A comparative study to assess the quality of nursing care rendered by staff nurses and the level of satisfaction perceived by patients in selected wards of selected government and private hospitals of Srinagar, Kashmir

Introduction

“I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care”. It implies that we as nurses are supposed to provide high quality of nursing care to our clients, and maintain high standards of professional conduct.

Caring is the essence of nursing and is the basic factor that distinguishes between nurses and other health professionals. The concept of caring in nursing has been defined in different ways. Watson1 says, “Caring includes knowledge, performance and the results”. Morse2 represented definitions of caring according to the five major conceptualizations of caring: ‘caring as a human trait, caring as a moral imperative, caring as an affect, caring as an interpersonal interaction and caring as an intervention’. Caring is an interpersonal process that is characterized by expert nursing, interpersonal sensitivity and intimate relationships. It is the most important and critical factor in enhancing the human life and is considered as the key role in the nursing team. Caring includes behaviors such as professional knowledge and skills, respect for the others, assurance of humanistic presence, positive communication, and attention to the experiences of the others.

Donabedian3 defined quality as “the harmony between actual nursing and the criteria prescribed beforehand”. Ovretveit3 states that the quality of health activities is the complete satisfaction of the needs of those who are in the most need of health services, for the lowest organizational costs, within the given limit and guidelines of higher administrative bodies and those paying. He also mentions the components of quality healthcare as: high level of professionalism, efficient use of resources (human, financial and material), the lowest possible risk for the patient, patient satisfaction and a (positive) influence on his/her state of health.

Frost3 stated that quality nursing care is extremely important for health care organizations. Lang3 defined quality nursing as “a process that seeks to attain the highest degree of excellence in the delivery of patient care”. Brown4, purported, “a logical definition of quality nursing care might be to benefit patients without causing harm, meet patient’s needs for nursing care, and assist patients to reach their goals for health promotion, maintenance and recovery from illness”.

There are three classic frameworks from which quality of nursing care can be evaluated. Furthermore an improvement in any elements is likely to produce favorable change in the other two. Structural elements include physical setting, instruments, and conditions through which care is administered, such as the nursing department’s philosophy and objectives, the health agency building, organization structure, financial resources, equipment, agency licensure and attitudes of patients and employees. Process elements include steps of the nursing process and all sub-systems within the nursing process, such as taking health history, performing a physical examination, making nursing diagnosis, determining patient care goals, constructing a nursing care plan, performing each prescribed care task, measuring patient outcomes and reporting patients response to care. Outcome elements include changes in patient’s health status that result from nursing interventions. These changes include modification of signs, symptoms, knowledge, attitudes, satisfaction, skill, and compliance with treatment regimen. Each of these three frameworks permits more than one approach to quality improvement. Structure can be examined from the standpoint of the total health agency or the nursing unit in which the patient receives care. Process can be examined by focusing on actions taken by the nurse or care received by the patient. Outcomes can be analyzed from the nurse’s or the patient’s and family’s frame of reference.5

Quality assurance frequently refers to the evaluation of the level of care provided by a health care agency, but it may be limited to the evaluation of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an agency, or even in a country. Quality assurance requires evaluation of three components of care: structure, process and outcome. Each type of evaluation requires different criteria and methods, and each has a different focus.6

According to Schroeder7, “Quality improvement is the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes”. Unlike quality assurance, quality improvement follows client care rather than organizational structure, focuses on processes rather than individuals, and uses a systematic approach with the intention of improving the quality of care rather than ensuring the quality of care. Quality improvement studies often focus on identifying and correcting system’s problems, such as duplication of services in a hospital or improving services.

