Parents' satisfaction concerning their child's hospital care

ORIGINAL ARTICLE

Parents’ satisfaction concerning their child’s hospital carejjns_171 163..173

Vasiliki MATZIOU,1 Barbara BOUTOPOULOU,2 Anthi CHRYSOSTOMOU,3

Efrosini VLACHIOTI,4 Theodora MANTZIOU5 and Konstantinos PETSIOS1,6

1Faculty of Nursing, National & Kapodistrian University of Athens, 2Neonatal Intensive Care Unit, “Attikon” GeneralUniversity Hospital of Athens, 3Hellenic Centre for Diseases Control and Prevention, 4Nursing Education Office, “Agia Sofia”General Paediatric Hospital of Athens, 6Pediatric Cardiosurgical Intensive Care Unit, “Onassis” Cardiac Surgery Center,Athens; and 5Department of Nursing, Technological Educational Institute of Thessaloniki, Thessaloniki, Greece

AbstractAim: To explore parents’ satisfaction concerning their child’s care during hospitalization and itsdeterminants.

Methods: A descriptive, non-experimental correlational design was used. The data collection was based oninterviews using a 63 item questionnaire, the Swedish Pyramid Questionnaire. The parents of 206 children(hospitalized in two pediatric and two surgical units) participated in the study.

Results: The independent t-test results demonstrated that the parents showed greater satisfaction with staffattitudes and medical treatment, whereas they were less satisfied with the information concerning routinesand the staff work environment. The stepwise multiple regression analysis revealed that adequacy of care,adequate pain management, parents’ involvement in care, a trusting relationship, and staff attitudes were themost important determinants of parental satisfaction.

Conclusion: Interventions in pediatric care should include measurements of parental and child satisfactionas a tool to assess the quality of care.

Key words: experiences, healthcare outcomes, parents’ satisfaction, pediatric care, quality care.

INTRODUCTION

In recent years, the scope of patients’ participation in theevaluation of healthcare services has been broadenedbecause patients’ experiences and satisfaction are con-sidered to be vital components in the evaluation ofhealthcare interventions, as well as in assessing thequality of care (Garratt, Bjertnaes, & Barlinn, 2007;Ygge & Arnetz, 2001). In addition, demands for effec-tive health care and improvement in patient outcomesare increasing worldwide. In order to deal with thesedemands, health care needs to be more evidence-basedand patient-centered (Kitson, 2001). Moreover, parents’satisfaction with health care is associated with an

improvement in their child’s health or with a reductionof symptoms, including adherence to the therapeuticregimen and understanding medical information. Thus,the level of parent’s satisfaction with health care can beused as a good proxy variable for important aspects ofquality of care (Ammentorp, Mainz, & Sabroe, 2006;Hall, Roter, & Katz, 1988). Increasingly, families’ per-spectives are taken into account in the appraisal ofhealth services and the views of parents are sought forthe evaluation of pediatric care quality (Homer et al.,1999; Kravitz, 2001).

Healthcare systems today are characterized ascomplex, in flux, technically proficient, competitive, andmarket-driven. Nowadays, there is increased evidencethat greater satisfaction with health services resultsin better treatment adherence, which leads to betterhealth outcomes (Garratt et al., 2007; Schmidt, Thyen,Chaplin, Mueller-Godeffroy, & Bullinger, 2008). More-over, healthcare organizations have started to show an

Correspondence: Konstantinos Petsios, 123,Papadiamantopoulou Street, Goudi 115 17, Athens, Greece.Email: [email protected]

Received 21 April 2010; accepted 14 October 2010.

Japan Journal of Nursing Science (2011) 8, 163–173 doi:10.1111/j.1742-7924.2010.00171.x

© 2011 The AuthorsJapan Journal of Nursing Science © 2011 Japan Academy of Nursing Science

increasing interest in examining and developing theirfunctions through a marketing perspective. This factleads to the examination of service provision from theperspective of both the service buyer and the serviceprovider and, in contrast, the examination of service useor consumption from the perspective of the customer. Asa result, the service provider’s success or competitivenessis based on providing services that meet the customer’sneeds (Hiidenhovi, Laippala, & Nojonen, 2001; Seidet al., 2001).

