jordan. This
16/6 [2003] 279-285
# MCB UP Limited
[ISSN 0952-6862]
[DOI 10.1108/09526860310495660]
Jafar A. Alasad
Assistant Professor, Clinical Nursing Department, Faculty of Nursing,
University of Jordan, Amman, Jordan
Muayyad M. Ahmad
Assistant Professor, Clinical Nursing Department, Faculty of Nursing,
University of Jordan, Amman, Jordan
Introduction
There has been increasing interest in
patients’ satisfaction with nursing care in the
past few decades (Comley and DeMeyer, 2001;
Shikiar et al., 1999). Patient satisfaction with
nursing care is considered an important
factor in explaining patients’ perceptions of
service quality. Satisfaction is the
psychological state that results from
confirmation or disconfirmation of
expectations with reality (Jackson et al., 2001;
Weingarten, 1995). Consequently, a
dissatisfied patient is not considered
psychologically or socially well and thus the
goal of nursing has not been attained
(Dufrene, 2000; Ottoson et al., 1997). It is
important for nurses to let patients express
their views of care and incorporate these
views in the provided care (Petersen, 1988).
Health care providers in developing
countries seem to be ignoring the importance
of patients’ perceptions regarding health
services (Andaleeb, 2001). Thus, a scarcity of
literature made it difficult to find research
examining patients’ satisfaction with
nursing care in developing countries.
Quality of health care in developing
countries usually is defined by health care
providers from technical perspective. Recent
literature however, emphasizes the
importance of patient’s perspective in
assessing quality of health care (Andaleeb,
2001). According to O’Connor et al. (1994,
p. 32):
It’s the patient’s perspective that increasingly
is being viewed as a meaningful indicator of
health services quality and may, in fact,
represent the most important perspective.
The Emerald Research Register for this journal is available at
http://w ww .emeraldinsight.com/researchregister
study, probably, is the first patient-centered
study that identifies the satisfaction factors
that are important to patients in Jordan.
Despite the enormous number of studies in
Western countries over the past decade on
patient satisfaction, it seems that consensus
on its definition remains a matter of
stipulation (Wallin et al., 2000). Patient
satisfaction is a term that can be interpreted
differently by patients and its meaning can
also differ for one patient at different times
(Larson et al., 1996; Shikiar et al., 1999). The
multidimensionality of patients’ satisfaction
forms an obscurity in examining this
concept. Through the extensive research that
has been done in the medical care
dimensions, many concepts have been used
to examine patients satisfaction. It has been
interpreted as art of care, technical quality of
care, accessibility and convenience, efficacy
of outcomes of care, cost of care, physical
environment, and availability and continuity
of care (Fakhoury, 1998). Furthermore,
Patients’ satisfaction has been used as an
indicator to measure the quality of health
care provided by nurses (Lledo et al., 1999;
Niedz, 1998). More specifically, the
assessment of quality of health care from
patient’s perspective has been
operationalized as patient satisfaction
(Dufrene, 2000). In this study, patient’s
satisfaction with nursing care is defined as
the patient’s opinion of the care received
from nursing staff and is acknowledged as an
outcome indicator of the quality of nursing
care.
Patients’ satisfaction has been advocated
as an outcome measure of quality nursing
care (Comley and DeMeyer, 2001;
Donabedian, 1980). There are seven main
dimensions that have been addressed in the
literature as crucial in the measurement of
patients’ satisfaction. These dimensions are:
The current issue and full text archive of this journal is available at
http://w w w .em eraldinsight.com /0952-6862.htm
[ 279 ]
Jafar A. Alasad and respect for patients’ values, preference
Muayyad M. Ahmad and expressed needs;
Patients’ satisfaction with coordination, integration and information
nursing care in Jordan
flow;
International Journal of Health
Care Quality Assurance information and education;
16/6 [2003] 279-285 physical comfort;
emotional support and alleviation of fear
and anxiety;
involvement of family and friends; and
transition and continuity (Ryden et al.,
2000).
Accordingly, patients’ satisfaction
measurement tools should consider the
aforementioned dimensions.
Various studies have presented
controversy in the results concerning
possible relationships between patient
characteristics and their satisfaction with
nursing care (Minnick et al., 1997; Williams
and Calnan, 1991). Satisfaction with nursing
care was found to increase when patients
become older in their age, having better
functional health status, being in private
rooms, and being hospitalized in surgical
wards (Crooker and Near, 1998; Jackson et al.,
2001; Thi et al., 2002; Williams and Calnan,
1991). On the other hand, no correlations
were found between patients satisfaction and
age, gender, or education (Arnetz and Arnetz,
1996; LoÈvgren et al., 1998; Wallin et al., 2000).
