Health Science Journal

Key words

Quality of Nursing Care, Clients’ Satisfaction, Community Health Centers, Community Health Nursing, Jordan

Introduction

Client satisfaction receives an increasing focus in research studies, mainly because the health care sector is considered as a competitive sector where consumers' satisfaction is very important. [1-3] Satisfaction level regarding the quality of nursing care has a substantial influence on the satisfaction level with the whole health care setting because nurses are the health care professionals clients deal with more often than others. [4-7]

Client satisfaction is the result of an evaluative cognitive reaction along with the associated feelings toward the actual care received and the expected care. [2,4,6-9] In addition to this cognitive evaluation, demographic variables such as gender, perceived health status, age, and educational level could also affect client satisfaction level, with male, healthier, older, and lower educated clients being more satisfied. [4,9-13] Nonetheless, client satisfaction has been reported as being positively associated with the quality of care. [4,14,15]

CIn fact, client satisfaction is considered one of the most important indicators of the quality of nursing care. [4,16] By measuring client satisfaction, health care services retrieve vital information which can be used to improve the quality of nursing care. [6] Consequently, higher levels of client satisfaction will be reached which, in turn, will help clients adhere to their treatment, return to the health care setting, and recommend it to others. [2,4,17]

Health care services in Jordan are operated by: The Ministry of Health (governmental hospitals and governmental Community Health Centers (CHCs)); the private sector (private hospitals and private clinics); Royal Medical Services (military hospitals); Universities (teaching hospitals); and International and charitable organizations (health centers that include United Nations Relief and Works Agency (UNRWA) CHCs). [18] In this study, governmental and UNRWA CHCs were utilized to measure client satisfaction with the quality of community health nursing care since they are the main types of CHCs in Jordan.

This study aimed to:

1.Determine client satisfaction level with the quality of nursing care in the selected CHCs.

2. Identify factors related to the quality of the provided community health nursing care that affected client satisfaction levels.

3. Identify demographical factors that affected client satisfaction levels.

Methodology

A descriptive comparative cross-sectional research design was utilized in this study. Client satisfaction was measured using the Satisfaction Scale for Community Nursing (SSCN) questionnaire developed by Cheng and Lai. [19] The SSCN was developed specifically to measure clients’ satisfaction level with community health nursing. It has a proven validity and reliability. [19] The SSCN is a self-administered questionnaire that contains 17 items grouped into three dimensions: coordination of services, technical competence, and interpersonal relationship (see Table 1). The SSCN was translated from English to Arabic by a professional in both languages, and then translated back from Arabic to English by another professional in both languages. A panel of three experts in community health nursing who were competent in both languages reviewed the translation and indicated that it was valid and understandable.

This study was conducted in two CHCs in Jordan. The first CHC was affiliated to the UNRWA and the second CHC was affiliated to the Jordanian Ministry of Health. Two different subsamples were recruited in this study; one subsample from each setting. The targeted population of this study was all of the clients who used the services of the two selected CHCs. To determine the subsamples sizes, Cochran’s [20] formula was used. The total sample size was (n = 304), with (n = 155, 51%) from the UNRWA CHC and (n = 149, 49%) from the governmental CHC.

A convenience sampling method was used to recruit participants from the UNRWA CHC. Then, a quota sampling method was used to recruit participants from the governmental CHC in a proportion that matched the proportion of the demographic distribution of the UNRWA subsample except the size. This was done to avoid any effects the two subsamples’ demographics could have had on their clients’ satisfaction levels. Written consent forms were provided that stressed that the participation was optional, the provided services would not be affected in case of participation refusal, and the data provided could not be linked to the participant. Also, cover letters explaining the purpose and the significance of this study were attached to each questionnaire with a declaration that the participant was 18 years or older and did not complete this questionnaire before. Additionally, questions related to the participants’ demographics were included.

Potential participants were approached by the researchers and the research assistants while they were sitting in the waiting halls of the selected CHCs. Each item the questionnaire measured was stated as a statement. Potential participants were asked to indicate their levels of agreement with the provided statements by circling one of five alternatives on a Likert scale ranging from “strongly agree” to “strongly disagree”. The potential participants were asked to place the questionnaires, whether they decided to complete them or not, in unmarked envelopes and then, leave them in one of three containers placed in different parts in the selected CHCs to ensure their anonymity. Then the researcher and the research assistants left the waiting halls to ensure the anonymity and the privacy of the potential participants.

The data collection took place from July 1, 2011 to October 1, 2011. The average response rate in both sample types was 86%, with 92% in the UNRWA CHC and 80% in the governmental CHC. The proposal of this study was approved by the Jordanian Ministry of Health Research Ethics Committee and the UNRWA medical services in Jordan. Permission to use the SSCN questionnaire was obtained from the original authors.