Parental satisfaction regarding the delivered care totheir hospitalized offspring has been the subject ofseveral studies during recent decades. Most of them havefocused on specific aspects of pediatric care, such asneonatal care (Saigal et al., 1999), intensive pediatriccare (Latour, van Goudoever, & Hazelzet, 2008; Vanden Heede et al., 2009), emergency care (Magaret,Clark, Warden, Magnusson, & Hedges, 2002; Spahr,Flugstad, & Brousseau, 2006), pain management (Reid,Chambers, McGrath, & Finley, 1997), primary care(Seid, Sobo, Gelhard, & Varni, 2004), and inpatientservices (Wells, Dahl, & Nilson, 1998).

According to the literature, nurses’ communicationwith the parents in pediatric inpatient units is a keyfactor that contributes to parents’ perceptions of theirchild’s care. In a survey of 3299 families, Marino andMarino (2000) reported that the most predictive indi-cators of overall satisfaction were questions about thelevel of collaboration between the nurses and parents.The satisfied parents reported care that was customizedto their needs and preferences (Marino & Marino,2000). Similarly, a very interesting study in Tokyo, con-cerning the use of parenting groups and consultationservices as parenting support services by Japanesemothers of 18 month old children, concluded that itwas essential to offer services that are specific to thesituation or desires of the mothers, who might needsocial support and the opportunity to freely discusstheir worries with both professionals and peers(Arimoto & Murashima, 2008).

There is a lack of studies that assess parents’ percep-tions of the quality of pediatric care from a broaderperspective. Most studies concerning parents’ satisfac-tion have been focused on specific parameters, such asstaff attitudes, doctor communication, or the manage-ment of pain (Latour, Hazelzet, & van der Heijden,2005; McPherson, Sachdeva, & Jefferson, 2000;Magaret et al., 2002; Schmidt et al., 2008). Latouret al. concluded that parental satisfaction surveys thatare based on parents’ needs and experiences need to bedeveloped. There were some early initiatives that con-

centrated on the needs of the patient and familymembers, but the evaluation tools that were used didnot always take into account their experiences. Only afew reliable family satisfaction surveys claim to bedriven by patient and family experiences. Emphasisshould be given to methodological issues, the results ofwhich can be accepted as valid and effective for pos-sible changes in clinical practise (Latour et al., 2005;2009).

In Greece during the last decade, two studies werecarried out in order to evaluate parental satisfaction. Inthe first study, Matziou, Galanis, Alexopoulou, Vlachi-oti, and Tsoumakas (2006) found that 93.9% of theparents considered that the care of their child in thehospital was quite good to excellent. In contrast,Moumtzoglou et al. (2000) reported that only 45% ofparents were satisfied with pediatric care. Both studiesfocused on specific parameters of the offered care andthey were aiming to provide a general estimation of theparents’ opinion on the provided health care and toconstruct a useful tool in order to assess parental satis-faction with their offspring’s care. None of them aimedspecifically at identifying the factors that determinedparental satisfaction. The main limitations of thesestudies were the unwillingness of the parents to respond,the characteristics of Hellenic National Health System(HNHS) (limited primary care, limited ambulatory ser-vices, hospitals are the major pediatric care centers,covering tertiary care needs, etc.), language problems,and culture effects in relation to immigrants ( Matziouet al.; Moumtzoglou et al.).

For this study, two different types of hospitals werechosen (pediatric and general) because pediatric care inGreece is provided mainly in hospitals (primary care isunderdeveloped) and because the number of pediatrichospitals in Greece is limited and a number of pediatricwards (mainly medical and surgical) has been developedin general hospitals (originally constructed and designedfor adult care) in order to cover the needs for pediatriccare through HNHS. That was the background for theidea to compare the satisfaction level in two differenttypes of hospital in order to describe the overall level ofsatisfaction with pediatric care in Greece. This studywas designed to rate parents’ satisfaction concerningtheir child’s care during hospitalization, along withinvestigating the factors that determine it. More specifi-cally, the study’s purpose was to identify the character-istics (derived from hospital care, parent and staffrelationships, parents’ information level, staff attitudes,and parental participation) that affect parents’ satisfac-tion and contribute to it positively or negatively.

V. Matziou et al. Japan Journal of Nursing Science (2011) 8, 163–173

164 © 2011 The AuthorsJapan Journal of Nursing Science © 2011 Japan Academy of Nursing Science

METHODS

Data collectionThe data for this descriptive, non-experimental correla-tional study were obtained via a questionnaire, theSwedish Pyramid Questionnaire (Quality of Patient CareQuestionnaire – Parents Version), for pediatric hospitalcare, along with a form that obtained background infor-mation (Ygge & Arnetz, 2001; 2004). These were com-pleted by 206 parents of hospitalized children in twodifferent Greek public hospitals. The inclusion criteriaincluded: (i) hospitalization of the child for at least3 days; (ii) good knowledge of the Greek language; and(iii) central role of the interviewed parent in the care ofthe child.

