Journal of Advanced Nursing, 1992,17,959-964
Patient satisfaction with care in the emergency department Kathryn E Lewis BN BEd MEd Associate Professor of Nurstng
and Reida E Woodside BN MScN Assoaate Professor of Nurstng. University of New Brunswick. Fredencton, New Brunswick. Canada
Accepted (or pubbcabon 9 December 1991
LEWIS K E & WOODSIDE R E (1992) Journal of Advanced Nurstng 17, 959-964 Patient satisfaction with care in the emergency department This paper looks at the patient satisfaction levels with care m an emergency department (ED) settmg Speafic aspects of nursmg care, information given to patients, auxibary persormel and ED environment are exammed m the light of the current literature on the subject Recommendations for practice are provided to assist the nurse and admimstrator m updatmg their accountability to the ED patient
BILL OF RIGHTS
LITERATURE REVIEW
The Pahent's Bill of Rights advises health care professionals that pahents are enhtled to considerate and respectful care (Kosier et al 1991) Although this is an ethical and not a legal document, the last decade has shown that consumers are now very aware of their nghts and often do not hesitate to register their complamts formally with the hospital administration or even the press On occasions, the fine bne between ethical and legal implications gives nse to lengthy and costly legal battles Busmesses are much more aware of their accountabibty to their cbents and good pubbc relations with the commuruty mvolved is considered a valuable marketmg strategy Do those m the health care system also subscnbe to this modem concept or are they bngenng behmd with the old ideas of omnipotence and control? The board of one regional hospital m eastem Canada became concemed with the complaints they had received about their emergency department (ED) and comrrussioned a study that would mveshgate the basis of such con^lamts
Patient satisfaction with services
^ , „,
,.
. ,.,
Corrapomkna KELeais.AssociakPn^e!isor Faculty (^Nursmg, Umvasity of New
. Fndentttm, fka Bnmsauk E3B 5A3. Canada
The emphasis on patient sahsfachon is consistent with the trend toward holding health professionals accountable to their consumers' (Roberts & Tugwell 1987) McMillan et al (1986) suggest that the satisfachon factor may impact on whether the person 'seeks medical help, complies with the prescnbed treatment and mamtains a contmumg relationship with a physiaan' bl a study by Hall & Doman (1988), the facets most likely to ebat a pahent's sahsfachon with health care were humaneness and techrucal abibty Other fadors m decreasmg order of pnonty were faabhes, contmiaty of care, access to faabty, mformahon received cost, bureaucracy and attenhon to psychosoaal problems Hall & Doman (1988) felt that this order of pahents' pnonttes was a reflechon of the emphasis that the health care system places on technical versus psychosoaal aspects of care and/or the possibibty that the pahent's lack of knowledge about technical matters resulted m higher ratings by default for that aspect of care Individual needs Current nursing bterature reflects the importance of '°
^L ^
^ c
L
i. u
..
1.1.
nursmg care systems that sahsty patients by meeting ttieir 959
KE Lewis and RE Woodstde
individual needs — needs from the pahent's pomt of view (Allanadi & Golden 1988, Lucas et al 1988, Rempusheski etal 1988, %>itzer 1988) Blairrfa/ (1982) felt that pnmary nursmg care on an episodic basis was an appropnate model for the emergency d^artment Rempusheski et al (1988) also reported on quabhes of the nurse-|>atient mterachon that ebated sahsfachon Indeed, Yoder & Jones (1981) report that 'the sahsfachon of psychological needs plays a tremendous role m the emotionai comfort of patients and m the restorahon of homeostasis to physical processes m the body' Gibbon (1988) and Vosburgh (1988) noted the importance of nursmg care of family members whose well-being plays a valuable role m pahent recovery Gibbon (1988) identified 'stress m relahves' as takmg overt and covert forms and pomted out nurses' responsibilihes for addressmg this important problem
would agree to complete a two-part queshormaire relating to their use of the ED, their demographic data and their sahsfachon with care Measurement The pahents' sahsfachon levels were measured by the use of a three-pomt Likert-type scale which asked them to rate as very satisfadory, satisfactory or not satisfactory detailed aspects of nursing care, information they received and their overall opiruon of the visit In addihon, patients were given the opporturuty to make comments about aspeds of the visit that parhculariy pleased or displeased them, as weU as any suggeshons they might have for improvmg nursing care
FINDINGS
Of the 152 patients who rated their nursmg care, 87 4%971% were sahsfied or very satisfied There was slightly Triage more dissahsfachon expressed with nurses regardmg their The tnage dassificahon of emergency department pahents concem for those accompanying the pahent than for the was found to be assoaated with their level of sahsfachon other aspect of care (see Table 1) (McMillan et al 1986) Emergency category pahents were Forty-three patients made positive open-ended comapparently more sahsfied than their urgent and non-urgent ments related to nursing care or mterachons with counterparts As it is unlikely that non-urgent pahents will nurses Another five pahents made negahve open-ended be treated much more quickly, due m part to finanaai comments related to nurses restramts, McMillan el al (1986) suggest improvmg The open-ended comments showed that a positive attitheir waitmg area (providing proxmuty to refreshments, tudefromnursing staff is noted and very much appreciated magazmes and pnvacy), and advising them of the estiFour of