Patient satisfaction with the perioperative surgical services and associated factors at a University Referral and Teaching Hospital, 2014: a cross-sectional study

Introduction Globally, increasing consideration has been given to the assessment of patient satisfaction as a method of monitor of the quality of health care provision in the health institutions. Perioperative patient satisfaction has been contemplated to be related with the level of postoperative pain intensity, patients’ expectation of the outcome, patient health provider relationship, inpatient services, hospital facilities, access to care, waiting time, cost and helpfulness of treatments received. The study aimed to assess the level of patient satisfaction with perioperative surgical services and associated factors. Methods Hospital based quantitative cross-sectional study was conducted in University of Gondar teaching hospital from April1-30, 2014. Structured Amharic version questionnaire and checklist used for data collection. All patients who operated upon during the study period were included. Both bivariate and multivariate logistic regression model used to identify the variables which had association with the dependent variable. P-values < 0.05 were considered statistically significant. Results Two hundred and seventy eight patients underwent surgery during the study period. Nine patients were excluded due to refusal to participate in the study. A total of 269 out of 278 patients were included in the study with a response rate of 96.8%. The overall level of patient satisfaction with perioperative surgical services was 98.1%. The variables that had association with the outcome variable from the multivariate analysis were patient admission status (AOR=0.073, CI=0.007-0.765, P=0.029), information about the disease and operation (AOR=0.010, CI=0.001-0.140, P=0.001) and operation theatre staff attention to the patients complains (AOR=0.028, CI=0.002-0.390, P=0.008) respectively. Conclusion The level of patient satisfaction with perioperative surgical services was high compared with previous studies conducted in the country and other countries in the world. Health professionals need to give emphasis for information on care provision processes, patients' health progress and patients' complaints.


Introduction
Patient satisfaction is one of the main indicators of patient experience about health care services and quality of care provided [1,2]. Patient satisfaction is also considered as one of the required outcomes of health care and it is directly related with utilization of health services. Assessing patients what they think about the care and treatment they have received is an important process towards improvement of the quality of care, to ensure whether the local health services are meeting patients' needs and identify possible barriers for the delivery of the services [3]. Patient satisfaction with perioperative service is another complex area where satisfaction can be affected by many factors. Patients may choose a different health institution and surgeon depending on their anticipation and overall satisfaction with the care provided [4]. Preoperative anxiety, limited functional status, and postoperative pain control are some of the important aspects in the management of surgical patients and are interrelated to a successful recovery and patient satisfaction [5].
The perioperative area is a distinctive environment that includes many challenging conditions: multifaceted clinical care performed by teams; high cost, use of sophisticated technologies and a large variety of supplies, instruments, and implants that are difficult to manage. These conditions can create an environment of massive complexity and, unfortunately, are a source of a significant percentage of patient safety related adverse events. Some of the kinds of errors that can occur during surgery are patient misidentification, surgical site misidentification, and medication errors and omissions [6][7][8]. There is increasing appreciation that clinically based measures of surgical outcome must be accepted with patients' awareness of their post-treatment situation and patient satisfaction research is becoming an independent growth indicator where emphasis is given for patient feedback on quality of care received [9].
There are many aspects of patient satisfaction with treatment such as overall satisfaction, interpersonal factors, competence of professionals, patient ranking of the result, materials, continuity of care, accessibility for facilities, information about procedure and treatment, system of service, and costs for treatment [10]. Patient satisfaction could be affected by patients' expectations, overall health status, psychological factors and nature of treatment of provided [11,12]. Preoperative anticipations of patients were the main predictors of patient experiences, dissatisfaction and mood disorder after operation [13][14][15]. Similarly, a study conducted in Norway showed that adequate information about their health status, treatment options, and relation with nursing and medical staffs were the major determinants of patient satisfaction [16]. On the other hand, perioperative discomforts were the main factors that affected patient satisfaction negatively [17]. On the contrary, quality of information did not have an effect on patient satisfaction but admission processes, information provision, nursing care, physician and nurse interactions affected surgical in-patient satisfaction [18].
Another study showed that postoperative pain, waiting time for surgery and patient changing room conditions were the most important factors influencing patient satisfaction [19]. Older inpatients were more satisfied whereas younger outpatients were more satisfied. The most influential factors on inpatient satisfaction were information at admission, knowing what type of professional was dealing about the patient any time and informed consent. And for outpatients, informed consent and information about home care after discharge were the most influential factors [20]. A study done in Brigham on patient satisfaction in a tertiary teaching hospital preoperative clinic services showed that assessment of patient load and clinic service delivery system led to alterations in the service processes that resulted in continued high clinical effectiveness, reduced waiting time, and improved patient satisfaction [21].
Younger patients and patients who had postoperative complication after breast surgery were less satisfied [22]. Surgical patients were moderately satisfied with nursing care in orthopedic wards and were highly satisfied with nurses' manner in going about their work but were less satisfied with the amount of time nurses spent with them [23].
A prospective cohort study done on 4709 patients about patient's satisfaction after joint arthroplasty was significantly affected by meeting of preoperative patients' expectations, symptomatic pain management after surgery and the overall hospital experience [24].
A study conducted in Cyrus showed that patients were more satisfied with the technical aspect of nursing care but were less satisfied with the provision of information and hospitalisation especially with food and resting time [25]. A study conducted on determinants of patient satisfaction in surgical ward at a University surgical team about the life style after operation and the quality of food in the hospital affected patient satisfaction negatively [26].
Similarly, a study conducted in Scotland on satisfaction of patients after day surgery revealed that waiting times between admission, operation, and discharge , and postoperative pain affected satisfaction negatively despite the overall patient satisfaction was high [27]. A study conducted in a teaching hospital in Nigeria depicted that patient provider relationship, inpatient services, hospital facilities and access to care affected patient satisfaction positively whereas waiting time, cost, delayed appointment, missing investigation results and folders affected patient satisfaction negatively [28]. A comparative evaluation of patients' satisfaction with cataract surgical services in a public tertiary and a private secondary eye care facilities in Nigeria found that patients were more satisfied with the pre-consultation time and cost of surgery [29]). A study done on determinants of patient satisfaction with outpatient health services at public and private hospitals in Addis Ababa, Ethiopia showed that self rated health status, expectation about the services, perceived adequacy of consultation duration, perceived providers' technical competency, perceived welcoming approach and perceived body signalling were determinants of satisfaction from both public and private hospitals [30].