The Pyramid Questionnaire was developed originallyby Arnetz and Arnetz (1996) in order to measure thequality of care from the patient’s perspective andhas been used widely in Sweden, with a database of>50,000 patients (Ygge & Arnetz, 2001). The versionof this questionnaire that was used to measure parents’satisfaction with the delivered care to their offspringwas piloted and validated by Ygge and Arnetz in tworegional hospitals in Sweden in 1998 (pilot) and 1999(complete study). It is a 63 item questionnaire that useseight measurement indices (composed of these items)and an overall quality rating that aims to estimateparental satisfaction with the delivered care. Theseindices cover eight domains: accessibility, staff atti-tudes, care processes, information about their child’sstate of health, information about routines, medicaltreatment, parent participation, and staff work environ-ment. All the questions ask the parents to rate a specificitem on a four-point Likert-type scale (“Yes, to a greatdegree”, “Yes, to a certain degree”, “No, not espe-cially”, or “No, not at all”). The questionnaire alsoincludes an estimation of the quality of care in pediatrichospitals by using a visual analog scale, from 1 (“verynegative”) to 10 (“very positive”). The mean values arecalculated for each index and then are converted to apercentage. The overall rating also is converted to apercentage and is treated as an index. Together, all ofthese categories aim to achieve a comprehensive pictureof the quality of care. The questions regarding thebackground information (all forced-choice replies) areabout demographic data, previous contact with thehospital, severity of the illness (as judged by theparent), and the parent’s anxiety about the child’s con-dition (Ygge & Arnetz).

For the Greek version of the Pyramid Questionnaire,the original questionnaire was translated by an autho-

rized segment (Translation Service) of The ForeignAffairs Ministry. Then, it was retranslated into Englishby a qualified translator. The questionnaire was dis-cussed by a Professor of Pediatric Nursing and twopediatric nurses regarding its compatibility with the con-ditions in Greek hospitals prior to its use. The indexreliability was examined by a confirmatory factor analy-sis that was carried out in order to determine the factorloadings of the individual items comprising eachdomain. The internal reliability of each index was mea-sured by using Cronbach’s alpha and reliabilities esti-mates also were compared to the original questionnaire.Both the content and construct validity have been estab-lished previously by Ygge and Arnetz (2001). The inde-pendence of the indices in the study was evaluated by acorrelation analysis.

SettingsAs already mentioned, the study was carried out in twodifferent Greek public hospitals. The first was a pediatrichospital, one of the major pediatric hospitals in Greece(380 beds) that offers specialized primary, secondary,and tertiary care for children who are <14 years old andtheir family. Per year, there are >25,000 hospitalizations,>5000 operations, and ~150,000 outpatient visits. Thesecond hospital was a general hospital, mainly foradults, but it contains a pediatric medical, surgical, andpsychiatric ward. The pediatric wards provide primary,secondary, and tertiary care for children who are<14 years of age, along with medical and nursingresearch. The pediatric medical ward has 30 beds and ithospitalizes >1000 children per year, with a mean dura-tion of hospitalization of 3 days. The pediatric surgicalward also has 30 beds and hosts >450 postoperativepediatric patients per year.

Ethical considerationsPermission for conducting the study was granted fromthe scientific councils of both hospitals. During the studyperiod (September to October 2006), a researcher ran-domly approached the parents of hospitalized childrenat least 3 days after their child’s admission and informedthem about the aims of the study and invited them toparticipate. After informed consent was obtained, thequestionnaires were completed via an interview. Theresearch conformed to the provisions of the Declarationof Helsinki (as revised in 2002) (World Medical Asso-ciation, 2007). Anonymity and all ethical considerationsconcerning the research were assured.

Japan Journal of Nursing Science (2011) 8, 163–173 Parental satisfaction with hospital care

165© 2011 The AuthorsJapan Journal of Nursing Science © 2011 Japan Academy of Nursing Science

Statistical analysisDescriptive statistic techniques were used to estimatethe means and frequencies. The t-test was used tocompare the means of the two independent groups. Atwo-tailed P-value of <0.05 was considered to demon-strate statistical significance. A stepwise multipleregression was used to explore the characteristics thatmight have affected the parents’ answers. The dataanalysis was carried out by using the statistical soft-ware package, SPSS for Windows (v.13.0; SPSS,Chicago, IL, USA).