Data entry and analysis were performed using the Statistical Package of Social Sciences (SPSS), Version 17 software (SPSS Inc., Chicago, IL, USA). The analysis was conducted using descriptive statistics. The dependent variable was client satisfaction with the quality of the nursing care provided in the selected CHCs. The responses for each statement in the questionnaire were entered as 5 = strongly agree to 1 = strongly disagree. The scores were reversed for negative statements. The satisfaction levels were calculated by adding responses. A higher mean (M) indicated a higher satisfaction level. A mean equals or less than (M = 2.0) was considered as an indicative of “dissatisfaction”, a mean range from (M = 2.1) to (M = 4.0) was considered as an indicative of a “moderate satisfaction”, and a mean equals or higher than (M = 4.1) was considered as an indicative of a “high satisfaction”.

The total satisfaction levels were compared across the two settings. Then, the demographics of the total sample including gender, age, educational level, and perceived health status were compared with their satisfaction levels. Mean, standard deviation, independent sample T-test, and one-way ANOVA test were used to guide the analysis of the data. P < 0.05 indicated a statistical significance and p < 0.001 indicated a high statistical significance.

Results

Characteristics of study sample

The majority (64.5%) of participants had an age between 26 to 55 years old, more than half (57.6%) of participants were females, around third (34.5%) of the study sample had a high school education, and around half (44.4%) of participants perceived their health status as good.

Satisfaction levels

Table (1) demonstrates the satisfaction of study sample with the SSCN dimensions and the 17 items in both settings. The table reflected that study participants from both settings were moderately satisfied (M = 3.34). A high significant difference was seen (p = 0.000 & t = 4.75) in the UNRWA CHC. Clients from both settings were less satisfied with the coordination level (M = 3.26) and the interpersonal aspect (M = 3.32) of the care provided (p = 0.000 & t = 4.38; p = 0.01 & t = 2.80 respectively) than the technical aspect (M = 3.45) (p = 0.000 & t = 4.85).

Satisfaction and demographic variables

Table (2) shows the relationship between participants' gender and satisfaction with the SSCN dimensions. The table reflected that female participants (M = 3.42) were more satisfied than male participants (M = 3.23) (p = 0.02 & t = 2.25).

Table (3) depicts the effect of age, educational level, and perceived health status on the SSCN dimensions among study sample. The table indicated that there were statistical significances in both age and educational level (p = 0.01 & f = 3.1; p = 0.006 & f = 3.7, respectively). Higher means (M) were seen in younger, less educated participants. While, no statistical significance was found in perceived health status (p = 0.2 & f = 1.7).

Discussion

Client satisfaction is one of the most important determinants of the quality of nursing care. [4,14,16] The current study revealed that clients were moderately satisfied which indicated providing a relatively acceptable nursing care quality. Clients reported higher levels of satisfaction in the technical competence dimension than in the other two dimensions of the SSCN scale (interpersonal relationship and coordination of services dimensions). This finding implied that nurses’ high technical skills in the selected CHCs were unmatched either by their interpersonal skills or by the level of coordinating the provided services. This finding was consistent with other satisfaction studies’ findings, which reported that being more responsive to clients’ needs and improving staff interaction with them would noticeably increase their satisfaction levels. [3,21]

The similar demographic distribution of both subsamples (UNRWA and governmental CHCs) suggested that the higher satisfaction levels in the UNRWA CHC were mainly related to providing a higher quality of nursing care. A review of the health care polices in the UNRWA and in the governmental CHCs was conducted by the researchers in order to further investigate possible reasons for this higher level of satisfaction in the UNRWA CHC. Two major policy differences were identified. Firstly, the UNRWA CHC offered free health care services, while the

governmental CHC offered low-cost health care services. This probably increased client satisfaction levels in the UNRWA CHC, since the affordability of services has a positive effect on client satisfaction. [22] Secondly, the UNRWA CHC used a family health team (FHT) approach for the delivery of their health care services, while such an approach was not used by the governmental CHC. The FHT approach is a method developed by the UNRWA medical services to deliver health care services to the whole family by a health care team that consisted of a doctor, one or more nurses, and a midwife. [23] Using such an approach could probably have increased their client satisfaction levels especially in the coordination of services dimension.

In the current study female, lower educated clients had higher levels of satisfaction. Two studies of client satisfaction with nursing care among a Jordanian population also reported that females had higher levels of satisfaction than males. [24,25] On the other hand, studies conducted among other populations reported that males were more satisfied than females. [4,11]

However, the effect of educational level in this study was consistent with studies conducted among both a Jordanian population and other populations. [10,24,25] This suggested that the effect of gender seemed to change in different population, while the effect of education seemed to be more universal.

In relation to age, younger clients were more satisfied in this study. This finding contradicted the findings of the two Jordanian studies which reported that age did not affect client satisfaction levels. [24,25] Moreover, studies that were conducted in different populations reported that older clients were more satisfied than younger clients. [4,10,11] In this current study, no effect of perceived health status on client satisfaction level was reported. This contradicted with another satisfaction study’s finding which reported that healthier clients tend to be more satisfied. [10] This lack of consensus in relation to age and perceived health status effects on clients’ satisfaction levels suggested that these two variables were not as important as gender and educational level. The current study concluded that clients were moderately satisfied with the quality of nursing care delivered in the selected CHCs. Policies in community health organizations should place more attention in coordinating their services especially by allowing their clients to be more actively involved in the planning of their own care. Also, staff development programs in community health organization should focus on increasing the ability of nurses to communicate more effectively with clients. Less educated clients tend to have higher satisfaction levels and the effect of gender seems to differ among different populations. Age and perceived health status seem to be less important determinants of client satisfaction.

