A study of patient perception for nursing staff in a tertiary care hospital – A qualitative study

Introduction: The evaluation of patients’ satisfaction with hospitalization, and the identification of their requirements are pivotal in the management of health establishments. Patient satisfaction is the cornerstone of Good Hospital services which is in turn related to nursing care. This study was thus planned to capture the perception of the inpatients for nursing staff keeping it a basis for further improvement. Materials and Methods: The present cross-sectional study was conducted in Sri Guru Ram Das Hospital Vallah Amritsar. A pre validated feedback questionnaire, including both open and closed ended questions regarding nursing care was filled by 500 patients or their attendants. The results were statistically analyzed. Results: The overall satisfaction level for nursing staff was very high being 94.21% for the communication skills of the nursing staff and most of them had to wait less than 10 minutes once the needed nursing supervision.. It was 87.3% positive indicating excellent staff caring skills whereas 88.7% replied they would positively recommend this hospital to others. Conclusion: The overall satisfaction level was very high but six patients complained about cleanliness and one patient said that he did not like anything in the hospital. The same was informed to the authorities for any corrective actions required. This was really helpful in improving the patient care. © 2019 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by/4.0/)


Introduction
Patient Satisfaction has long been considered as one of the critical healthcare outcome indicators. Healthcare providers also have incorporated continuous quality methods into process improvement of healthcare delivery. 1 Nurses job satisfaction, patient education and general inpatient satisfaction with nursing care have been identified in the nursing care reported for adult care. (American Nurses association 1995) as an important Nursing Quality Nursing care forms the pillar of the inpatient department and patient recovery. Donabedians ' (1996) views on evaluating quality of care from structures (having the right things), process (doing things right) to outcomes (having the right things happen) have guided many studies. 2 Patient satisfaction surveys for acute care indicate that patients perceive a lack of communication during their hospitalization. 3,4 Active communication and sharing of information from patient to nurse are a venue to improve patient satisfaction with communication. Patient involvement in care is one of the 2011 National Patient Safety Goals set by the joint commission and is mentioned in the Institute of Medicine Executive Summary, A Bridge to Summary. 5 This cites that communication is a venue that serves to assist with patient focused care, utilization of evidence based practice and application of Quality Improvement. 6,7 Nursing Shift report has long been a practice that serves to exchange information from nurse to nurse. Shift report often takes place at nurses desk or behind closed doors and rarely has included patient in real time. The exchange in information in this setting often does not involve the patient until after the off going shift goes home and current shift does the round. This opens the doors for misinformation and does not give the family a venue to exchange information that may be sometimes very important. 8,9 The evaluation of patients' satisfaction with hospitalization, and the identification of their requirements are pivotal in the management of health establishments. The introduction of the quality management system in hospitals provides opportunities for improving medical services and fulfilling customers ' needs. These objectives can be achieved by effective methods, techniques and tools. An example of identifying patient's expectations during hospitalization is a survey (with the aid of a questionnaire) on the level of patient satisfaction.
Although WHO recognizes nurses as frontline service providers, nursing is generally considered a "cost" rather than revenue in a hospital context, which makes nursing a constant target for cost reductions. 10 These cutbacks combined with the phenomenon of permanent shortages of nurses are making rationing of care an increasingly prominent feature in health care.
Patient satisfaction is generally accepted as a crucial indicator of the quality and effectiveness of care as well as an important part of value-based health care, and it appears to be particularly sensitive to rationing. Theoretically, patient satisfaction is connected with nursing care, nurses, and the organisational environment. 11 Several environmental factors have been reported as hindering the nursing profession in its ability to achieve improved health outcomes through the provision of competent, culturally sensitive, evidence-based care. These factors include poor working conditions, heavy workloads, lack of participation in decision making, and limited opportunities for career mobility. Consequently lack of resources, as well as professional, environmental and other restraints and limitations when combined with the invisibility of caring could lead to negative outcomes for patients, nurses and the health care system in general. Patient satisfaction due to care is a critical outcome because it influences adherence to treatment, health services utilization and general attitudes towards the health care system. Apart from being an important indicator of quality nursing care, patient satisfaction has a reciprocal effect meaning it can be used to improve nursing care that will in turn increase satisfaction.
Implicit rationing of nursing care is the withholding of or failure to carry out all necessary nursing measures due to lack of nursing resources such as time, staffing or skill mix. 11,12 According to the conceptual framework of nursing care rationing developed by Schubert, such nursing measures include actions of surveillance, therapy, prevention, rehabilitation and support, and these actions are important in order to achieve desired outcomes for patients. Rationing of nursing care occurs at the patient-to-nurse interface, it is based on the nurses' assessments and it is a product of clinical decision making and clinical judgment. The rationing process is influenced by a number of factors including patient and nurse variables, the characteristics of the work environment, organizational variables, the philosophy of care and it is linked to patient and nurse outcomes. The effect of the work environment on rationing is also stressed in the Missed Care Model. [13][14][15] The model argues that the factors underlying missed care are linked to the context of the care environment, they are external to nurses and create a need to decide what care will be provided.
The documented questionnaire surveys from patients will make the nursing staff aware of their strengths and weaknesses and thus improving the quality of care in the inpatient department or wards. [16][17][18] The higher staff nurses scores on strength of the organizational culture, the higher their job satisfaction. Higher the job satisfaction of the nurses, higher the inpatient satisfaction Higher the level of inpatient satisfaction with information on home care and follow up, the higher their scores on general inpatient satisfaction with nursing care. 19,20 This study was thus planned to capture the perception of the inpatients for nursing staff keeping it a basis for further improvement.

