finance and management

Patient satisfaction as a measure of quality in the care of the elderly Anne O ’Leary, Parkhill Nursing Home, Birmingham This article examines the relevance of obtaining patients’ views in the measurement of quality in nursing care. The literature on the selection of instruments that measure quality in the care of older people is reviewed.

H n 1983, the Griffith report (HMSO, 1983) stated that ‘as a caring, quality ser­ vice, the NHS has to balance the interests of the patient, the community and the em­ ployee’. As a result of this and the more recent 1990 NHS and Community Care Act, quality has become an integral word in the vocabulary of managers and clinicians.

Definitions of quality The ultimate definition of quality has prov­ ed difficult to determine. While The Oxford English Dictionary defines quality as ‘the degree or grade of excellence,’ it has most commonly been interpreted as meaning consumer satisfaction, both of the patient and of the employee. Keithley (1989) de­ fines quality as ‘the totality of features and characteristics of a product or a service which bear on its ability to satisfy a given need’. In the field of business, quality is often a trademark that ensures consumer protec­ tion of services and goods. With the rising tide of consumerism the British public is becoming increasingly informed and is de­ veloping a questioning approach to the ser­ vices it receives. The health service is under increasing pressure to provide sound assur­ ance of quality of care both in hospitals and in the community (Duddy, 1990).

Consumer satisfaction

Ms O ’Leary is the Nursing Sister at the Parkhill Nursing Home, Parkhill Drive, Handsworth Road, Birmingham B21 1DU, and is on secondment from West Bjrmingham Health Authority

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If quality is consumer satisfaction then the obvious way to measure the quality of a service is to ask its consumers, as their ex­ periences of the service will provide a valid measurement of the quality of care they re­ ceive. In their examination of consumer be­ haviour in the private sector, Engel et al (1973) highlight problems that are relevant to the NHS ‘concerning the issues of what consumers want versus what they ought to want and what they know versus what they need to know.’ Many nursing research studies are based

on Donabedian’s (1980) model for evaluat­ ing quality healthcare which involves the assessment of the structure of institutions, the processes that enable services to be de­ livered and patient outcomes. Donabedian (1980) states that evaluation of patient satis­ faction determines ‘the provider’s success at meeting those client values and expecta­ tions which are matters on which the client is the ultimate authority.’ However, Donabedian emphasizes that the client, be­ cause of limited knowledge of the technol­ ogy of care, cannot be the ultimate author­ ity on quality. Part of the dilemma when attempting to determine patients’ satisfaction with the care they have received is that the expecta­ tions of care held by patients differ from the expectations held by nurses (Fitz­ patrick, 1991a). Indeed, several authors have identified what patients expect from nurses. Tagliacozzo (1965) reported that patients, when asked to identify what they expected from a nurse, selected qualities such as a kind and friendly personality, knowledge of the patient, dedication, a fast response, enough time, and kindness. In a more recent study, Gill Taylor et al (1991) reported that out of a sample of 140 patients and their significant others, quality of nursing care was most often de­ scribed in terms of the nurse’s personal qualities, holistic care, therapeutic nurse-patient interaction, and proficiency. Sira (1980) suggested that patients were more concerned with the interpersonal skills of hospital staff than with their tech­ nical skills and competence. If this is the case then the patients’ opinion could be construed as being an emotional, subjective measurement as opposed to a reliable, ob­ jective measure. Another reason to doubt the reliability of consumer satisfaction as a measurement of quality care is the number of patients who do not express negative comments about their healthcare in the NHS. FitzBritish Journal of Nursing, 1992,Vol l,N o 9

Patient satisfaction as a measure of quality in the care of the elderly ‘ As Klein (1979) points out, there is noone more qualified to know what it feels like to be a patient than a patient and therefore patients have unique authority. 5

patrick (1991a) states that at least 80% of respondents express satisfaction for any given question. One reason for this could be the patient’s dependence on the service. Although dissatisfaction may be expressed following discharge, this may be muted by the possibility of having to return (King, 1985; Duddy, 1990).

