Patients‘ Satisfaction with Surgical Care Impaired by Cuts in Expenditure and After Interventions to Improve Nursing Care at a Surgical Clinic

PergamonIntanationai Journal for Quality tn Health Care, VoL 9, No. 1, pp. 43-53,1997

Copyright O 1997 Elsevia Science Ltd. All rigbu reservedPrinted in Great Britain

PH: S1353-4505(96)00082-8 1353-4505/97 sn.oo+o.oo

Patients' Satisfaction with Surgical Care Impairedby Cuts in Expenditure and After Interventions toImprove Nursing Care at a Surgical Clinic

BARBRO OTTOSSON,f INGALILL R.HALLBERG.t KARIN AXELSSONJ andLARS LOVEN§

t Care Research and Development Unit, Lund University andKristianstad University College of Healdi Sciences, Box 98, S-291 21 Kristianstad, Sweden; J Department of AdvancedNursing, University of Umea, S-901 87 Umea, Sweden;§ Department of Surgery. County Hospital, S-291 85,Kristianstad, Sweden

Between 1991 and 1994 the number of beds in the surgical dinkat a central hospital in Southern Sweden was cut back by almost50%. To derelop the nursing care and to control the effects of thebudgetary cuts, an intervention, including nursing care develop-ment, of an organization that would secure continuity in the nurse-patient relationship, individually planned care and qualityassurance for aspects believed to be crucial to the quality ofnursing care was implemented. The aim of this study was toanalyse patients' satisfaction with surgical nursing care between,under and after the last cut in expenditure and the concludedintervention. A patient satisfaction questionnaire covering suchareas as: patient satisfaction with information and decision-making; patient satisfaction with contact and the staff-patientrelationship; patient satisfaction with ward facilities and thephysical treatment or examination and patient satisfaction withvarious other aspects of care, was administered (1993 a = 131;1994 n —128). Subsample analysis showed lower scores forpatient satisfaction if the respondents were women, young, oracutely fll when admitted. While surveys carried out between 1991and 1993 showed an overall improvement hi the quality of care, asmeasured by patient satisfaction, it remained at the same level in1994 as hi 1993, or decreased, regarding patient contacts withstaff and physicians, involvement in decision-making, anxietybefore examination/treatment, anxiety regarding professionalsecrecy, opportunity to influence the solution to their physicalproblems, chance to get sleep without being disturbed, physicalnursing care and preparations before discharge. Thus a deteriora-tion in quality seemed to take place in 1994 indicating that the cutsin expenditure may have been too hard and had been made at theexpense of patient satisfaction. © 1997 Elserier Science Ltd. A0rights reserved.

Key words: Patient satisfaction, nurse-patient relationship,nursing care, questionnaire, surgical nursing care,information, quality improvement, patient participation.

INTRODUCTION

Patients' satisfaction is considered an important out-come criterion to health services. This professed utilityrests on a number of implicit assumptions regarding thenature and meaning of expressions of satisfaction [1].Logically, patient satisfaction is an important measurewhen the quality of nursing care is assessed. A dissatisfiedpatient is not psychologically or socially well and thus thegoal of nursing has not been attained [2].

Patient satisfaction is based on patients' own opinionand evaluation of the care they receive [3]. It is a measurewith limitations when the quality of nursing care isassessed. Patients do not always have enough knowledgeto appreciate the various aspects of care for instance. Thisreduces their ability to evaluate the care [4]. If patients aresuccessfully treated, the state of their health can bereflected in high satisfaction [5]. Also satisfaction seemsto relate to expectations. Patients who are positivelysurprised have an overall higher mean score on patientsatisfaction than patients who are negatively surprisedduring the treatment period [6]. Older people tend to bemore satisfied with most aspects of hospital care thantheir young or middle-aged counterparts [7]. Anotherlimitation in the assessment of patient satisfaction is thatpatients may be reluctant to be honest when the hospitalis small and they can feel they might be identified [8].

Issues concerning nurses' professional competence,together with the nature and quality of the nurse-patientrelationship, are assumed to be key predictors of patients'overall satisfaction with general medical practice [7]. Thequality of the nurse-patient relationship for instance issignificant for how information is interpreted and under-stood. If they do not understand each other, mistakes caneasily be made and important information may be lost[9]. Nurses' attitudes and ways give the tone to theinterpersonal environment where patients and nursesrelate to each other. Patients depend on informationand need to know what goes on and why, since they arenot in charge of their own health and care. Thereforeadequate information is one important aspect of nursingcare quality. It is also important to involve patients in the

Received 25 March 1996; accepted 23 August 1996.Correspondence to: Barbro Ottosson, Care Research and Development Unit, Kriitianstad University College of Health Sciences, Box 98, S-291 21Krijtianstad, Sweden. Tel: 46-44-20-30-00, Fax: 4644-2(M0-19.