U.S. National Library of Medicine defines patient satisfaction as the degree to which the individual regards the health care service or product or the manner in which it is delivered by the provider as useful, effective, or beneficial. Patient satisfaction is an attitude, a person’s general orientation towards a total experience of health care. Keegan8, stated that satisfaction comprises both cognitive and emotional facets and relates to previous experiences, expectations and social networks. Meredith and Wood7 have described patient satisfaction as ‘emergent and fluid’. Mclivor8, described it as a particularly passive form of establishing consumer’s views. Satisfaction is achieved when the patient’s perception of the quality of care and services that they receive in healthcare setting has been positive, satisfying, and according to their expectations. Satisfaction, like many other psychological concepts, is easy to understand but hard to define. The concept of satisfaction overlaps with similar themes such as happiness, contentment, and quality of life. Satisfaction is not some pre-existing phenomenon waiting to be measured, but a judgment people form over time as they reflect on their experiences. A simple and practical definition of satisfaction would be the degree to which desired goals have been achieved.

Aiello et al.9, stated that ‘patient satisfaction is the patient’s perception of care received compared with the care expected during hospitalization’. According to Han10, patient satisfaction represents a balance between the patient’s perception and expectation of their nursing care. Patient’s satisfaction with nursing care has been reported as the most important predictor of the overall satisfaction with hospital care and an important goal of any health care organization by Mrayyan.11 Yunus et al.12 purported, “Dissatisfaction with the nursing care services may further lead to lower utilization of the nursing care services by the patients”. Merkouris et al.13, “many researchers have acknowledged that patient’s satisfaction is not simply a measure of quality, but the goal of health care delivery system”.

Background of the Study

In health systems dominated by the private sector, as in India, understanding their properties is essential in order to develop and promote reform oriented strategies. Health services utilization statistics indicate that the private sector accounts for around 60% of inpatient care use and 80% of outpatient care use in India (National Sample Survey Organization 2006). The presence of a voluntary or charitable sector is limited, accounting for only about 4% of inpatient care and less than 1% of outpatient care (NSSO 1998). The bulk of health expenditure is incurred in the private sector. National Health Accounts Estimates for India show that private healthcare expenditure accounts for 72% of total health spending (Ministry of Health and Family Welfare 2005). Despite its dominance and ever-increasing clout in the country’s health system, policy planners have always overlooked the private sector’s potential in contributing to the public policy agenda. Part of this neglect arises from a lack of clarity on its scope and potential arising out of a paucity of reliable data from profit-motivated and largely unregulated private providers. Although the public health care system provides curative care services free or at nominal cost, a high demand for private health care facilities exists for a number of reasons. According to the (National Family Health Survey-III), the three major reasons cited for not seeking treatment from the public sector are: (1) poor quality of care, (2) no government facility nearby and (3) long waiting time for services. However, the evidence regarding practices in the private health care sector in India is not encouraging. Health researchers are highly skeptical about the quality of care and social responsibility of medical professionals in the unregulated private health care system (Baru and Nandraj).14 Most of the existing literature highlights either the poor physical standards or unethical profit-motivated practices in the private sector. Despite these criticisms, the private health care sector has maintained a steady growth and its dominance in the delivery of health care services has been ever increasing.

Taner and Antony15, conducted a study to examine the differences in service quality between public and private hospitals in Turkey. This study applied the principles behind the SERVQUAL model and compared Turkey's public and private hospital care service quality. The study sample contained a total of 200 patients. Through the identification of 40 service quality indicators and the use of a Likert-type scale, two questionnaires containing 80 items were developed. The former measured patients’ expectations prior to admission to public and private hospitals and the latter measured patients’ perceptions of provided service quality. The results indicated that the patients in the private hospitals were more satisfied with service quality than those in the public hospitals. The results also showed that the patients in the private hospitals were more satisfied with doctors, nurses and supportive services than their counterparts in the public hospitals.

Need of the Study

Mufti et al.16, among all the healthcare workers nurses spend maximum time with the patients. Therefore, the nurse is in a unique position to influence and promote effective consumer relationships. Though patient satisfaction surveys with nursing care are routinely conducted in the developed world to monitor and improve the quality of care, the same is not true for the developing world especially in the Indian subcontinent.