Measurement of older people’s satisfaction The fastest growing segment of the UK population is the group aged 80 years and over, therefore the number of older people in need of healthcare is increasing. If the experiences of patients and their degree of satisfaction goes some way to determining the quality of care in the health service, then obtaining the views of older people must be a significant factor in its measurement. In reviewing the literature, it becomes clear that few of the studies on patient satisfaction involved older people. Yet, Fitzpatrick (1991b) points out that levels of satisfaction with hospital care appear to in­ crease with advancing age. Younger people express more negative views. He states that the reason for this is unclear although poss­ ible reasons could be differing levels of ex­ pectation or a real difference in the quality of the care received. Abrams (1973) puts forward one explanation: ‘For many women who are now ap­ proaching 80, the first three-quarters of their lives were lived against a back­ ground of abject poverty, hard work, danger and wretched housing. It would not be surprising if their present criteria of what they need, of what they arc en­ titled to, and of what gives them satis­ faction are modest.’ In the past, contact with older people being cared for in institutions such as long-stay wards and nursing homes led to the devel­ opment of stereotyped attitudes where be­ ing old was equated with being ill, senile and helpless. Recent advances in the spe­ cialty of geriatric nursing and increased support in the community has led to the recognition of older people’s intrinsic strengths as well as needs (Mezey and Lynaugh, 1989). If these strengths are to be developed to their optimum level, nurses must aim to dispel the many myths about older people that abound in today’s society.

Dispelling the myths One such myth is that older people experi­ ence a decrease in mental capacity. This is not part of the natural ageing process but British Journal o( Nursing. !992,Vol I, No 9

often a symptom of an underlying disease process that requires thorough assessment and investigation (Kick, 1989). Another common myth is that older people are un­ able to learn. Most had to leave school early to start work or raise a family. This does not mean that older people cannot learn but rather that they are more selective as to what they need to learn and need more time to develop their learning skills (Kick, 1989). Elderly people may not be used to being asked their opinion. Indeed, the Depart­ ment of Health (DHSS Welsh Office, 1976) reported that the absence of protest in older people about their care was due to the re­ spect that the public has for nursing staff. This, it was suggested, restrained criticism of such apparently trival matters as early rising. When faced with such stereotyped attitudes, one cannot be blamed for doubt­ ing the whole relevance of asking older people to express opinions on the quality of care.

Research design However, as Klein (1979) points out, there is no-one more qualified to know what it feels like to be a patient than a patient and therefore patients have unique authority. By selecting specific, well-designed ques­ tionnaires that are tailored to meet the needs of the research design, the investi­ gator can reveal valuable information re­ garding different aspects of specific epi­ sodes of healthcare. Testing for reliability (the internal con­ sistency of a questionnaire) and validity (the extent to which a questionnaire is measuring what it claims to measure) are important factors, although very difficult to achieve owing to the subjective nature of satisfaction surveys. The selection of the best method to gather information, i.c. in­ terview or self-completed questionnaire, must be considered. Often, restrictions of time and resources are deciding factors. In a comprehensive review of the literature, French (1981) compared studies that used interview with those that used self-com­ pleted questionnaires and concluded that the response rates were similar. It may at this point be useful to return to the definition of quality as ‘consumer satisfaction’. It can be seen that the defini­ tion of quality must go beyond this. In­ deed, Donabedian (1980), when attempting to define quality, concluded that it was so *. .. diverse in nature that neither a unifying construct nor a single, empirical measure could be developed’. Because of this, many

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Patient satisfaction as a measure of quality in the care of the elderly authors return to Donabedian’s original model to evaluate the quality of healthcare. Many recommend that by measuring all three aspects — structure, process and out­ come including patient satisfaction — a more holistic, reliable result is achieved (Maxwell, 1984). This approach is un­ doubtedly preferable to the fragmented one of obtaining patients’ views alone which are often deceptively positive.