Study design and period
Hospital based cross-sectional study was conducted in University of Gondar teaching hospital from April1-30, 2014.

Study area
University of Gondar hospital is one of the largest referral and teaching hospitals in Northwest Ethiopia that provides health services for about 5 million people. The hospital has about 500 beds and 17 wards. There are seven operation theatres; four for surgery and gyn-obs, one for ophthalmology and two for fistula. There is one recovery room for the recovery of surgery and gynaecology patients after operation. One obstetrics ward used as labouring ward and recovery of operated obstetrics patients. The hospital has medical and paediatrics ICU but no surgical ICU. Six thousand three hundred fifty operations were done under anaesthesia in 2013 (retrospective audit of operation registration books).

Source and study population
Source population: All adult (minor-major, outpatient-inpatient, elective -emergency) surgery, obs-gyn (obstetrics, gynaecology, fistula) and ophthalmology patients who operated upon in University of Gondar teaching hospital.
Study population: All adult (minor-major, outpatient-inpatient, elective -emergency) surgery, obs-gyn (obstetrics, gynaecology, fistula) and ophthalmology patients who operated upon in University of Gondar teaching hospital during the study period were included in the study.

Inclusion and exclusion criteria
Inclusion criteria: All adult (minor-major, outpatient-inpatient, elective -emergency) surgery, obs-gyn (obstetrics, gynaecology, fistula and ophthalmology who operated upon in University of Gondar teaching hospital during the study period were included. presence of co-morbidity, type of operation (minor-major, electiveemergency, outpatient-inpatient, and surgery, obs-gyn and ophthalmology) and duration of surgery (short-long).

Factors related with reception at OPD, preoperative visit
and preparation: Nurses/physician concern for patient's problem Page number not for citation purposes 4 during presentation, concern for privacy during examination, adequacy of the answer for patients' questions, adequacy of information about the nature of the problem or operation, adequacy of information regarding possible complications and their management after operation, cleanliness of the site for the patient, chance to know the importance of the investigations ordered and waiting time.  All consecutive adult (minor-major, outpatient-inpatient, electiveemergency) surgery, obs-gyn (obstetrics, gynaecology, fistula) and ophthalmology patients who operated at the University of Gondar teaching hospital during the study period were included.

Data collection procedures
A pre-tested, structured and Amharic version questionnaire used to interview patients within 24 hours after operation after the patients are fully awake. The Amharic version questionnaire was pre-tested before actual data collection in an area not included in the research area. Checklist was used to extract data from the patients' chart and anaesthetic record sheets. Two BSc holder data collectors were selected and one day training was given.

Data quality control
To ensure the quality of data, training was provided for data collectors and the investigators directed and monitored the whole data collection processes for consistency, completeness and accuracy. Pre-test was done, data cleaned and checked every day, and double data entry technique used during data entry.

Data processing and analysis
The data coded, entered and analyzed using SPSS version 20 software. Associations between dependent and independent variables were assessed and its strength was presented using adjusted odds ratios and 95% confidence interval. Binary and multiple logistic regressions used to assess the association between  whereas 31 (11.5%) were obs-gyn operation. Two hundred and three patients were interviewed at recovery room (n=203, 75.5%), gynaecology ward 11(4.1%), obstetrics ward 20 (7.4%), general ward 2 (0.7%), surgical ward 13 (4.8%), orthopaedic ward 6 (2.2%) and trauma unit 14 (5.2%) respectively. The minimum, maximum and median duration of surgery were 30, 360 and 70+49.18 minutes respectively. The minimum, maximum and median length of hospital stay were 8 hours, 5328 hours and 55+375.59 hours respectively (Table 1).

Overall patient satisfaction level with perioperative surgical services and associated factors
The overall level of patient satisfaction with perioperative surgical services at the University of Gondar Teaching and Referral hospital was 98.1%. The variables that had p-value of < 0.2 from the bivariate analysis but had no association from the multivariate analysis were physician and nurse concern for the patients' problem,

Discussion
This study revealed that the level of patient satisfaction with the perioperative surgical services was 98.1%. This finding was high compared with the previous studies conducted in our country [2,3,30] and in other countries in the world [23,26]. This discrepancy could be due to the difference in patient perception of the services rendered and study design. In this study, from the

Competing interests
The authors declare no competing interest.

Authors' contributions
EGG and GFL conceived the study, developed the proposal, collected data, analyzed data, prepared the manuscript, approved the final manuscript and agreed to publish in Pan African Medical Journal. All authors have read and agreed to the final version of this manuscript.

Acknowledgments
We would like to thank the study participants and data collectors. Table 1: socio-demographic variables   Table 2: patient satisfaction with OPD services Table 3: patient satisfaction with operation theater services Table 4: patient satisfaction with postoperative management in the wards Table 5: patient satisfaction with postoperative management in the wards (continued)