Moreover, patients’ ability to evaluate the
care they receive is reduced when they do not
have enough knowledge about their
condition (Donabedian, 1980; Vuoei, 1991).
The study aims to:
1 examine patients’ satisfaction with
nursing care at a major teaching hospital
in Jordan;
2 assess the quality of nursing care that is
provided at this particular hospital as
indicated by patients’ satisfaction; and
3 compare patient’s satisfaction with
nursing care at major areas within the
hospital.
Method
Sample and setting
An exploratory approach utilizing
cross-sectional survey design was used to
examine patients’ satisfaction with nursing
care at a 600-bed teaching hospital in Jordan.
Sample size was estimated using Cohen’s
technique (1988) for power analysis for F-test
(ANOVA). Since data on the effect size of
relationship between nursing care and
satisfaction of patients were not available,
and to be conservative in estimating the
sample size, a medium effect size (0.25) for
ANOVA was considered. A sample size of 44
for each of the three groups in the study
[ 280 ]
(medical, surgical, and gynecological) was
obtained from the appropriate tables (Cohen)
for an alpha of 0.05, and a power of 0.80.
The study sample (n = 266) constituted all
patients who were admitted to the study
wards and met the inclusion criteria, that is,
being:
18 years or older
in the ward for two nights or more; and
not disorientated.
The participants’ characteristics can be seen
in Table I. A total of 267 in-patients were
invited to participate and 266 agreed.
Participants were recruited from medical
(two wards), surgical (three wards), and
gynecological (one ward) wards. The median
age for participants was 37 years (range 18 to
87); 54 per cent were women. The mean
duration for the length of stay was seven
nights (SD = 8.4).
Procedure
Participation in the study was voluntary and
based on patient’s ability to give informed
consent. The relevant Institutional Review
Board approved the study. Inguanzo (1992)
pointed out that patients tend to be reluctant
to be honest when they feel they might be
identified and or their care may be
jeopardized. McColl et al. (1996) recommend
that administration of patients’ satisfaction
instruments should be carried out by a
neutral individual not involved in patient
care. Accordingly, research assistants from
outside the hospital were recruited and
trained to collect data. Research assistants’
roles were to recruit patients who meet the
inclusion criteria, obtain informed consent,
and deliver and collect the completed
questionnaires. Data was collected from the
relevant wards in two months,
simultaneously. Participants were
guaranteed confidentiality.
Measures
Patients’ satisfaction with nursing care was
assessed using the Newcastle Satisfaction
with Nursing Scale (NSNS); (Thomas et al.,
1996). The NSNS is considered parsimonious
and empirically supported. Moreover, it
covers most of the dimensions of patients’
satisfaction suggested in the literature such
as quality of care and patients views of their
care. The NSNS includes demographic
information, satisfaction with nursing care
scale, and one item-scale (seven point
response scale) of overall patients
satisfaction (Thomas et al., 1996).
The satisfaction scale consists of 19-items.
All items are scored on a five-point Likert
scale (1 = not at all satisfied, 2 = barely
Jafar A. Alasad and satisfied, 2 = quiet satisfied, 4 = very satisfied, satisfaction scale in the wards of the hospital.
Muayyad M. Ahmad and 5 = completely satisfied). Participants In addition, logistic regression was
Patients’ satisfaction with conducted to examine the effect of selected
nursing care in Jordan were asked to rate their satisfaction with
various aspects of nursing care by selecting variables on the probability of patients’
International Journal of Health
Care Quality Assurance only one number that best describes their satisfaction with nursing care (Polit, 1996).