the negahve comments related to the pahent's mated treatment time They recounted that mcreased perception of the nurse's athtude and one to a combination anxiety is assoaated with seekmg medical help and that an of attitude and lack of follow through of care mcreased number of consumers want 'a quick diagnosis' Pahent suggestions for ways to improve nursmg care m and 'fast treatment by the emergency department physthe ED related to mcreased staff dunng busy tunes (5), ician' People generally dislike waitmg and it is worse when improvmg their athtude (4), providmg better follow you are anxious and uncomfortable (McMillan et al 1986) through of care (2) and providmg information more McMillan et al (1986) reported the inadequacy of sahs- readily (2) fachon surveys which concentrate only on the 'overall sahsfachon' factor They felt that one facet of a posihve or r^gahve expeneiKe may be overshadowed by a greater Information given to patients negahve or posihve one Thus, it becomes impossible to Pahents were asked to rate their satisfachon with the smgle out speafic areas that need improvement They also mformahon they received regarding their health problem pointed out that sahsfachon surveys are biased toward and ED visit Those who responded were quite sahsfied the posihve as most consumers are hesitant to cnhaze except for a perceived lade of mformahon related to the However, pahents may be openly negahve m their waihng time (see Table 2) conversahons with fnends Auxiliary personnel
METHOD A systemahc survey of ED pahents was earned out by askmg every fifth pahent who registered dunng 24 predetermined day, evenmg, night and hobday shifts if they 960
Pahents were asked to rate their sahsfachon with the ED recephorust, orderbes, ambulance dnvers, fracture room attendants and X-ray staff A large number of patients did not answer parts of this queshon because they were not
Pattent satafactton wtth emergency departments
Table 1 Patient satisfaction ratings of con^nents of nursmg care (in percentages)
Satisfaction ratmgs CompOTients of nursmg care
Very satisfactory
(H = 152)''
'FcHty^eight pahents did not respond to this queshon
Table 2 Patients' sahsfachon with mformahon received dunng their ED visit (m percentages)
Amount of tune spent with patient Skill with medicahons and treatments Knowledge of problem and care Concem for patient's pnvacy Explanations given about care Recognition of individual quabties and needs of pati«tt Mort to understand patient's problem Concem for those with patient Overall canng and compassion Made difference m how patient felt Watchfulness of patient's condition Ease of obtammg nurse when needed
Not
Satisfactory
sahsfactory
471
48-0 46 7 43 3 45 7 43 7 44 3
510
428
62
38 7
48 7
12 6
518
415
46 3 413
45 5 48 9
44 5
469
6-4 82 98 86
454
50 4 48 9 45 7 47 4
66 29 78 86 89 86
Satisfaction rating Information received (« = 200)
Very satisfactory
Length of wait Diagnosis Medicahons Tests Treatments Prevenhon Self-care Complications
applicable to them Although these staff members usually are not diredly under the supervision of the nursing department, often there are overlaps m onentations, contmumg educahon workshops, evaluations or mstances where nurses role model for other staff m the department It IS important for nurses to take a leadership role m the funchon of their units Results of this study showed that pahent satisfachon with auxiliary staff was generally high However, the athtude of recephonists was rated as unsahsfactory by 8 5% of pahents, whereas the next highest was 15% for X-ray staff This was also bome out by four negahve comn^iits i ^ u t the recephtHiists m the open-ended questums Althcnigh these are not highly relahve to the
Not
No
Satisfactory
satisfactory
answer
200
275
22 5
25 0 24 5 14 0 15 0
37 0 22 5 14 0 23 0
30 0 30 5
65 175 115
105 265 180
75 15 15 25 60 50 85
515
70 5 59 5 77 0 510
62 0
overall number of participants, the receptionists were of particular note because they play a key public relahons role man ED Emergency department environment Again, the ED environment may not be diredly under the supervision of the nursing department but nurses can and do have sigruficant input mto its control The study showed that the majonty of patients were satisfied with the ED environment Many pahents chose not to answer this queshoa possibly mdicahng a neutral athtude or because they felt it was unimportant Abo, some pahents did not use the waitmg room 961
KELewtsandRE Woodstde
Open-ended queshons yielded a anall number of posi1 hve and negahve comments Four pahents commented on what they f)erceived as a lack of pnvacy dunng registrahon and/or care Specific suggeshons regardmg the ED environment were also offered by pahents Induded m these were requests for refreshments, more toys for children and a 2 rockmg chair for fussy babies
faffing Almost half the patients surveyed felt that the department was well staffed Over one-quarter of the pahents felt the ED was not well staffed enough Many pahents assoaated long waits with madequate staffing
Overall satisfaction Pahents' overall sahsfachon with their emergency department visits was abnost evenly divided between very satisfactory and sahsfadory by the urgent and nonurgCTit category patients The emergency patient category (« = 1) m the study is statistically inadequate for comment In the former two categones, findmgs mdicate that the more urgent the tnage category, the more sahsfied the pahent Pahents' overall satisfachon was highest m pahents who perceived themselves as havmg 'no' and 'moderate' fear/anxiety, followed dosely by pahents with 'severe' fear/anxiety Patients with 'slight' fear/anxiety had more complamts Somefromthis category also refused to parhapate in the survey The 'paruc' category (« = 3) was too small for accurate analysis