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44 B. Ottosson et al.

decision-making to give them a feeling of power [10].Thus nurses must strive to understand the needs andthoughts of the patients they serve and continuallyimprove the structure, process and outcome of theircare [11]. Patients expect health care services, includingtechnical treatment and nursing care, to be of consis-tently high quality [12].

The nurse-patient relationship may have some impacton patients' recovery, satisfaction and intention toparticipate in the treatment programme and its qualitydepends, among other things, on the nurse's ability toperceive and react to patients' verbal and nonverbalcommunication. It has been found that if nurses show aninterested and caring attitude to patients, they reduceanxiety and also the need for postoperative medicine [13].Promoting patients' participation in self-care by meansof improved nurse-patient interaction significantlyincreased patients' rate of recovery from surgery andsatisfaction with care [14]. Elderly patients especiallyneed individually planned care to promote independenceand/or prevent apathy, this has become even moreimportant as the number of old people is increasing [15].This emphasizes the importance of an effective assess-ment of the psychological aspects of care and of theactions to solve problems that may delay or hinderrecovery.

It is even more important to assess the various aspectsof the quality of care when the surgical services availableare curtailed. There is a need to control the rising costs ofthe health care system which results in shorter in-patientperiods and fewer in-patient beds [14]. It is particularly

important that the patient does not suffer when theresources of surgical services are drastically reduced.

The surgical clinic at a central hospital

During the three-year period 1991-1994, the numberof beds in the surgical clinic at a central hospital inSouthern Sweden were reduced from 105 to 52, plus 13beds for short-term care and the budget was cut by about20%. The turnover rate went up from 34.2 patients perbed per year in 1990 to 47.1 in 1994 and the mean timespent in hospital for each patient during the same periodfell from 8.0 to 6.8 days. One of the four nursing wards ofthe clinic was closed down and another ward changedinto day-time surgical care (10 beds) and short-term care(13 beds). The two remaining wards (26 beds per ward)provided general surgery, vascular surgery and urology.The changes took place on three different occasions (Fig.1). The two wards had practically the same staff ratio asbefore and the ward for short-term care had reduced theirstaff. During the first two months of 1994 the two generalwards were constantly overcrowded, while the ward forshort-term care had empty beds. Therefore the third wardchanged into day-time surgical care (8 beds), short-termsurgical care (13 beds), and 6 beds for terminally illpatients (in all 52 + 19 beds plus day-time care).

An intervention (Fig. 1) aiming at developing care andto control the effects of the budgetary cuts, started inAugust 1991. Steps were taken to improve the quality ofcare and to assess the outcome of it before andthroughout the intervention. In May 1991, all patients

1991 1992 1993

Wards

Intervention

5) 5)

Patient surveys

I Patient survey n » 105Y Jakobsson

II Patient survey n = 138 «' al. 1994

III Patient survey n » 131

IV Patient survey n » 128(Thii study)

Expenditure cut back

a) From 105 bed! to 90 beds/4 wards

Intervention

b) Beds 78/3 wards

1) Adapted nursing careorganization

2) Implementation of individuallyplanned care

c) Beds 52/2 wards +10 day-time surgical 3) Implementation of qualityand 13 short-term care/1 ward assurance

d) Beds 52/2 wards + 13 short-term care 4) Nursing documentationand 6 terminally ill patients/1 ward introducing VIPS-model

5) Team development

FIGURE 1. Timetable for patient surveys, intervention and changes in number of beds and wards at a surgical clinic.


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Patients' satisfaction with surgical care 45

discharged from the surgical clinic during a three weekperiod were included in a survey (estimated n = 120) [16].Another survey was effected in May 1992 (estimated7i= 160) [16]. Patient satisfaction improved significantlybetween 1991 and 1992 in variables related to nursingcare, overall satisfaction, whether they thought they hadsome impact on their own care situation, if they hadsomeone to talk to when they needed, if they receivedwritten information, what kind of information they hadbeen given prior to admission about their examination/surgery and treatment and if they had been continuouslyinformed about their future progress and prospects.Also in 1992 there were significantly more respondentswho felt they had recovered well than the year before.The results were interpreted to mean that, so far, theintervention had counteracted any negative impact thatthe reduced budget might have had [16]. Whether thisimprovement has continued during the budget cuts andintervention that followed is the focus of this study.

AIM

The aim of this study was to analyse and comparepatient satisfaction with surgical nursing care between1993 and 1994, that is during and after budgetary cutsand the concluded intervention which introduced newforms of individual nursing care plans and qualityassurance.