References

1. Graham J, Denoual I, Cairns D. Happy with your care. Journal of Psychiatric and Mental Health Nursing 2005; 12(2): 173?178.
2. Hills R, Kitchen S. Toward a theory of patient satisfaction with physiotherapy: Exploring the concept of satisfaction. Physiotherapy Theory and Practice 2007; 23(5): 243?254.
3. Laos CM, DiStefano MC, Cruz AT, Chantal CA, Hsu DC, Patel B. Mobile Pediatric Emergency Response Team: Patient Satisfaction during the Novel H1N1 Influenza Outbreak. Academic Emergency Medicine 2012; 19(3): 274?279.
4. Johansson P, Oleni M, Fridlund B. Patient satisfaction with nursing care in the context of health care: a literature study. Scandinavian Journal of Caring Sciences 2002; 16(4): 337?344.
5. Merkouris A, Papathanassoglou EDE, Lemonidou C. Evaluation of patient satisfaction with nursing care: quantitative or qualitative approach. International Journal of Nursing Studies 2004; 41(4): 355?367.
6. Laschinger HS, Hall LM, Almost JA. Psychometric Analysis of the Patient Satisfaction with Nursing Care Quality Questionnaire. Journal of Nursing Care Quality 2005; 20(3): 220?230.
7. Wagner D, Bear M. Patient satisfaction with nursing care: a concept analysis within a nursing framework. Journal of Advanced Nursing 2009; 65(3): 692?701.
8. AgostaLJ. Patient satisfaction with nurse practitioner-delivered primaryhealthcare services. Journal of the American Academy of NursePractitioners 2009; 21(11): 610?617.
9. LeeDS, Tu JV, Chong A, Alter DA. Patient satisfaction and its relationshipwith quality and outcomes of care after acute myocardial infarction.Circulation 2008; 118(19): 1938?1945.
10. HekkertKD, Cihangir S, Kleefstra SM, van den Berg B, Kool RB. PatientSatisfaction Revisited: A Multilevel Approach. Social Science &Medicine 2009; 69(1): 68?75.
11. S?il?T, Mattila E, Kaila M, Aalto P, Kaunonen M. Measuring patient assessmentsof the quality of outpatient care: a systematic review. Journal of Evaluationin Clinical Practice 2008; 14(1): 148?154.
12. KuosmanenL, H?t?nen H, Jyrkinen AR, Katajisto J, Välimäki M. Patient satisfactionwith psychiatric inpatient care. Journal of Advanced Nursing 2006; 55(6):655?663.
13. HiidenhovH, Nojonen K, Laippala P. Measurement of outpatients' views of servicequality in a Finnish university hospital. Journal of Advanced Nursing2002; 38(1): 59–67.
14. Leonard KL. Is patient satisfaction sensitive to changes in the quality of care? An exploitation of the Hawthorne effect. Journal of Health Economics 2008; 27(2): 444?459.
15. Bryant R, Graham MC. Advanced Practice Nurses: A Study of Client Satisfaction. Journal of the American Academy of Nurse Practitioners 2002; 14(2): 88?92.
16. Coban GI, Kasikci M. Reliability and validity of the scale of patient perception of hospital experience with nursing care in a Turkish population. Journal of Clinical Nursing 2010; 19(13-14): 1929-1934.
17. Land LM, Jobanputra P, Webber J, Ross JD. Patient satisfaction in three clinics managing long-term conditions. British Journal of Nursing 2012; 21(3): 186?188.
18. Hijazi S. Major Health Issues in Jordan. Ethnicity & Disease 2005; 15(1): 77?82.
19. Cheng WLS, Lai CKY. Satisfaction Scale for Community Nursing: development and validation. Journal of Advanced Nursing 2010; 66(10): 2331?2340.
20. Cochran WG. Sampling techniques. 3rd ed. New York: John Wiley & Sons; 1977. 428 p.
21. Levoy B. The Keys to Patient Satisfaction. Podiatry Management 2012; 31(1): 39?40.
22. Dib HH, Sun P, Minmin Z, Wei S, Li L. Evaluating community health centers in the City of Dalian, China: How satisfied are patients with the medical services provided and their health professionals. Health & Place 2010; 16(3): 477?488.
23. 23. United Nations Relief and Works Agency. Health [Internet]. 2010 [cited 2010 Jan 28]. Available from: https://www.unrwa.org/etemplate.php?id=28.
24. Alasad J, Ahmad M. Patients' satisfaction with nursing care in Jordan. International Journal of Health Care Quality Assurance 2003; 16(6): 279?285.
25. Alhusban MA, Abualrub RF. Patients' satisfaction with nursing care in Jordan. Journal of Nursing Management 2009; 17(6): 749?758.