RESULTS

The Greek version of the Pyramid Questionnaireshowed great internal consistency of the indices as theCronbach’s alphas ranged from 0.75 to 0.96 (seeTable 1 for a comparison with the findings from theoriginal questionnaire in Sweden).

In our study, 214 parents were approached and a totalof 206 parents participated in the study (response rate:96.25%). Five (2.35%) parents refused to participateand three (1.40%) parents were excluded from thestudy. Most of the participants were mothers (n = 140,67.97%). Table 2 illustrates the demographic character-istics of the sample.

All the parents were asked to rate their child’s healthstatus at the time of the hospital admission. Eighty-two(39.80%) considered their child to be at great risk, 93(45.14%) at a moderate or low risk, 14 (6.81%) at no

risk at all, and 17 (8.25%) could not rate it. Therefore,the parents who believed that the condition of their childwas serious rated significantly higher the staff’s attitude(Kruskal-Wallis test = 17.296, P < 0.001), caringprocesses (Kruskal-Wallis test = 14.078, P = 0.003),and work environment (Kruskal-Wallis test = 13.518,P = 0.004), compared to those who thought that theirchild’s condition was not serious at all.

The majority of the participants stated that they felt agreat level of anxiety (n = 87, 42.23%) or anxiety to acertain degree (n = 79, 38.35%). The parents who werenot anxious about their child’s condition rated signifi-cantly higher satisfaction with their participation in care(Kruskal-Wallis test = 9.030, P = 0.029) and the medicaltreatment (Kruskal-Wallis test = 11.061, P = 0.011) andstated a higher overall quality level (Kruskal-Wallistest = 8.842, P = 0.003), compared to the parents whofelt anxious to a great degree.

Staff attitudes were acknowledged by the parents. Themajority of them stated that they were very satisfied.More specifically, 184 (89.32%) parents believed thatthe nursing personnel was very polite and 195 (94.66%)stated the same for the doctors. They also were pleasedby the nursing care (n = 180, 87.37%), nurses’ concern(n = 179, 86.89%), and respect for their needs (n = 181,87.86%) or their child’s needs (n = 186, 90.29%). Onthe contrary, the parents were less pleased with the levelof personal contact with the health professionals or thelevel of personal contact with their child. More specifi-cally, about half of the parents were not pleased at allwith their personal contact with the nurses (n = 108,52.42%) and with the doctors (n = 90, 43.7%). Never-theless, they acknowledged the nurses’ and doctors’support because 77.18% stated that they were “very” or“to a certain degree” satisfied by the nurses’ willingnessto support them and 82.52% expressed the same inrelation to the doctors. That was noted in both hospitalsas there was no stated significant difference concerningstaff attitudes. Interestingly, the parents in both hospi-tals rated staff cooperation as good (n = 192, 93.20%),despite the fact that they work under stress (n = 162,78.64%) and they have a heavy workload (n = 161,78.15%).

Moreover, 44 (21.35%) parents were barely informedor not informed at all about their child’s illness, 42(20.38%) were barely informed or not informed at allabout their child’s treatment or diagnostic tests, and 47(22.81%) were barely informed or not informed at allabout their child’s progress or diagnostic results. Theparents of the children in the general hospital werefound to be more satisfied with the provision of infor-

Table 1 Comparison of the Cronbach’s alpha for the indices ofquality of care between the original Swedish Pyramid Ques-tionnaire and the Greek version of the Pyramid Questionnaire

Care index

OriginalSwedish Pyramid

Questionnaire

Greek versionof the PyramidQuestionnaire

Cronbach’s alpha Cronbach’s alpha

Accessibility 0.81 0.86Staff attitudes 0.76 0.96Care processes 0.80 0.94Information about

illness0.86 0.91

Information aboutroutines

0.62 0.75

Medical treatment 0.79 0.89Parent participation 0.80 0.78Staff work

environment0.79 0.89



mation, especially concerning their child’s disease(94.8%), in comparison to the parents at the pediatrichospital (78.6%). The data analysis revealed that themajority of the parents understood the information thatthey received (n = 176, 85.43%) and had the opportu-nity to ask questions about their child’s condition(n = 171, 83.00%) or to discuss treatment goals with thephysician (n = 143, 69.41%). On the contrary, theystated fewer opportunities to participate in discussionsconcerning diagnostic tests, examinations, or treatments(n = 100, 48.54%). Furthermore, the fathers gave statis-tically significantly higher ratings regarding informationabout the illness than did the mothers (U = 2416.000,P = 0.035).