MATERIAL AND METHOD

Intervention

One part of the intervention was to develop anorganization that would secure closeness and continuityin the nurse-patient relationship (Fig. 1). Another partwas to implement individually planned care and writtendocumentation by means of diagnostic reasoning and toimplement quality assurance for those aspects believed tobe so crucial to the quality of nursing care. Two nurseteachers (RNTs) were appointed to instruct the staff(August 1991-January 1994) in how to implement theintervention [16]. The head nurse and the RNTs hadregular meetings with the staff to inform and stimulatethem to take on the intervention. The RNTs delegatedtheir supervision task to the staff in January 1994. Once ayear from 1991 to 1994 all staff members spent a day, or ahalf day, discussing the care organization and thecollaboration, one ward at a time. All staff membersalso took part in the results of the assessment of patientsatisfaction and discussed what improvements wereneeded.

The nursing care organization changed (1993) toworking in pairs (an RN worked together with a licensedpractical nurse, LPN) and each pair was responsible for 6to 7 patients. Each ward had four pairs and the headnurse had the overall responsibility for them (furtherdetails see [16]). Individually planned care began in

November 1991 with the RNs and some LPNs attendinga one-week course in diagnostic reasoning according toCarnevali's method [17] and thereafter all staff memberswere trained in individually planned care, focusingespecially on the admission interview and documenta-tion. The nurses were also specially trained to interviewpatients and to document nursing care according to theVIPS model (short for Wellbeing, Integrity, Preventionand Safety) [18], which was introduced to all staffmembers in autumn 1992. The implementation of qualityassurance started with a three-day seminar on theDynamic Standard Setting System [19]. The RNs weretrained to distinguish areas suitable for quality assur-ance, to set standards [4] and decide on measures forevaluating the outcome of nursing care. The RNs trainedall staff members and standards were set for areas like theinformation provided prior to admission, for varioustreatments, ulcerative care, pain relief and patient diary.After one year the nurses had a two-day follow upseminar. An RN and an LPN from each ward attendedand worked on the specific topic they had been assigned(e.g. the admission interview, the nursing care documen-tation, how to secure patients' integrity and the informa-tion patients were given prior to examination andtreatment).

Sample

Evaluation of patient satisfaction. One of the surveyswas carried out in May 1993 (Fig. 1). All patientsdischarged from the three wards of the surgical clinicduring a four-week period were included (estimatedn= 150; response rate n= 131; 87.5%). The next surveywas effected in May 1994 (Fig. 1) under the samecircumstances as the year before (estimated n = 150;response rate n= 128; 85.5%) (Table 1).

Patients who did not speak Swedish, dementedpatients or patients suffering from confusion (1993n=14; 1994 /j = 17) were excluded. When the patientswere discharged, but before they left the ward, aquestionnaire was given to them by the head nursealong with stamped return envelopes addressed to eitherof the two nurse teachers in the University College ofHealth Sciences. Each questionnaire was chronologicallynumbered and a patient record was kept by the headnurse in order to send out reminders. After three weeks,the reminders were sent from the University College ofHealth Sciences. After that the record was destroyed andno more reminders were sent

Method. The Swedish Institute for Health ServicesDevelopment (SPRI) has developed a questionnaire [20],which has been widely used and this was used in thisstudy. Little modified, it consists of 51 structuredquestions regarding patients' views on their satisfactionin general, their satisfaction with information anddecision-making, with contacts and staff-patientrelationship, with physical nursing care and ward


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TABLE 1. Characteristics of respondents comparison between1993 and 1994 by One Way Analysis of Variance applying

Bonferroni and the Oil-Square tests (*/•)

1993 1994 p-value(/t—131) (/t-128)

AgeYears; mean ± SD

GenderFemaleMale

Living conditionsSingleWith family

Previous in-patient periodsOtime1 time2-3 times4 times and more

AdmissionWaiting listCasualty

Inpatient days1-3 days4-7 days8-14 daysmore than 14 days

Diseases ofthe digestive systemthe genitourinary systemthe circulatory systemmalignant neoplasmendocrine, nutritionaland metabolic systemother isolated diagnosisof the nervous system,external causes ofmorbidity

61.4±16.4 60.7±18.3 0.03*

43.856.2

28.771.3

59.717.814.08.5

63.136.9

*42.726.620.210.5

*442213125

/vvalue <0.05 *Internal drop-out 1-10 respondents• 11-20 respondents121-30 respondents

52.847.2

30.369.7

59.420.315.44.9

58.241.8

•33.933.022.610.4t

431320174.5

1

0.05

0.2

0.8

0.07

0.3

RESULTS

The respondents' demography can be seen in Table 1.Most respondents who were admitted from the waitinglist (62.2% 1993; 58.2% 1994; NS) waited less than amonth (56.1% 1993; 52.3% 1994; NS). While waiting foradmission 30.9% respondents (1993) and 35.4% (1994)felt bad or very bad during the waiting time (p-value0.05).