16/6 [2003] 279-285 opinion in each item of the scale. The total
score was transformed to yield an overall
satisfaction score of 0 to 100, where 100 Results
denotes complete satisfaction with all aspects
Correlations between each item in NSNS and
of nursing care. The NSNS was found to be
the medical, surgical, and gynecological
valid and reliable in previous studies (McColl
wards were examined using Pearson
et al., 1996; Preist et al., 1995; Walsh and
product-moment correlation coefficient
Walsh, 1999). The Cronbach alpha of NSNS in
(Table II). While patients in medical wards
the current study was 0.93.
had low satisfaction with the amount
of information they received from nurses
Data management (r = ±0.17, p µ 0.01), they have high
All univariate descriptive statistics were
satisfaction with the nurses’ helpfulness
computed using the Statistical Package for
(r = 0.13, p µ 0.05). A total of 14 items indicated
the Social Sciences/Personal Computer
low levels of satisfaction for patients in
(SPSS/PC). Preliminary data analyses were
surgical wards. Mostly, patients had low
conducted to describe the study sample via
levels of satisfaction with the speed of nurses’
the mean, median, range, standard deviation,
response to their calls, the amount of freedom
variance, and index skewness. The one-way in the ward, nurses’ willingness to respond to
analysis of variance (ANOVA) statistic was requests, and in treating patients as
computed to compare total patients scores in individuals. In gynecological wards, patients
had high levels of satisfaction at 11 items on
Table I NSNS. The highest correlation was with
Participants’ characteristics by area of admission (n = 266) speed of nurses’ response to patients’
M edic al Su rgical G yneco logical requests (r = 0.25, p µ 0.01).
C atego ry n = 82 n = 14 5 n = 39 To tal Table III summarizes the result of
comparing the three main areas (medical,
A g e ye ars )
surgical, and gynecological wards) with
M (SD ) 42 .1 (16 .6 ) 3 6.9 (1 3.5) 37.1 (9 .7) 38 .5 (14 .2)
respect to patients’ score on the satisfaction
G en der scale. The ANOVA results showed a
M ale 43 73 0 116 significant difference in the total score across
Fe m ale 39 72 39 150 wards, F(2, 263) = 8.89, p < 0.001; therefore, it
C las s of adm is s ion was followed by Scheffe’s multiple
P riva te 2 2 5 9 comparison tests to determine which specific
First 9 13 1 23 pairs of areas were significantly different.
Se cond 32 51 13 96 The post hoc tests revealed that patients in
Th ird 39 79 20 138 gynecological ward were more satisfied than
patients in surgical wards. There were no
E duc ation significant differences between medical
Less than nine grade 26 40 12 78 wards and other wards.
H igh sch ool 19 38 8 65 A dichotomous logistic regression model
D iplom a 11 24 8 43
was used to estimate the probability of
B ac helor de gree and 26 43 11 80
patients’ satisfaction with nursing care.
ab ove
There was significant correlation (0.70,
O pe ration s tatus p µ 0.01) between patients’ scores on the
W aiting for opera tion 3 30 6 39 19-item satisfaction scale and the one
O pe ration do ne 8 97 16 121 item-scale (seven point response scales) of
N o operation 71 18 17 106 overall patients satisfaction which reflects
H ea lth ins ura nc e the internal consistency of the NSNS. Thus,
P resen t 78 126 39 243 the one item-scale of overall patients’
N ot prese nt 4 19 0 23 satisfaction was used in the logistic
regression. As performed by Jackson et al.
H aving other disea se(s) 37 55 10 102 (2001), satisfaction was considered as either
Leng th o f s ta y nig hts ) fully satisfied (i.e. rated their overall care as
M (SD ) 8 .4 (10 .9 ) 6.8 (7 .5) 4.9 (3 .9) 7 .1 (8.4) excellent or very good) or not fully satisfied
(i.e. rated their overall care as less than very
Sa tisfaction M (SD ) 7 8.3 (12 .2 ) 74.7 (1 2) 83.6 (1 2.7) 77 .1 (12 .5) good). The process of selecting and entering
[ 281 ]
Jafar A. Alasad and Table II
Muayyad M. Ahmad Correlations between wards and satisfaction items (n = 266)
Patients’ satisfaction with
nursing care in Jordan Item s M edical n = 82 Surgical n = 145 Gynecological n = 39
International Journal of Health
Care Quality Assurance 1The am ou nt of tim e nurses spent w ith you 0.0 6 ±0.12 0.09
16/6 [2003] 279-285 2Ho w capa ble nu rses w ere at their jo b 0.0 8 ±0.12 0.06