As far as pain treatment was concerned, the parentswere satisfied with the pain treatment in 88 (42.72%)cases, 83 (40.29%) to a certain degree and 28 (13.59%)

were only a little or not satisfied at all. Additionally, 82(39.80%) parents were satisfied and 83 (40.29%) werequite satisfied because they believed that their childreceived satisfactory pain management within a reason-able period of time.

An analysis of the parents’ estimation about thequality of care in pediatric hospitals, using a visualanalog scale, revealed that the mean value was 6.9 forthe whole sample. More specifically, the parents at thegeneral hospital were more satisfied as their mean esti-mated value regarding the quality of care was 8.1, incomparison to 6.4 for the parents in the pediatric hos-pital. Moreover, the parents whose child was hospital-ized in a surgical ward were found to be more satisfiedwith the medical treatment (U = 4053.5, P = 0.025),compared to the parents whose child was in a medicalward. Conversely, the parents of a child in a medical

Table 2 Demographic characteristics of the study’s participants (n = 206)

Characteristic

Pediatric hospital General hospital Total sample

N % N % N %

Parents (total) 148 100.0 58 100.0 206 100.00Fathers 52 35.1 13 22.4 66 32.03Mothers 96 64.9 45 77.6 140 67.97

Parents’ ageFathers’ age

Mean (years) � SD 38.04 � 7.17 39.54 � 6.29 37.98 � 6.95Range 23–55 30–50 23–55

Mothers’ ageMean (years) � SD 32.58 � 6.18 32.7 � 7.57 33.29 � 6.81Range 16–60 16–48 16–60

Parents’ level of educationLow (<6 years) 23 15.5 10 17.2 33 16.02High (6–12 years) 82 55.4 36 62.1 118 57.28Higher (>12 years) 43 29.1 12 20.7 55 26.70

ChildrenBoys 84 56.8 33 56.9 117 56.80Girls 64 43.2 25 43.1 89 43.20

Children’s age (years)<1 65 43.9 13 22.3 78 37.862–6 42 28.4 23 39.7 65 31.547–11 27 18.2 11 19.0 38 18.45>12 14 9.5 11 19.0 25 11.65

Previous hospitalizationsNone 99 66.9 32 55.2 129 62.21Once 32 21.6 19 32.7 51 24.74>1 (or repeated hospitalizations) 17 11.5 7 12.1 24 11.65

Patient classificationAll 148 100.0 58 100.0 206 100.00Pediatric ward 97 65.5 32 55.2 129 62.61Surgical ward 51 34.5 26 44.8 77 37.39



ward were more satisfied with the staff work environ-ment (U = 4045.5, P = 0.025) than the parents of a childin a surgical ward.

During the data analysis, the mean percentage of theparental satisfaction for each care index and the overallquality scale was calculated. Overall, the parents weremost satisfied with staff attitudes and medical treatmentand less satisfied with the information about routinesand the staff work environment. A general comparisonof the two hospitals led to the conclusion that theparents whose child was hospitalized in a pediatric wardof the general hospital were more satisfied in all the careindices (P < 0.05), except for the one concerning acces-sibility. Figure 1 illustrates the mean values for parentalsatisfaction of the total sample and those of the generalhospital and pediatric hospital.

Finally, a stepwise multiple regression was used toidentify the characteristics that might affect parents’ sat-isfaction for each index and the overall quality scale.

The variables that were used were first correlated witheach index and those that had a value of P < 0.05 wereused for the multiple regression analysis as independentvariables. These variables were demographic character-istics, type of hospital, type of ward, level of parents’anxiety and child’s health status at the time of admission(as judged by the parents), the adequacy of health care,and satisfied with pain management. Table 3 shows theresults from the stepwise multiple regression analysis.Appendix I gives a summary of the most importantfindings.