In 1993 the respondents admitted acutely were treatedin hospital for longer than those admitted from thewaiting list (p-value 0.03). The respondents admittedfrom the waiting list in 1994 had been at the surgical clinicseveral times before, compared with those admittedacutely (p-value 0.01). In 1993 the younger respondents(< 55 years) spent less time in hospital than the older ones(> 55 years) (p-value 0.02). The older respondents weremore often acutely admitted (p-value 0.02) than theyounger respondents. In 1994 the younger respondentshad shorter hospital stays than the old respondents (p-value 0.04).

Overall satisfaction

In 1993 respondents' overall satisfaction with informa-tion showed that 94.5% felt satisfied or very satisfiedafter their hospital stay, as compared with 94.3% in 1994(NS). The respondents (97.6% in 1993) thought that theyhad had the right treatment during their stay, corre-sponding to 94.7% in 1994 (NS) and they had recoveredfully or partly, 68.4% (1993) and 62.2% (1994) (NS),respectively.

In 1993 the older respondents rated their stay at theward more positively than younger respondents (p-value0.04). More women than men said that they had notreally, or not at all, recovered (p-value 0.04). Also in 1994the older respondents rated their stay at the ward morepositively as compared with the. younger respondents (p-value 0.04).

facilities, physical treatment or examination. Theresponse alternatives varied from fully disagree to fullyagree (see Tables 1-5).

Analysis. Comparisons were made for differencesbetween 1993 and 1994 for age, gender and betweenthe respondents admitted from the waiting list andthose who had been admitted acutely. Overallcomparisons between the two years were also made.The Chi-square test, the Mann-Whitney U-test andOne Way Analysis of Variance with the Bonferroni test[21,22] were used along with the Statgraphics version5.0 package. Only significant (p-value <0.05)differences are reported. The International StatisticalClassification of diseases and related problems (ICD-10) [23] was used to classify the respondents reportedmedical problems.

Satisfaction with information and decision-making

The number of respondents satisfied with informationdecreased in some aspects from 1993 to 1994 (Table 2).The respondents were of the opinion that they had beengiven no written information during their hospital stay(68.9% in 1993; 73.1% in 1994; NS). More writteninformation was wanted (13.7% in 1993; 19.8% in 1994;p-value 0.03). The information to families about therespondents' condition was not at all satisfactory or notsatisfactory enough (15% in 1993; 22.2% in 1994; NS).The medical records were read by 3.2% (1993) and 2.7%(1994) of the respondents. A majority of them (62.3% in1993; 56.6% in 1994; NS) did not in fact know that theycould read their medical records. Most respondents(84.6% in 1993; 77.4% in 1994; NS) felt that they couldfully or partly influence decision-making.

In 1993 the old respondents were more satisfied than


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the young ones regarding: the information prior toadmission (p-value 0.003), the information about thedisease, treatment and in-hospital stay (p-value 0.004),their involvement in the decision-making about theexamination, surgery and treatment (p-value 0.005), theinformation relating to the outcome (p-value 0.003),written information in general (p-value 0.01), and theinformation to the respondents' families (p-value 0.001).Alsathe women said more often than the men that theirfamilies had no, or not enough, information about theirdisease (p-value 0.03). More respondents admitted fromthe waiting list stated that they received help with theireveryday problems compared to acutely admittedpatients (p-value 0.02).

In 1994 more elderly respondents than youngerrespondents stated that they did not have enough helpor that they had no help at all, to find out about theeveryday problems that would affect the future (p-value0.02). Women more often than men stated that they wereless satisfied regarding; their involvement in decision-making about the examination, surgery and treatment (p-value 0.01), information about the consequences of theirdisease (p-value 0.02), information about their disease totheir families (p-value 0.04), information about futureprospects (p-value 0.04), and written information ingeneral (p-value 0.006). More people admitted from thewaiting list responded positively to information aboutthe routines, rules and facilities of the ward (p-value0.003), information about their disease given to theirfamilies (p-value 0.009), and written information duringtheir stay in hospital (p-value 0.000) compared with theacutely admitted respondents.

Satisfaction with contacts; staff-patient relationship

The respondents' satisfaction with their contacts withthe staff (Table 3) decreased from 1993 to 1994, (87.6%and 76.7%, respectively; Rvalue 0.04). About half of therespondents knew the staff (55.5% in 1993 and 52.5% in1994; NS) and 17.1% did not know who was who (1993)as compared with 19.2% in 1994 (NS). Those who hadhad a special staff member to contact if they wanted were41.3% in 1993 and 19.3% in 1994. Most of them turnedto the nearest staff member available (56.4% in 1993 and73.9% in 1994) though some of them had some difficultyin finding someone to turn to (2.4% in 1993 and 6.7% in1994; NS).