According to Ranjeeta et al.17, health care consumers today, are more sophisticated than they were in the past and now demand increasingly more accurate and valid evidence of health plan quality. Patient-centered outcomes have taken center stage as the primary means of measuring the effectiveness of health care delivery. It is commonly acknowledged that patient’s reports of their satisfaction with the quality of care and services, are as important as many clinical health measures. Health care organizations are operating in an extremely competitive environment, and patient satisfaction has become a key to gaining and maintaining market share. Patients’ satisfaction with the healthcare services largely determines their compliance with the treatment and thus contributes to the positive influence on health.

Khan et al.18, conducted a cross-sectional study at District Headquarter Hospital Dera Ismail Khan, to examine the level of satisfaction with specific dimensions of nursing care, in an effort to provide quality improvement knowledge that will lead to understand and identify the principal drivers to patient satisfaction. In the description of nursing care, a questionnaire regarding satisfaction was administered by the investigator in line with Henderson’s Basic Nursing Care Model. Six dimensions of care were selected for examination. Sample size was 122. Results showed that overall patients had a variable experience of nursing care; 45 % patients were satisfied with care provided, while 55 % were partially dissatisfied. Among 6 dimensions of care, 94 % liked nursing practice of keeping privacy of patients. When asked about behavior, 90 % patients were not feeling comfortable talking to nurses. Only 10 % felt nurses were excellent. 84 % patients had negative experiences as they observed nurses were not attentive to their needs, particularly at night. The same percentage also had negative perception with respect to the physical care provided by the nurses. Overall, the data showed that patient’s expectations were not sufficiently met. The study concluded that nursing care is a key determinant of overall patient satisfaction during hospital admission. Patient’s comments suggest that number of concerns must be addressed. The nurses need to know what factors influence patient’s satisfaction, if we want to improve the quality of health care.

Ryan and Rahman19, conducted a study to examine if demographic factors influence patient’s perception of satisfaction with care provided by nurse practitioners in rural urgent care centers. Data were collected using an 18 item self report survey from a convenience sample of 53 patients in two rural urgent care centers. No statistical significance was noted in regards to patient satisfaction for the demographic factors age, gender, country of upbringing, and education level. Presence of health insurance was a significant factor, with uninsured patients rating higher levels of satisfaction. However, based on patient’s responses to role clarity for this survey, it was evident that there continues to be insufficient public understanding of the role of nurse practitioners. The future of the nurse practitioners relies on patient approval as well as acceptance of the role. This study joins the pioneering efforts towards describing what patient satisfaction is and supports nurse practitioners serving as providers in rural, non primary care venues. By identifying influential factors of satisfaction, nurse practitioners can bridge the gap between availability of quality care versus a lack of access and inform policy changes in the future.

Suhonen et al.20, conducted a, descriptive, correlational study of the maintenance of individualized care from surgical patient’s point of view and examined associations between individualized care, patient satisfaction with nursing care, and health related quality of life. The data were collected with surgical adult patients (n = 279, response rate 93%) in surgical wards in Finland using self-administered questionnaires, including the Individualized Care Scales, Patient-Satisfaction Scale, and Finnish versions of the Nottingham Health Profile and EuroQol 5D. Associations between individualized care, satisfaction with nursing care and health-related quality of life were examined. Cronbach's alpha values and item analysis were used to evaluate the psychometric properties of the instruments, especially the Individualized Care Scales. The results showed that, the more often the patients felt they received support for individuality through specific nursing interventions; the higher was the individuality of care received. Secondly, the more individualized patients regarded their care, the higher the level of reported patient satisfaction with nursing care. However, the correlation between individualized care and health-related quality of life was fairly low. The study concluded that individualized care may produce positive outcomes, such as patient satisfaction.

As very little is known about the quality of nursing care and the level of patient satisfaction in both government as well as private hospitals in India so the researcher felt the need to conduct a study on quality of nursing care rendered by staff nurses and the level of satisfaction perceived by patients in selected wards of a selected government and a private hospital of Srinagar, Kashmir.

Organization and Presentation of Data

The data was tabulated in Microsoft Excel spread sheet (Annexure P) and the analysis was done using descriptive and inferential statistics using SPSS version 16. The level of significance was kept at 0.05 level. The findings were presented according to objectives set for the study. The findings were organized under the following sections.