DISCUSSION

Based on the findings, most of the parents were generallymore pleased when the level of information, the treat-ment, and the staff’s behavior were satisfying. Thisstudy’s results correspond with several studies, showingthat satisfaction with the provided care is related to

0

10

20

Care index

Overallquality grade

Workenvironment

Medicaltreatment

Participation Informationroutines

Informationilness

Staffattitudes

Caringprocesses

Accesibility

30

40

50

60

%

70

80

90

Figure 1 Mean parental satisfaction with the measurement indices. ( ) Total sample (n = 206); (�) pediatric hospital (n = 148);( ) general hospital (n = 58).



experiences of clear communication, empathy, and com-petence (Keating et al., 2002; Matziou et al., 2006).Matziou et al. reported that 93.9% of the parents con-sidered the care of their child in the hospital to be quitegood to excellent, even though difficulties concerningmainly interpersonal cooperation were identified. Thepatient’s expectations and the level of the care that isreceived are important determinants of satisfaction(Sitzia & Wood, 1998). Additionally, other studies haveshown a close correlation between the fulfillment ofexpectations and patient satisfaction (Kravitz, 2001;Wells et al., 1998).

Accessibility, the level of the provided information,and communication with the staff, along with pain man-agement, were rated higher by the parents with a child inthe general hospital than by the parents with a child inthe pediatric hospital. Consequently, the analysis of theparents’ estimation about the quality of care, using avisual analog scale, showed that the mean estimatedvalue regarding the quality of care by the parents at thegeneral hospital was higher than that of the parents atthe pediatric hospital. Generally, interpersonal care, thelevel of information, and desired improvements inservice (e.g. accessibility, facilities, time, and quality offood) are recognized as important determinants ofparental satisfaction in different modes of care and/ortypes of pediatric hospital (Bikker & Thompson, 2006).

Childrens’ first hospital admission is considered to bemore serious and to hold greater uncertainty than sub-sequent admissions and therefore is rated as moreimportant (Hiidenhovi et al., 2001).

In our study, the parents who believed that the con-dition of their child was serious, but they were notanxious about their child’s condition, rated significantlyhigher satisfaction and stated higher overall quality,compared to the parents who felt anxious to a greaterdegree. In Greece, the involvement of parents in thedecision-making and care processes is limited. Interest-ingly, the parents who were not anxious about theirchild’s condition rated significantly higher satisfactionwith their participation in care and the medical treat-ment. This is in accordance with the results of a recentstudy concerning the factors that affect parental satis-faction following pediatric procedural sedation. Theparents who thought that their child was afraid oranxious reported less satisfaction than did the parentswho thought that their child was not afraid or anxious(Lew, Lalwani, & Palermo, 2010).

The literature acknowledges the importance of infor-mation for parents and their presence during interven-tions as these can reduce anxiety and increase parents’

Table 3 Results from the stepwise multiple regression analysis

Care index Value

Accessibility R = 0.175Satisfactory pain management B = 17.175, t = 5.994,

P < 0.001Staff attitude R = 0.493

Adequacy of care B1 = 13.115, t = 9.27,P < 0.001

Satisfactory pain management B2 = 6.594, t = 4.58,P < 0.001

Caring processes R = 0.405Adequacy of care B1 = 13.659, t = 7.686,

P < 0.001Satisfactory pain management B2 = 7.106, t = 3.930,

P < 0.001Information about illness R = 0.409



Information about routines R = 0.317Satisfactory pain management B1 = 11.490, t = 4.640,

P < 0.001Adequacy of care B2 = 7.910, t = 3.050,

P = 0.003Parent’s sex B3 = 9.220, t = 2.480,

P = 0.014Type of hospital B4 = 9.165, t = 2.340,

P = 0.020Medical treatment R = 0.721



Family status B3 = 3.654, t = -2.586,P = 0.010

Hospital’s ward B4 = 3.859, t = 2.504,P = 0.013

Participation R = 0.318Adequacy of care B1 = 11.164, t = 5.428,


P < 0.001Staff work environment R = 0.661


Type of hospital B2 = 2.818, t = 2.192,P = 0.029

Overall quality scale R = 0.570Type of hospital B1 = 19.432, t = 10.702,

P < 0.001Adequacy of care B2 = 7.479, t = 4.194,


P = 0.016



satisfaction with care (Chan & Molassiotis, 2002;Coyne & Cowley, 2007; Lam, Chang, & Morrissey,2006; Soderback & Christensson, 2008). Specifically,Ygge and Arnetz (2004) commented that, although ithas become common practise for parents to stay withtheir sick child in hospital, most hospitals lack the rou-tines and staff guidelines for involving parents in thecare processes and decisions. In their qualitative study,they identified four themes (support, professionalism,work environment, and responsibility) that describedthe experience and perceptions of parents who regularlyspend time in the hospital with their child (Ygge &Arnetz). As already mentioned in our study, most of theparents were very satisfied (89.32–94.66%) by the staffattitudes, although it was acknowledged that they hadlimited involvement.