There was a significant decrease in the number ofrespondents that had been introduced to the head nurse(82.5% in 1993 and 70.0% in 1994;/>value 0.01) while nodifference was seen with regard to the ward physician(80.3% in 1993 and 66.7% in 1994; NS) or to the RNs(94.4% in 199.3 and 90.6% in 1994; NS). Contact betweenthe respondents and their physicians was at the bedsideduring medical rounds, or in the presence of otherpatients (63.8% in 1993 and 78.8% in 1994; NS). Therewas a significant increase from 1993 to 1994 in thenumber of respondents who were dissatisfied with their

contacts with the physicians (4.8% in 1993 and 11.7% in1994; rvalue 0.004).

In 1993 the acutely admitted respondents more oftenstated less satisfaction than those admitted from thewaiting list concerning: when they needed someone totalk to (p-value 0.02), wanted to talk to their physiciansalone (p-value 0.002), or wanted more contact with thephysician (p-value 0.02). In 1994 the elderly respondentswere more satisfied than the young respondents on thefollowing points: they had been introduced to the headnurse (p-value 0.01) and the ward physicians (p-value0.000), they had someone to talk to when they needed (p-value 0.03), their contacts with the staff (p-value 0.002)and with their physicians (p-value 0.000). More menstated satisfaction compared to the women concerning:they had been introduced to the ward physician (p-value0.007), they had someone to contact (p-value 0.01), theyhad someone to talk to when they needed (p-value 0.04),they were satisfied with their contacts with the staff (p-value 0.04), they were not so anxious about theexamination, surgery and treatment (p-value 0.001),they were given time to talk to staff about their anxiety(p-value 0.04). More acutely admitted respondents statedthat they had difficulties in finding a staff member to turnto than those admitted from the waiting list (p-value0.005) and they also complained more that they could nottalk to their physicians alone (p-value 0.005).

Satisfaction with physical nursing care; ward facilities andphysical treatment or examination

The medical examinations and treatments were con-sidered to be carefully or rather carefully performed(98.4% 1993; 96.6% 1994; NS) in most cases.

Satisfaction with pain relief, assistance with personalhygiene and the ability to influence how their everydayproblems were solved showed no significant differencebetween the two years (Table 4). There were 35.6% in1993 and 37.4% in 1994 who did not sleep well and theysaid that the reason for this was other patients who keptthem awake (53.1% in 1993 and 50.0% in 1994) (Table5). There were also other factors, like noise made by thestaff (15.6% in 1993 and 24.3% in 1994) and some of therespondents said that their illness had kept them awake(31.3% in 1993 and 25.7% in 1994) (NS).

In 1993 more elderly respondents were satisfied thanthe younger ones regarding: the food (p-value 0.01), thedistribution of meals per day (p-value 0.008), visitinghours (p-value 0.01), the availability of activities (p-value0.01), privacy (p-value 0.001), placement in the ward (p-value 0.000), and the opportunity to sleep without beingdisturbed (p-value 0.001). Women were less satisfied thanmen with the beds (p-value 0.04) and the privacy (p-value0.01). More acutely admitted respondents were satisfiedwith their placement in the ward (p-value 0.01) than thoseadmitted from the waiting list.

In 1994 the food (p-value 0.01), visiting hours (p-value0.01) and the places for hygiene facilities (p-value 0.009)


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TABLE 2. Satisfaction with rariora aspects of information and decision making.Comparison between 1993 (a-131; *n-85) and 1994 (»°128; *n-66) by the Mann-

Wbitney U-test and tbe Cm-Square test (%)

Completely orpartly satisfied

19931994

Less or not atall satisfied

19931994

p-value

Information prior to admission fromwaiting list *

satisfaction with information

decision-making

information about illness, treatment

Information during stayabout ward facilities

prior to examination/treatment

continuously about progress

realities about treatment/disease

Information before dischargeimpact of disease on daily life

prospects for the future

answers concerning illness/treatment

/rvalue <0.05*<o.oitInternal drop-out 1-10 respondentsX 11-20 respondents§ 21-30 respondents0 32 respondents

I

XXX

X

§XXaX

92.895.490.894 083.183.3

90.377.695.388.989.280.797.593.1

84.982.980.872.693.992.9

7.24.69.15 i

16.916.7

9.722.44.7

11.110.819.32.56.9

15.217.119.227.56.07.1

0.9

0.7

0.4

0.02*

0.003t

0.1

0.08

0.2

0.1

0.04*

TABLE 3. Respondents' experience of personal contact with nursing staff. Comparison between 1993(II -131) and 1994 (« -128) by tbe Mann-Whitney U-test (%)