Aims
The main aim of the study was to recognize the areas that need more attention in the provision of Nursing Care in inpatients at Sri Guru Ram Das Institute of Medical Sciences & Research, Vallah Sri Amritsar, in order to improve the quality of patient care.

Material and Methods
The present study was a cross-sectional study, conducted in patients attending Clinical Laboratory of Sri Guru Ram Das Institute Of Medical Sciences & Research, Vallah, Sri Amritsar. People of the area were sensitized regarding the study. A pilot study was done on 20 patients /attendants who visited Sri Guru Ram Das Institute of Medical Sciences & Research, Vallah, Sri Amritsar, by taking their interview. The data for the study was also collected through observation method. Observation method, till now is the most important and extensively used method.
After their interview, a semi structured feedback questionnaire was prepared in two languages -English & Punjabi (vernacular language understood by most patients of Amritsar, Punjab). The Questionnaire was then validated by 7 faculty members and only those questions having a sum of 8 were included and rest discarded. The final questionnaire had 10 questions in total ( 8 closed ended and 2 open ended).
We randomly selected 500 patients / attendants visiting Clinical Biochemistry Laboratory at different times after excluding 7 Kashmiri patients. Before giving them the questionnaire, they were explained the need for the same and their consent was taken. They were specifically requested not to read all the items at once, but go through each individual statement and answer it and then only move to the next. Respondents were assured of the confidentiality of their responses. Precautions were also taken to obtain unbiased results. The approval of the ethical committee of the institute was taken for the same. The feed questionnaires were collected and analyzed statistically.

Statistical analysis
The validation of questionnaire was done through Cronbach's alpha statistics using SPSS software v17.0. The participants were selected using randomization technique with the help of SPSS software v17.0. The analysis for closed ended questions was qualitative, whereas for open ended questions it was a descriptive analysis by coding system.

Results
This study was a cross-sectional study. A total of 507 patients were enrolled in the present study after a pilot study was conducted in 2 0 patients. Seven patients declined to participate and thus were excluded because of considerable language barrier as they were from Srinagar and only understood Urdu. Thus the study included total 500 patients. There were in total 10 quest ions in the questionnaire, 8 closed ended and 2 open ended questions. The closed ended questions included 3 questions regarding demographic detail and rest about perception for laboratory services. These questions were qualitatively analyzed. Question number 9 & 10 being open ended were analyzed using descriptive analysis by coding system. There were in total 2 codes generated for each question. Most of the patients were between the age group of 25-34 (25.71%), whereas the least belonged to the age group of 65-75 years (2.86%) (Figure 1). Among all patients, 65.71% were Females and 77 % were married. The overall satisfaction level for nursing staff was very high being 94.21 % for the communication skills of the nursing staff and most of them had to wait less than 10 minutes once the needed nursing super vision (Figures 2 and 3). It was 8 7.3% positive indicating excellent staff caring skills whereas 88.7% replied they would positively recommend this hospital to others (Figures 4 and 5).