It is well known that communication between thepatient and the health professionals is a component ofhealthcare services that has an important impact on thepatient’s experience and is one of the components ofpediatric health care that correlates most strongly withoverall parent ratings (Haines & Childs, 2005; Homeret al., 1999). In our study, more than half of the parentswere not pleased with their personal contact with thenurses and with the doctors. This can be explainedpartly by the nurse–patient ratio in Greek hospitals thatleads to a heavy workload and limited time for personalcontact and by the paternalistic model of health care inGreece, which leads to the doctor driving the decision-making process, with a limited contribution by thenurses or parents (Matziou et al., 2006).

A large number of parents stated that they were barelyinformed or not informed at all about their child’sillness, their child’s treatment or diagnostic tests, andchild’s progress or diagnostic results. Furthermore, theparents of a child in the general hospital were found tobe more satisfied with the provision of information,especially concerning their child’s disease, compared tothe parents with a child in the pediatric hospital. Severalstudies acknowledge the influence of adequate, accurate,truthful, and personalized information in the overallrating of parental satisfaction (Ammentorp et al., 2006;Haines & Childs, 2005; Homer et al., 1999). For thoseparents who are expecting to learn about the cause andnature of their child’s illness, the failure to have thisexpectation met can lead to considerable dissatisfaction(Kravitz, 2001). This was more obvious in the mothersin this study, as the fathers gave statistically significantlyhigher ratings for information about illness than did themothers. This can be explained partly by the fact thatmothers find receiving information from too many pro-

fessionals to be highly stressful (Latour et al., 2009).Characteristically, Homer et al. concluded that informa-tion transfer to parents emerges as the highest priorityfor improvement.

Furthermore, the participants in this study stated thatparental involvement was limited and they expressedtheir need for active participation in the decision-makingprocess and the interventions or procedures during thehospitalization of their offspring. The expectations oftheir role during their child’s treatment and the level of itsfulfillment seemed to affect their overall satisfaction. Inan Irish study, in an inpatient children’s unit of a regionalgeneral hospital, both the parents and the nurses agreedthat there were differences in what the parents and thenurses saw as their roles in the unit (Hughes, 2007).Generally, in pediatric care, the parents seem to be moredissatisfied if the communication and information do notmeet their expectations (Homer et al., 1999). A qualita-tive study that was conducted in a pediatric intensive careunit suggested that the best nursing behaviors are thosethat facilitate and complement critical aspects of theparental role, thus reinforcing family integrity during atime of turmoil and uncertainty (Harbaugh, Tomlinson,& Kirschbaum, 2004).

Despite the above-mentioned problems, the partici-pants acknowledged the nurses’ and doctors’ supportbecause the majority stated that they were “very” or “toa certain degree” satisfied by the willingness of the nursesand doctors to support them. Moreover, there was nosignificant difference concerning staff attitudes betweenthe two hospitals. In a Swedish study, the parents’ secu-rity was derived from trusting nurses who knew how totake care of their child, having control over what wasgoing on with their child, and trusting themselves as thosewho knew their child best (Kristensson-Hallström,1999). Furthermore, the great majority of parentsacknowledged that, despite the fact that the staff workedunder stress and had a heavy workload, their cooperationwas good. In general, patients and parents are moresatisfied with the quality of care that they receive ina work environment that they perceive as positive(Ammentorp et al., 2006; Ygge & Arnetz, 2004). ADanish study that investigated parents’ understandingand evaluation of the quality of treatment of their childidentified three key concepts that seem to be central toparents’ understanding and evaluation of quality: trust,time, and peace of mind (Dellholm-Lambertsen, 1999).

The influence of pain resolution in children on paren-tal satisfaction is a novel finding, demonstrating theimportance of appropriate pain and anxiety assessmentand treatment of children (Magaret et al., 2002). Our



findings indicated that the parents were satisfied to acertain degree with the pain treatment and also weresatisfied or were quite satisfied with the administrationof pain relief within a reasonable period of time. Theparents who were satisfied with the pain treatmentreported a higher level of satisfaction for almost all thedimensions of care. Ygge and Arnetz (2001) also foundthat the parents who were satisfied with their child’spain treatment responded with significantly higherratings in all the improvement areas. These results areconsistent with those of other studies that noted thatpain management has a direct impact on parental satis-faction with the quality of care (Magaret et al., 2002;Marino & Marino, 2000; Reid et al., 1997; Ygge &Arnetz, 2001).