Often

19931994

Ratheroften19931994

Seldom

19931994

Notat all19931994

p- value

Anxiety before examination/treatment *

Experience of embarrassment *

Anxiety regarding professionalsecrecy

Needing someone to talk to butnot finding anyone *

There is someone to talk to aboutexperiences of examin./treatm. *

There is someone to talk toabout personal situation *

10.210.31.6

0.9

1.61.7

0.80.9

60.954.3

41.6

t

15.022.2

1.7

0.82.5

2.43.4

25.229.3

17.638.1

29.132.511.2

11.3

4.75.9

18.123.9

12.212.9

3.217.7

45.735.087.2

86.1

92.989.8

78.771.8

1.63.5

4.06.2

0.1

0.8

0.4

02

0.3

0.93.5

* 11-15 respondentst not applicable 1993-33.6%; 1994=34.5%Internal drop-out 1-10 respondents


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TABLE 4. Experience of help with physical and/or other problems. Comparison between 1993(ii -131) and 1994 (n -128) by The Mann-Whitney U-test

Always Almost Seldom Never Notapplic. p-valuealways

1993 1993 1993 1993 19931994 1994 1994 1994 1994

Pain relief within reasonable time*

Assistance with personal hygienewithin reasonable time

Impact on designing help withfood, hygiene, elimination *

Preparations made to cope with *daily life at home *

Help received with problems tcoping with daily life at home *

59.758.9

53.743.2

46.036.8

42.741.9

50.541.8

14.515.4

11.416.1

11.116.2

21.026.5

30.330.8

0.9

3.4

0.81.7

4.82.6

8.116.5

0.80.9

0.81.7

0.81.7

5.76.8

11.111.0

25.023.9

34.135.6

41.343.6

25.822.0

-

0.8

0.9

0.6

0.6

0.1

Internal drop-out 1-10 respondents* 11-20 respondents132 respondents

TABLE 5. Experience of ward fadUties. Comparison between 1993 (a = 131) and 1994 («-128) by theMann-Whitney U-test

Experience of the ward regardingfood

distribution of meals/days

hygiene facilities

opportunities to maintain contactsoutside hospital

visiting hours

bed facilities

privacy

opportunities for activity

opportunity to get undisturbed sleep

**

tt•*

Very good19931994

45.756.3

47.245.8

55.046.6

82.278.3

81.0802

61.266.1

37.5372

14.011.9

27.021.7

Good19931994

44.931.9

48.048.3

34.940.7

16.320.0

19.019.0

25.630.6

41.141.6

54.758.3

37.440.9

Not so good19931994

7.110.9

4.74.2

6.211.0

1.60.8

0.8

10.13.3

16.114.2

26.735.0

24.328.7

Poor19931994

2.40.8

1.7

3.91.7

0.8

-

3.1

5.47.1

4.74.8

11.38.7

Rvalue

0.1

0.7

0.2

0.5

0.9

0.1

0.9

0.9

0.6

Internal drop-out 1-10 respondents* 12-20 respondents144-45 respondents


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were more often considered not very good, or bad amongthe younger respondents than among the older respon-dents. Women were less often satisfied with the food (/svalue 0.03) and the distribution of meals per day (p-value0.02) than men. Most of the respondents agreed withtheir physicians that they had been discharged at the righttime (90.3% in 1993 and 80.7% in 1994; /rvalue 0.02)while the rest felt they had been discharged tod early.

DISCUSSION

The aim of this study was to analyse and comparepatient satisfaction with surgical nursing care between1993 and 1994. This was during and after cuts inexpenditure and the intervention which introducedorganized individual nursing care plans and qualityassurance projects. The study looked at experiences ofinformation, decision-making, personal contacts, helpwith special problems (e.g. pain), physical nursing careand the ward facilities.

The response rates for the two surveys were 87.5% in1993 and 85.5% in 1994 which seems fair when comparedwith the results of studies made by the SPRI which showresponse rates ranging from 80% to 95% [20]. Ques-tionnaires have commonly been used to assess patientsatisfaction [24]. To draw definite conclusions it isimportant to take the factors affecting the reliability ofthe method into account. The results of this study werebased on two patient surveys made during the sameperiod of each of the two years. These periods are perhapsnot representative of the year of this surgical clinic.Admissions before the summer may for instance concernother diseases than those treated during other periods ofthe year. Logically the impact of this is evenly distributedbetween the two years. The design of this study was alsosimilar to the previous two patient satisfaction surveys[16]. Thus, the results of the four years give a fairly goodindication of the quality of care and the effects the cutsand the intervention have had.

The sampling and the consequences of drop-outs andnon-responders are important to the validity of the studyand to the possibility of making comparisons [24].Patients unable to speak Swedish, demented patientsand patients with any degree of confusion (1993 n= 14;1994 n = 17) were excluded. Seen from a quality perspec-tive the vulnerable groups are patients who are seriouslyill, people with communication difficulties and immi-grants. Also those who were terminally ill remained silentsince they were still in hospital or died during the periodof the survey. These groups are the ones that need nursingcare most. This is also a problem in other studies [24]. Themost vulnerable people are not represented in this samplewithin the surgical clinic. Thus generalizations aboutquality of care must be made with great care.