3There a lw ays be ing a nurse aroun d if you need on e 0.0 7 ±0.14* 0.11
4The am ou nt nurses knew a bout you r c are ±0 .07 ±0.04 0.14*
5Ho w quickly nurse s ca m e w he n you called for them 0.0 7 ±0.24* * 0.25* *
6The w a y the nurses m ade you fee l at h om e 0.0 7 ±0.20* * 0.19* *
7The am ou nt of in form a tion n urses ga ve to you abou t
co ndition and trea tm ent ±0 .17 ** 0.03 0.18* *
8 Ho w often nurses che cked to see if you w ere O K 0.0 1 ±0.14* 0.18* *
9 Nu rse s’ he lpfulne ss 0.1 3* ±0.15* 0.04
10 The w ay the nurses exp lain ed things to you 0.0 6 ±0.15* 0.13*
11 H ow nurse s helped pu t yo ur re latives’ or friend s’
m inds at rest 0.1 1 ±0.15* 0.06
12 N urses’ m an ner in going ab out their w o rk 0.1 0 ±0.17* * 0.11
13 The type o f inform a tion nurse s gave to yo u about
your condition a nd tre atm en t ±0 .04 ±0.07 0.15*
14 N urses’ treatm ent of yo u a s an individua l 0.1 9** ±0.26* * 0.11
15 H ow nurse s liste ned to your w orries and c oncerns ±0 .02 ±0.13* 0.21* *
16 The am o unt of freedom you w e re given in the w ard 0.0 9 ±0.22* * 0.19* *
17 H ow w illing nurses w ere to respo nd to your requ ests 0.0 6 ±0.22* * 0.23* *
18 The am o unt of privacy nu rses gave you 0.0 8 ±0.15* 0.10
19 N urses’ aw aren ess of your nee ds 0.0 2 ±0.15* 0.18* *
No tes: * p µ0.05. ** p µ0.01

Discussion and conclusions

Table III
The aim of the study was to examine patients’
Means of satisfaction scores in the study areas and F statistics
satisfaction with nursing care at a major
Area n (M /F)* M (S D) F statistics teaching hospital in Jordan. Patients’
M edic al w ards 82 (43/ 39) 7 8.2 7 (12.19) satisfaction was examined in the medical,
Fifth w a rd 38 (17/ 21) 8 0.1 4 (10.87) surgical and gynecological wards of the
Six th w ard 44 (26/ 18) 7 6.6 5 (13.13) hospital in relation to patient’s gender, age,
S u rg ic al w ards 145 (73/ 72) 7 4.6 8 (12.02) class of admission, level of education, length
Sec ond w ard 48 (24/ 24) 7 1.5 1 (12.31) of stay in the hospital, operation status,
Third w ard 49 (25/ 24) 7 5.2 5 (8.1 9) having other diseases, and health insurance.
Fou rth w ard 48 (24/ 24) 7 7.2 6 (14.32) Patients’ response rate was almost 100 per
G yne c olog ic al w ard 3 9 (0/ 39) 8 3.6 4 (12.65) (8.8 9** ) a cent. The problem of low response rate
A ll areas 2 66 (116/1 50) 7 7.1 0 (12.52) associated with postal questionnaires
N otes : * M = M ales, F = Fem ales; ** p µ0.001 ; a D iffere nce b etw ee n surgical w ards and addressed in the literature was avoided in
gyne cologica l w ard this study by having research assistants from
outside the hospital to deliver and collect the
questionnaires. Thus, from the 267
approached potential participants, 266
the variables to the logistic regression model accepted to participate in the study.
was repeated with various orders of entry. Completion of the questionnaire by the
The model that adequately fitted the data ( 2 participant appeared to be simple and there
Hosmer-Lemeshow = 3.32, eight degrees of was no systematic pattern of items being
freedom, p = 0.91) included eight predictor missed. The similarities in response rate in
variables. The estimate of the variance the different areas in the hospital make the
accounted for in the patients satisfaction are comparison between these areas credible.
11.9 per cent (Cox and Snell) and 15.8 per cent Having nurses from the same ward to collect
(Nagelkerke). Three predictors were data imposed threat to patients’ which
significant at p < 0.05. Female patients tended affected their responses (Weingarten et al.,
to be more satisfied than male patients. Less 1995). Therefore, having external data
educated patients and those with no other collectors is recommended to avoid imposing
diseases tended to have high satisfaction threat to patients’ satisfaction results,
(Table IV). increase response rate, and minimize
[ 282 ]
Jafar A. Alasad and
Muayyad M. Ahmad
Patients’ satisfaction with
nursing care in Jordan
International Journal of Health
Care Quality Assurance
16/6 [2003] 279-285
Table IV
Predictors of patients’ satisfaction among fully satisfied patients (n = 134)
versus not fully satisfied patients (n = 132)
Va riables
G en der
C lass of adm ission
Age (ye ars)
Area o f adm ission
H aving other disea se
E duc ation le vel
N ights in hos pital
O pe ration status
N otes : * p µ0.0 5;** p µ0.001
systematic errors in completing
questionnaires.