Section I: Findings Related to Demographic Characteristics of Staff Nurses in Medical and Surgical Wards of the Government and Private Hospital.

This section describes the demographic characteristics of the staff nurses. Frequency and percentages were computed for describing the demographic characteristics. Summary of the sample characteristics are presented in Table 1.

1(a) Frequency and percentage of staff nurses of the government and the private hospital as per their demographic characteristics.

Data presented in table no: 6 shows that in government hospital, majority of the staff nurses 19 out of 30 i.e. (63%) were in the age group of 30 - 39 years and 11 (37%) were in the age group of 20 - 29 years. In Private hospital, majority of the staff nurses 16 (53%) were in the age group of 30 - 39 years and 14 (47%) were in the age group of 20 - 29 years. In both the hospitals, the entire staff nurses 60 out of 60 (100%) were females. The educational qualification of majority of staff nurses 25(83%) in the government hospital was Diploma GNM and of 5(17%) was B. Sc Nursing. In the private hospital, majority of the staff nurses 20 (67%) had done Diploma GNM and 10 (33%) had done B. Sc Nursing. In the government hospital, 16 out of 30 nurses (53%) had work experience of 1 - 5 years and 14 out of 30 (47%) had work experience of 6 - 11 years. In case of the private hospital, majority of staff nurses 20 (67%) had work experience of 6 - 11 years followed by 7 (23%) of staff nurses who had work experience of 1 - 5 years and 3 (10 %) had work experience of 12 - 17 years.

Section II: Findings Related to Quality of Nursing Care Rendered by Staff Nurses in Medical and Surgical Wards of the Government and the Private Hospital.

This section deals with the analysis, description and interpretation of the data collected to assess and compare the quality of nursing care rendered by staff nurses in medical and surgical wards of the government and the private hospital.

2(a) Assessment of quality of nursing care rendered by staff nurses in medical and surgical wards of the government and the private hospital.

Mean, Median, Standard Deviation, Mean Difference, Standard Error of Mean Difference were calculated and unpaired‘t’ test was used to find significance of mean difference in the quality of nursing care rendered by staff nurses in the government and the private hospital.

The data in Table 7 shows that the mean score of quality of nursing care rendered by staff nurses in the private hospital is (42.067 ) which is higher than (34.767), the mean score of quality of nursing care rendered by staff nurses in the government hospital. This indicates that the quality of nursing care rendered by staff nurses is better in the private hospital than in the government hospital. The standard deviation of quality score of nurses in the government hospital is (3.319), which is higher than (2.703), the standard deviation of quality scores of nurses in the private hospital. This indicates that the group is more homogeneous in private hospital. Unpaired “t” test was used to find significance of difference of the means which was found to be statistically significant as p value is less than 0.05.

2(b) Comparison of quality of nursing care rendered by staff nurses in the Government and the Private Hospital.

The data in Table 8 reveal that in the government hospital, majority of the staff nurses that were 23 (77%) rendered average quality of nursing care, followed by 4 (13%) of the staff nurses who rendered poor quality of nursing care and 3 (10%) of the staff nurses rendered good quality of nursing care. In case of private hospital, majority of the staff nurses 22 (73%) rendered good quality of nursing care followed by 8 (27%) of staff nurses, who rendered average quality of nursing care and none of the staff nurses in private hospital, rendered poor quality of care. It implies that quality of nursing care rendered by staff nurses in private hospital is better than the quality of nursing care rendered by staff nurses in government hospital.

Figure 1

Bardiagram showing frequency percentage distribution of quality of nursing care rendered by staff nurses in the government and the private hospital.