Another reliability issue is whether the questionnaireactually covers the areas appropriate to be able to judgequality; the questions, the respondents' interpretation ofthe questions and the manner of distributing the

questionnaire [3,22]. Patients' loyalty to the concept of ageneral health care system may make them reluctant toexpress unduly negative views of it [25]. Also the fact thatthe staff knew about the assessment may have had aneffect on their attitude to their patients, which, in turn,made patients report a higher degree of satisfaction.Steps were taken to reduce such bias effects, for instanceby having the patients send their responses to theUniversity College of Health Sciences.

Overall satisfaction showed a high level (94.5% in 1993and 94.3% in 1994) in this study, which seems common inother surveys in Scandinavia as well as internationally [5,16,26]. Several studies have shown that respondents givelittle negative feedback, even if they are not satisfied withthe nursing care provided. This is believed to be the resultof the fact that they feel that their health has improvedduring their hospital stay or that they worry aboutsanctions [5,26-28].

In the earlier study comparing patient satisfactionbetween 1991 and 1992 there was a significant increasefrom 1991 to 1992 in, for instance, overall satisfaction,factors related to nursing care, information and decisionmaking, with contact and staff-patient relationships [16].When comparing 1992 with 1993 patient satisfaction wasthe same or had increased in some aspects. Comparisonsbetween 1993 and 1994, on the other hand, showed thatthe respondents' satisfaction decreased significantly withregard to information about ward facilities, informationprior to examination/surgery and other treatments,information before discharge, future prospects, contin-uous information about the progress of their disease andthe introduction to the ward physician and the headnurse. The care aspects that seem most important toassess quality seem to be patient satisfaction withinformation, their opportunity to influence decision-making and communication in general. In the studymade by Aharony et al. [27] the least satisfactory aspectwas overall satisfaction and satisfaction with physicians'communication. The findings of that study are also trueof this study; for instance, satisfaction with informationduring hospital stay and before discharge and contactswith staff including nurses and physicians decreased from1993 to 1994 (Tables 2 and 3). Dissatisfaction withinformation has turned out to be common in severalstudies [2,3,27]. The results of this study showed that74% in 1993 and only 62% in 1994 said that they werealways given enough information regarding treatmentand medication. Other studies have shown that the moresatisfied the patients were the more they were inclined toassume responsibility for decisions regarding surgery[29].

The subsample analysis showed that some groups weremore satisfied with the quality of nursing care thanothers; for instance, elderly respondents, patientsadmitted from the waiting list and male respondentswere more satisfied than their counterparts. Elderlyrespondents were more satisfied both in 1993 and 1994which is in accordance with the findings of other studies


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[7,24,25,27,30,31]. Camel [26] has found that age is apredictor of satisfaction regarding physicians and sup-portive services. The reason for elderly respondents'being more satisfied may be that they are actually offeredbetter service. Another reason may be that they are moregrateful and do not expect as much help from the staff asyounger respondents do. They were in fact brought up ina different cultural context, where people were notsupposed to claim "their rights" to services provided bypublic authorities like the health care system, whileyounger people know more about their rights and aremore likely to claim them. Younger respondents wantedmore information prior to admission, about routines,about their diseases and treatments, and for theirfamilies, which accords with the findings of a Canadiansurvey (n = 4599, 66% of respondents younger than 60years) [28]. Their main rinding was that younger patientsreported more problems than older patients regardingpatient satisfaction.

The differences between the patients admitted from thewaiting list and acutely admitted patients can beexplained by the fact that waiting list admission givesthe staff time to plan for care. Acutely admittedrespondents felt that they not could talk to theirphysicians alone and they were less satisfied with theirphysician contacts. The patient-physician contact wassaid to take place at the bedside during medical roundsand in the presence of others. In other studies [28,33]medical rounds, especially at surgical clinics, were oftensaid to be the only opportunity for personal patient-physician contact. The round "is a public event in whichthe surgeon is accompanied to the bedside by othermedical and nursing staff" (28, p.597). Patients feltunable to ask certain fundamental questions becausethey felt embarrassed to bring them up in front of anaudience and with other patients overhearing theirconversation [28,33]. Thus, in order to increase acutelyadmitted patients' satisfaction improved routines toreceive them must be developed; for instance, routinesfor individual care plans with an interview performed assoon as possible on arrival, either when the patients enterthe ward or perhaps at the emergency clinic. Also patient-physician contact needs to be improved.