Discussion
Implicit rationing of nursing care is the withholding of or failure to carry out all necessary nursing measures due to lack of resources. There is evidence supporting a link between rationing of nursing care, nurses' perceptions of their professional environment, negative patient outcomes, and placing patient safety at risk. Research evidence supports that there is a link between rationing of nursing care and negative patient outcomes such as increased mortality, patient falls, low quality of care, pressure ulcers and hospital acquired infections. Some authors have placed the issue within the patient safety movement suggesting that "acts of omission" are identified as one of the major types of errors not addressed in the literature. 17,18 Patient satisfaction is generally accepted as a crucial indicator of the quality and effectiveness of care as well as an important part of value-based health care, and it appears to be particularly sensitive to rationing. Theoretically, patient satisfaction is connected with nursing care, nurses, and the organizational environment. Several environmental factors have been reported as hindering the nursing profession in its ability to achieve improved health outcomes through the provision of competent, culturally sensitive, evidence-based care. These factors include poor working conditions, heavy workloads, lack of participation in decision making, and limited opportunities for career mobility. Consequently lack of resources, as well as professional, environmental and other restraints and limitations when combined with the invisibility of caring could lead to negative outcomes for patients, nurses and the health care system in general. 19 Patient satisfaction due to care is a critical outcome because it influences adherence to treatment, health services utilization and general attitudes towards the health care system. Apart from being an important indicator of quality nursing care, patient satisfaction has a reciprocal effect meaning it can be used to improve nursing care that will in turn increase satisfaction. Several studies have demonstrated an association between nursing and patient satisfaction identifying nursing care as the only hospital service having a direct and strong relationship with overall patient satisfaction. Other researchers identified that patientperceived nurse caring is a major predictor of patient satisfaction. A co relational study examining surgical patient satisfaction as an outcome of nurse caring in six European countries, reports that caring behaviors enacted by nurses determined a consistent proportion of patients' satisfaction. The authors found that 44.1% of satisfaction variance was explained by the nurse caring behaviors as perceived by the patients. Similarly, patient satisfaction was examined as an outcome of individualized care providing further evidence that a specific dimension of care, that is " individualized " care, is related with patient satisfaction.
A plethora of studies have also examined the relationship between nurses' perceptions of their work environment and the quality of care patients receive showing that improved work environments were associated with increased ratings of care quality and patient satisfaction. 20 Some researchers have examined the specific contribution of nurses' work environments to patient satisfaction indicating that patients' reports of satisfaction are higher in hospital settings where nurses practice in better work environments. On the other hand, an unstable environment is linked with negative patient outcomes including nursing tasks being delayed, patient falls, and medication errors in both medical and surgical departments.
Also there is evidence of a positive relationship between some aspects of the professional work environment such as leadership style, and higher patient satisfaction, lower patient mortality rates, medication errors, restraint use and hospital-acquired infections. Similarly, a work environment that facilitates patient-centered care is considered to increase patient safety and nurse satisfaction.
More specifically, Rathert and May 21 found that nurses whose work units were more patient-centered reported that medication errors occurred less frequently in their units, and felt more comfortable to report errors and near-misses than those in less patient-centered units. Aiming to investigate environmental dimensions predicting nursing care rationing in a cross-sectional multicenter study, Schubert et al. 22 found that better unit level staff resource adequacy and a more favorable hospital level safety climate were both consistently and significantly associated with lower rationing levels.
Some studies have focused on rationing of nursing care and related concepts such as care omissions, delays and care priority setting and provide evidence of a relationship between nursing care rationing and patient negative outcomes. For example, Kalisch et al. and Schubert et al. 21,22 showed that unmet care needs, missed nursing care and rationing of nursing care had significant effects on nurse-reported adverse events such as hospital acquired infections, patients receiving wrong medications or dosage errors, and more incidents of patient falls causing injury.
In our study the patient perception for nursing care was very high amounting to 91.87% for the communication skills of the nursing staff. They were also very much satisfied with the waiting time on call for nurses which was in almost every case less than 10 minutes. All were very happy with the cleanliness of the wards (This is our hospitals major concern as it is safe I accreditated). They were also explained nicely about the medicines on discharge and the follow up procedures. Only one patient complained about cleanliness and one patient said that he did not like anything in the hospital. He was directed to the authorities and his problems solved. The calculated percentages were informed to the nursing staff through their nursing superintendent which would lead to an increase in their morale and thus leading to still better services in future. 23 Only two studies were found to provide evidence of interlinks among patient satisfaction, nursing care rationing and practice environment factors. In a sample of 1338 nurses and 779 patients, Schubert et al. 21 identified that patient satisfaction with care was adversely affected by even a low level of rationing, and was accompanied by a 57% decrease in the number of patients who reported being very satisfied with their care.

Source of funding
None.

Conflict of interest
None.