The data in Table 9 reveals that in the government hospital, on average, good quality of nursing care was rendered by staff nurses in the area of nurse’s communication and behavior and patient safety with modified means of (0.78) and (0.72) respectively. In the government hospital, the nurses on average rendered average quality of care in areas of environment and documentation, with modified means of (0.57) and (0.54) respectively and rendered poor quality of care in the area of general nursing care with modified mean of (0.53). The descending order of the ranks of nursing care rendered by staff nurses in government hospital was nurse’s communication and behavior (I), patient safety (II), documentation (III), environment (IV) and general nursing care (V). In case of the private hospital, on average, good quality of nursing care was rendered in the areas of environment, patient safety, nurse’s communication and behavior and general nursing care with modified means of (0.79), (0.78), (0.75) and (0.72) respectively while as average quality of nursing care was rendered in the area of documentation. The descending order of the ranks of nursing care rendered by staff nurses in private hospital was environment (I), Patient safety (II), Nurse’s communication and behavior (III), General nursing care (IV) and Documentation (V).

Section III: Findings Related to the Association between Quality of Nursing Care Rendered by Staff Nurses in Medical and Surgical Wards of the Government andthe Private Hospital and their Selected Demographic Variables.

This section describes the association between quality of nursing care rendered by staff nurses and their selected demographic variables (age, educational qualification and years of work experience). Fisher’s Exact test was used to find association between quality of nursing care rendered by staff nurses in medical and surgical wards of the government and the private hospital and their selected demographic variables.

3(a) Determination of association between quality of nursing care rendered by staff nurses in medical and surgical wards of the government and the private hospital and their selected demographic variables.

As seen in Table 10, in the government hospital, the Fisher’s exact test was used to find association between quality of nursing care rendered by staff nurses and demographic variables (age, educational qualification and years of work experience). No significant association was found between the quality of nursing care rendered by staff nurses and their age, educational qualification and years of work experience.

As seen in Table 11, in the private hospital, Fisher’s exact test was used to find association of quality of nursing care rendered by staff nurses with demographic variables (age, educational qualification and years of work experience). The findings showed no significant association between the quality of nursing care rendered by staff nurses and their age, educational qualification and years of work experience.

Section IV: Findings Related to the Demographic Characteristics of Patients in Medical and Surgical Wards of the Government and the Private Hospital.

This section describes the demographic characteristics of patients. Frequency and percentages were computed for describing the demographic characteristics of Patients in medical and surgical wards of the government and the private hospital.

4(A) Frequency and Percentage Distribution of Patients of the Government and the Private Hospital as Per their Demographic Characteristics.

Frequency and percentage distribution of patients of the government and the private hospitals as per their demographic characteristics are shown in the following Table 6.

The data in Table 6 shows that in government hospital, majority of the patients 18 (60%) were in the age group of 39- 59 years, 6 (20%) of patients who were in the age group of 18 - 38 years, and 6 (20%) were in the age group of 60 years and above. As of private hospital, majority of the patients 16 (53%) were in the age group of 38- 59 years, followed by 8 (27%) of patients who were in the age group of 18 - 38 years, and 6 (20%) of patients were in the age group of 60 years, or above. In government hospital, majority of the patients 24 out of 30 i.e. (80%) were married, 6 out of 30 (20%) were unmarried. In private hospital, majority of the patients 21 out of 30 i.e. (70%) were married, and 9 (30%) were unmarried. In government hospital 14 out of 30 (47%) patients were males and 16 (53%) females. In private hospital, 16 (53%) of the subjects were males and 14 (47%) of the patients were females. In government hospital, 11 out of 30 (37%) of patients had stayed in the hospital for 2 - 4 days, 8 out of 30 (26%) had stayed for 5 - 7 days, and 11 (37%) had stayed for 8 - 10 days. In private hospital, 9 out of 30 patients i.e. (30%) had stayed in the hospital for 2 - 4 days, 14 (47%) had stayed for 5 - 7 days, and 4 (13%) had stayed for 8 - 10 days and 3 out of 30 (10%) had stayed in the hospital for 11 days or above. As of history of previous hospitalization, in government hospital, majority of the patients (57%) had no history of previous hospitalization and (43%) had history of previous hospitalization. In private hospital, majority of the patients (73%) had no history of previous hospitalization and (27%) had history of previous hospitalization.

Section V: Findings Related to the Assessment and Comparison of Level of Satisfaction Perceived by Patients in Medical and Surgical Wards of the Government and the Private Hospital.