Female respondents were the largest risk groupregarding low patient satisfaction in 1994. The numberof significant differences in female patients' satisfactionincreased between the two years. This may indicate thatin times of decreasing resources, female patients may bethe first to be affected by lower care quality. Femalerespondents reported more often that they did notparticipate in the decision-making and that they werenot informed about the consequences of their illness.Neither were their families given information about theirdiseases. Written information and information aboutfuture prospects was also unsatisfactory. These differ-ences in gender regarding patient satisfaction have beenseen in other studies [7,28,32] and may indicate that menask more aggressively for what they want or are

spontaneously given more information than women. Itmay also indicate more profound differences, for instancein different communication styles. The dominance ofmale surgeons may for example have an impact on theircommunication with female patients, or perhaps womenask for a different type of information than men.

The intervention started in 1991 and a study compar-ing 1991 and 1992 showed several instances of increasedpatient satisfaction, e.g. with information and decisionmaking (1991, 76.0%; 1992, 88.1%; /rvalue 0.002,completely or partly satisfied), with staff-patient relation-ship (more patients felt that they had someone special totalk to about their own situation: 1991, 46.6%; 1992,68.9%; /rvalue 0.003), overall satisfaction, physicaltreatment and decision making [16]. When the respon-dents' satisfaction in 1993 was compared with the resultspresented in 1991 [16] satisfaction had also increasedduring 1993; for instance their satisfaction with informa-tion and decision-making, with contacts with theirphysicians and with the fact that the staff had been therewhen the respondents needed them (Table 3). Thisimprovement was interpreted to be a result of theintervention; improved care organization and the intro-duction of individual nursing care plans and qualityassurance. In 1994 the level of the respondents' satisfac-tion had dropped to the level of 1991 [16] in, for instance;anxiety before examination/treatment, anxiety regardingprofessional secrecy, ability to influence how theirphysical problems would be solved and opportunity tosleep without being disturbed. Some results were evenlower than in 1991, for instance regarding the respon-dents' involvement in decision-making, their contactswith staff and physicians, the physical nursing careprovided and preparations made before discharge.

The decrease in patient satisfaction in 1994 must beseen in the light of the total cuts in expenditure (Fig. 1)from 1991 to 1994 (from 105 to 52 plus 19 beds). Theresults of the three studies of 1991, 1992 [16] and 1993showed that patient satisfaction continued to increase,perhaps as a result of the intervention. The 1994 cuts,however, could not be counteracted by the interventionso patient satisfaction could not be maintained at thesame level. Several studies have shown a relationshipbetween costs and the quality of care [34-39]. Donabe-dian [38] declared that there is a hypothetical relationshipbetween the monetary costs of successively more effectivehealth care strategies and improvements in health. Theimprovements in health become smaller and smaller untilfinally there is a point where the proposed additionalcosts will bring about no further improvement. Cuttingcare costs has been possible by the elimination of uselessor potentially harmful care. This may be a result of theintervention. Logically the reverse process also takesplace when resources are cut and this decrease in costscan take place without a decrease in quality up to acertain point The decrease in patient satisfaction in 1994may be a sign of this phenomenon. When the last cut wasmade in 1994, patient satisfaction dropped to the level of


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1991. Donabedian said that "the health care professionstoday are caught between the opposing pulls of twoimplacable imperatives: to maintain quality and tocontain cost" (38, p. 142).

The results of the surveys made from 1991 to 1993showed an overall improvement in nursing care qualityregarding patient satisfaction e.g. with contact, physicalnursing care, information and decision making [16]. Theintervention and attention paid to the issues of qualitymust have had some influence on the improved qualitywith regard to patient satisfaction and may haveprevented the negative consequences usually caused bycuts. The comparisons between 1993 and 1994 showedsomething different; patient satisfaction decreased, whichpoints to a deterioration in quality in 1994 compared with1991 to 1993. Especially vulnerable groups seem to bewomen and acutely admitted patients. These results mayindicate that the cuts in expenditure had been too largeand made at the expense of patient satisfaction. Thefindings of this and the previous studies [16] indicate thatcuts do not necessarily result in a decrease in quality interms of patient satisfaction, especially if the cuts arecombined with interventions to improve care quality. Thefindings also indicate that there may be a break evenpoint which cannot be passed without a resultingdecrease in care quality. Management should be awareof and identify this point. This can be done by regularfollow-up studies of the quality of care in terms of patientsatisfaction for instance. The findings of this studyindicate that the care of acutely admitted patients,younger patients and women needs special attention. Insome of these areas more research is needed and in otherspractical steps need to be taken.

Acknowledgements: This study was supported by the CountyCouncil of Kristianstad and the Swedish Working Life Fund,Kristianstad. We are grateful to the staff and patients at thesurgical clinic. We are also grateful to Ms Iiselotte Jakobssonfor her assistance in this research and to Ms Asa Sundh, UmeaUniversity, for revising the English.

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Documents

Patients‘ Satisfaction with Surgical Care Impaired by Cuts in Expenditure and After Interventions to Improve Nursing Care at a Surgical Clinic