The result of logistic regression analysis in
this study was relatively consistent with the
findings of other studies (Jackson et al., 2001;
Ottosson et al., 1997; Thi et al., 2002; Wallin
et al., 2000). In their logistic regression
analysis, Thi et al. (2002) identified factors
associated with in-patient satisfaction with
nursing care. They reported that older age
and higher general health perception were
the strongest predictors of higher
satisfaction. Jackson et al. (2001) emphasized
the importance of functional health status as
a predictor for patients’ satisfaction. In our
study, being female, having less education,
and having no other diseases were the
significant predictors for higher satisfaction.
Patients with no other diseases tended to
have higher satisfaction than those with
other diseases. This finding is consistent
with Ottosson et al. (1997) who concluded that
patients who are successfully treated, the
state of their good general health will result
in high satisfaction scores. Moreover,
Greenfield et al. (1993) found that patients
with co-morbid diseases may be sicker and
have a worse outcome than other patients.
Using a valid measure such as ``Charlson et al.
(1987) index’’ to give weight for the co-morbid
conditions among the study population could
control for the effect of health status on the
outcome measure
While there was no correlation between
gender and patient satisfaction in Wallin et
al. (2000) study, Ottosson et al. (1997) reported
higher satisfaction among males than among
females. In the current study, female patients
tended to have higher satisfaction than male
patients. Further analysis revealed
significant correlation (p < 0.01) between
gender and education level. The logistic
regression finding that patients with higher
educational level were not satisfied with
their care goes consistent with the findings of
other studies (Minnick et al., 1997; Wallin
B SE W ald O dd s ratio (C I 95 per cent)
0.66 0 .29 5.28 1.93*
0.02 0 .18 0.01 1.02
0.01 0 .01 0.29 1.01
0.27 0 .24 1.28 1.31
±1 .13 0 .30 14.03 0.32**
±0 .29 0 .12 5.79 0.75*
0.02 0 .02 1.37 1.02
0.21 0 .21 1.01 1.24
et al., 2000). In the current study, of the 143
patients who have less than high school
education, 63 per cent were females. On the
other hand, 44 per cent of the 80 patients who
have baccalaureate degree and above
education were females. This could
contribute to the difference in satisfaction
between males and females.
In comparison between wards,
gynecological ward had significantly higher
percentage of satisfaction with nursing care
than the surgical wards. Although
gynecological ward includes only female
patients, mostly the difference between
gynecological and surgical wards would not
be the contribution of gender effect only, as
this difference did not appear between
gynecological ward and medical wards.
Inconsistency in the literature was found
regarding the relationship between age and
satisfaction. While Wallin et al. (2000) did not
find a correlation between age and patient
satisfaction, other studies found age to be a
significant predictor for satisfaction
(Jackson et al., 2001; Ottosson et al., 1997;
Singh et al., 1999). In the current study; age
was not found to be a significant predictor for
patients’ satisfaction.
In order to explore any potential factors in
the settings of the studied areas that may
alter patients’ responses in the NSNS, the
researchers of this study made a follow up
visit to the relevant wards. The main obvious
landmark was that the gynecological ward is
designed in a close to circle shape which
could make the nursing’ station closer to all
patients. However, if this factor contributed
to the significant difference between
gynecological ward and surgical wards, it
should be also the same with medical wards.
The director of nursing in the hospital
commented that one of the three surgical
wards involved in the study had high
turnover during the period of data collection
which could explain the differences.
Examining individual items in the
satisfaction scale revealed aspects of nursing
care with which patients were most and least
satisfied. Consistent with findings of
previous studies (Larson et al., 1996; McColl
et al., 1996), the aspects with which patients
were least satisfied (regardless of admitting
ward) were the amount and type of
information they receive regarding their
condition and treatment. The top aspects that
patients scored highest for their satisfaction
with nursing care were the feeling of privacy,
nurses capability at their job, and nurses
helpfulness. It is generally believed that
elements of privacy, respect, and advocacy
which nurses consider through their practice
[ 283 ]
Jafar A. Alasad and
Muayyad M. Ahmad
Patients’ satisfaction with
nursing care in Jordan
International Journal of Health
Care Quality Assurance
16/6 [2003] 279-285
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