This section deals with the assessment and comparison of level of satisfaction perceived by patients in medical and surgical wards of the government and the private hospital.

5(a) Assessment of the Level of Satisfaction Perceived by Patients in Medical and Surgical Wards of the Government and the Private Hospital.

The data in the Table 8 reveals that in government hospital, majority of the patients, 18 out of 30 i.e. (60%) were satisfied with the nursing care and 18 (40%) were not satisfied. In private hospital, majority of the patients that numbered 24 i.e. (80%) were satisfied with the nursing care and 6 (20%) were not satisfied with the nursing care. This indicates more patients were satisfied with nursing care in private hospital than in the government hospital.

Figure 2

Cylinder diagram showing frequency percentage of patients in government and private hospitals by their level of satisfaction.

5(b) Comparison of the level of satisfaction perceived by patients in medical and surgical wards of the government and the private hospitals.

Mean, Median, Standard Deviation, Mean Difference, Standard Error of Mean Difference were calculated and unpaired‘t’ test was used to find significance of mean difference between the patient satisfaction scores of the government and the private hospital. The findings are presented in Table 9 on the next page.

As seen in Table 9 the mean satisfaction score of patients in private hospital is (102.9), which is greater than (92.03), the mean satisfaction score of patients in government hospital. It implies patients are more satisfied with nursing care in private hospital than in the government hospital. The standard deviation of patient satisfaction scores in government hospital is (9.66) and is lower than (11.03), the standard deviation of patient satisfaction scores in private hospital which implies the group is more homogenous in the government hospital. Unpaired “t” test was used to find significance of difference of the means which was found to be statistically significant as p value is less than 0.05.

The data in Table 10 shows that in government hospital, patients were satisfied with nurse’s communication and behavior and were dissatisfied with general nursing care and care facilities in the ward. The descending order of level of satisfaction perceived by patients in government hospital was nurse’s communication and behavior (3.22), general nursing care (2.96) and care facilities in the ward (2.31). In private hospital, the patients were satisfied with the general nursing care and nurse’s communication and behavior but were dissatisfied with care facilities in the ward. The descending order of the ranks for the level of satisfaction perceived by patients in private hospital was general nursing care (I), nurse’s communication and behavior (II) and care facilities in the ward (III). The data in the above table shows that the rank order for the areas of satisfaction perceived by patients differed in government and private hospitals.

Section VI: Findings Related to Association between Level of Satisfaction Perceived by Patients and their Selected Demographic Variables in Medical and Surgical Wards of Government and Private Hospitals.

This section describes the association between level of satisfaction perceived by patients and their selected demographic variables in medical and surgical wards of the government and the private hospital.

6(a) Determination of association between the level of satisfaction perceived by patients and their selected demographic variables in medical and surgical wards of the government and the private hospital and selected demographic variables.

In order to find association between level of satisfaction perceived by patients and their selected demographic variables, Chi Square test and Fisher’s exact test were used.

As seen in Table 11, in government hospital, there is statistically significant association between the level of satisfaction perceived by patients with age and marital status as the Fisher’s exact p values are 0.00 and 0.00 respectively, both of which are less than 0.05 level of significance. There is statistically no significant association between level of satisfaction perceived by patients and their gender and history of previous hospitalization as the calculated as found by Chi square test p values of 0.201 and 0.362 respectively. The findings also show that there is no significant association between level of satisfaction perceived by patients and their history of previous hospitalization as Fisher’s exact p value is 0.54 which is greater than 0.05 level of significance.

As seen in Table 12, Fisher’s exact test was used to find association between the level of satisfaction perceived by patients in private hospital and age, marital status, days of stay in the hospital and history of previous hospitalization. The findings showed no significant association between the level of satisfaction perceived by patients and their age, marital status, days of stay in the hospital and history of previous hospitalization. Chi square test was used to find association between level of satisfaction and gender and no significant association was found between the two.

Conclusions Drawn from the Findings

The major conclusions drawn on the basis of findings of the study were as follows:

Source of Funding

None.

Conflict of Interest

None.