Consumer-professional partnership If patients and, more specifically, older pa­ tients are to express valid and reliable views on the quality of care they receive from the health service, it would seem clear that pa­ tients and nurses must work together in partnership as consumers and professionals to determine what they mean by the phrase ‘quality care’. The education of patients is vital if they are to make informed decisions regarding their needs and expectations. At present, the nurse often directs health education to the family rather than the older person. However, together with an increased life span, the older person should have an in­ crease in knowledge. If nurses claim to pro­ mote self-care then is it the older person’s right to be more independent by learning about their personal health, illness and treatment choices (Kick, 1989). In this way, the value of the patient’s opinion as a measureable outcome in research will be strenghencd.

K EY P O INTS • Quality in healthcare can be defined as consumer satisfaction, both of the patient and the employee. • Patient satisfaction relies on the provider meeting clients' values and expectations. • Patient satisfaction is difficult to analyse as there may be a gap between expectation and reality owing to patients' limited knowledge of the technology of care. • Nurses must aim to dispel the myths that surround older people in today's society, e.g. diminished mental capacity. • Levels of satisfaction with hospital care appear to increase with advancing age. Younger people generally express more negative views. • The education of patients is vital if they are to make informed decisions in relation to their needs and expectations. To achieve this there needs to be a partnership between consumer and professional.

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/ would like to acknowledge Professor J Brooking, Head o f Department, Nursing Studies, Birmingham University, for her invaluable constructive suggestions.

Abrams M (1973) Beyond Three Score Years and Ten. A First Report on a Survey o f the Elderly. Age Concern Publications, Mitcham DHSS Welsh Office (1976) The Organisation o f the Inpatient’s Day. HMSO, London Donabedian A (1980) The Definition o f Quality and Approaches to its Measurement. Health Adminis­ tration Press, Ann Arbor, Michigan Duddy I (1990) The patient’s experience. Nurs Stan­ dard 5(9): 7 Engel IF, Kallett DT, Blackwell RD (1973) Consumer Behaviour, 2nd edn. Dryden Press, London Fitzpatrick R (1991a) Surveys of patient satisfaction: 1 — Important general considerations. Br Med I 302y 887-90 Fitzpatrick R (1991b) Surveys of patient satisfaction: 2 — Designing a questionnaire and conducting a survey. Br Med J 302: 1129-32 French K (1981) Methodological considerations in hospital patient opinion surveys, hit / Nurs Stud 18: 7-32 Gill Taylor A, Hudson K, Keeling A (1991) Quality of nursing: the consumer’s perspective revisited. J Nurs Quality Assur 5(2): 23-31 HMSO (1983) Recommendations on the Effective Use o f Manpower and Related Resources (Griffith Re­ port). HMSO, London Keighley T (1989) Developments in quality assurance. Sen Nurs 9(9): 7-8 Kick E (1989) Patient teaching for elders. Nurs Clin North Am 24(3): 681-6 King T (1985) More than a buzz. word. Nurs Mirror 160(8): 34-5 Klein R (1979) Public opinion and the National Health Service. Br Med J 1: 1296 Maxwell RJ (1984) Quality assessment. Br Med I 288: 1470-2 Mezey M, Lynaugh J (1989) The teaching nursing home program: outcomes of care. Nurs Clin North Am 24(3): 769-80 Sira ZB (1980) Affective and instrumental components in the physician-client relationship. J Health Soc Behav 21:170-80 Fagliacoz/.o D (1965) The nurse from the patient’s point of view. In: Skipper JK, Leonard RC, eds. Social Interaction and Patient Care. Lippincott, Philadelphia: 219-27

Finance and management If you have any views on this section, or have any particular subjects you would like to see covered, please write to: The Managing Editor, BJN, Mark Allen Publishing, Croxted mews, 288 Croxted Road, London SE24 9DA British Journal ol Nursing, 1992, Voi 1,N o 9

Patient satisfaction as a measure of quality in the care of the elderly.

This article examines the relevance of obtaining patients' views in the measurement of quality in nursing care. The literature on the selection of ins...
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