Moreover, the adequacy of care, as can be seen inTable 3, was acknowledged as an important factor foroverall parental satisfaction. Matsumori et al. (2006), intheir study on a care model for informing and reassuringchildren who are undergoing medical examinationsand/or procedures, found that the children toleratedprocedures best when: they were provided with anexplanation; they were allowed to make choices relatedto the procedure; they were given continuous explana-tions during the procedure; the timing of the proceduresuited the child; and distraction techniques were used.

With respect to sociodemographic characteristics, ourresults are consistent with earlier findings showing thatsociodemographic characteristics are a minor predictorof the satisfaction level of parents with a child with achronic disease (Schmidt et al., 2008). The response ratewas high, mainly because of personal contact with theresearcher and the completion of the questionnaire in aninterview.

In summary, the parents were most satisfied with staffattitudes and medical treatment and less satisfied withthe information about routines and the staff work envi-ronment. A general comparison of the two hospitals ledto the conclusion that the parents whose child was hos-pitalized in a pediatric ward of the general hospital weremore satisfied in all the care indices, except for the oneconcerning accessibility. However, according to Thomp-son and Suñol (1995), hospital environmental factorsmight influence the level of satisfaction with informationor care.

CONCLUSIONS

This study has shown that the parents reported quitehigh levels of satisfaction concerning pediatric inpatientcare. However, it was strongly stressed that there is a

great need for clinical practises regarding parentalinvolvement to be established in order to optimize thehospital care of ill children. Although parents cannotevaluate all aspects of care and treatment, their perspec-tives can make valuable contributions to the interper-sonal aspect of care, communication, information, andorganization of care.

Quite important differences between nurses’ and phy-sicians’ ability to fulfill parents’ needs were identifiedand these results can lead to further investigations andto more-specific quality care development. Staff atti-tudes and, more specifically, interprofessional collabo-ration, parents’ involvement in care, the trustingrelationship, and information for parents and children,emerge as the most important determinants of parentalsatisfaction with care. Personal contact and communi-cation with children and their parents is an area whereboth nurses and doctors need to improve.

The value of assessing parents’ satisfaction is increas-ingly important and necessary as hospitals are obligedby the state and private sector to document quality-improvement measures. Parents’ satisfaction can be usedas an indicator of the quality of care that is experiencedby parents and patients.

ACKNOWLEDGMENTS

We gratefully acknowledge the kind cooperation of allwho participated in the study. Without them, this studywould not have been possible.

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APPENDIX I

Summary of the most important findingsParents reported a quite high level of satisfaction con-cerning pediatric inpatient care. More specifically:1 The parents who believed that the condition of their

child was serious rated significantly higher satisfac-tion with the staff’s attitude, the caring processes,and the work environment.

2 The parents who were not anxious about theirchild’s condition rated significantly higher satisfac-tion with their participation in the child’s care andmedical treatment.

3 The parents in both hospitals rated the staff’s coop-eration as good despite the fact that they workedunder stress and had a heavy workload.

4 The parents whose child was hospitalized in thepediatric ward of the general hospital were moresatisfied with all the care indices, except for the oneconcerning accessibility.

5 The parents whose child was in the general hospitalwere more satisfied as their mean estimated valueregarding the quality of care was higher.

6 The parents whose child was hospitalized in a sur-gical ward were found to be more satisfied with themedical treatment, compared to those parents whosechild was hospitalized in a medical ward.

7 Parental involvement was limited and the parentsstated a clear need to participate in order to improvethe care of their ill child.

8 The parents with a child in the general hospital werefound to be more satisfied with the provisionof information, especially concerning their child’sdisease, in comparison to the parents with a child inthe pediatric hospital. The fathers gave statisticallysignificantly higher ratings in relation to informationabout the child’s illness, compared to the mothers.

9 Personal contact and communication with the chil-dren and their parents was an area that the nursesand doctors needed to improve.

10 The level of information, treatment outcomes, andstaff’s behavior were rated by the parents as the mostimportant determinants of their satisfaction.

11 The parents who were satisfied with their child’spain treatment reported a higher level of satisfactionfor almost all the dimensions of care.



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Parents' satisfaction concerning their child's hospital care