3
In the 'very satisfactory' category, overall sahsfachon ratings matched with the total specific ratmgs for less than half of the respondents, l e only 24 of the 52 respondents who reported bemg very sahsfied m the overall also reported being very satisfied with the nurse, dodor, environment, auxiliary staff and waits For the 'satisfadory' category, less than one-third of respondents showed a match between overall and specific (nurse, physiaan, etc) aspects of care It must be noted that some sj)ecific aspeds were rated as 'very satisfadory' and others as 'not sahsfadory', resultmg m an averaging effed For those 18 not sahsfied with overall care, no mstances showed dissahsfaction with all speafic aspects of care One instance of overall dissatisfaction was related to nursing care exclusively, for six others, the nursmg care was mduded with other unsahsfactory fadors, and for 11, the nurse was not mduded m their dissahsfachon
DISCUSSION Although satisfadion was expressed by a high percentage of pahents m this survey, McMillan et al (1986) pomt out that 'health care literature well documents the fact that consumers report sahsfachon levels that are generally, if not always biased toward the completely sahsfied end of the scale' Therefore, afrer the lrutial glance, one must take the dissahsfachon of pahents more senously than might be thought Family members
Gibbon (1988) and Vosburgh (1988) state that posihve mvolvement by nurses with family members contnbutes to pahent recovery In the bght of this, it is mterestmg to note Overall satisfaction/specific satisfaction that the onergency department nurses m our study had a Pahents' 'overall sahsfachon' scores for the entire visit 12 6% dissahsfachon rating m relahon to their concem for were compared to their speafic scores for 'nursmg care', those accompanymg the pahent This rate is sbghtly higher 'physician care', and other aspeds such as environment, than the other dissatisfachon ratmgs for nurses This may auxibary staff, overall waihng time, and time spent in the mean that the nurses m this emergency department may waihng room However, before this companson was made, need to place more emphasis on the pahent's fmmly Gibbon (1988) found stress m relahves takmg forms those pahents who rated everything as 'very sahsfactory' across the board were deleted This deasion was based on such as 'fiustrahon or anger, overadivity or impaired the premise that m some cases pahents did not appear to concentrahon' He identified three groups of relahves, difi^enhate their satisfadioa some answenng queshons 'those who constantly ^ek infomiahon from nurses, those who attempt to do so, aruifinally,those who avoid contact that did not even apply to them. Ccmipansons based on the ronainmg resporwlents with niffses' Gibbtm's (1988) sugge^ion for mtervenhcm mdude the flowed only a loose matdi betw^»t the sp^ifk sahsfac^vmg of otfomudion and lndusion of rdatives m tlw care hon ratmgs and the overall sahsbchon ratings 962
Pattent satisfaction mth emergency departments
as much as possible In addihon, relatives need similar onohonal support as do pahents and, at times, even more so The success of the nursmg staff m relahon to technical competence is demonstrated by the high sahsfaction levels given to this aspect of care by patients Hall & Doman (1988) acknowledged that health care professionals place a high emphasis on technical competence, and Spitzer (1988) found that pahents complamed about nurses 'focusing on the equipment and procedure rather than on the patient' 'High touch' care is needed m this age of 'high tech' care To Magill & Scheuerman (1984), this amounts to considerate staff debvermg high quality care This desire on behalf of patients is certainly bome out by the appreaation expressed through posihve comments of the pahents surveyed
Complaints Although the number of complaints about 'follow through of care' was small, this represents a fundamental aspect of nursing care In a study by Blair et al (1982), the pnmary nursmg care model on an episodic basis was shown to be one type of nursmg care appropnate for emergency department use which might address the contmuity problem Spitzer (1988) found that 'explanation of treatment' was a factor important to patient satisfachon However, except for waiting times, the question related to satisfaction with information received from staff was not weU responded to by patients m our survey Perhaps this mdicates their pre-occupahon with physical achon as suggested by Hall & Doman (1988) Some pomted complamts were made about certam staff manbers, l e nurses and receptionists Other comments complimented staff, mdicahng that the problems were bkely to be mdividual and situahonal Spitzer (1988) remmds us that 'nurses are goodwill ambassadors' and, as physiaans are seen apart from the hospital, 'nurses are often seen as responsible for all achvities m the faabty and thus may mcur negative feelmgs' The suggeshons made by patients m the study for the improvement of the emergency department envirorunent were similar to those speafied by McMillan et al (1986) Although the negahve comments made by patients about pnvacy were small m number, the concept is important and refleds one of ttie basic patient nghts
one posihve or negahve aspect of care may be overshadowed by another negahve or posihve aspect Also, they are not specific enough to analyse and improve mdividual aspects of care This is bome out by the findmgs of this study which showed, at best, only a 46% match between the overall scores and the scores for speafic aspects of the visit This view was also douded by patients who gave blanket 'very satisfactory' ratings, which upholds McMillan et al's (1986) condusion that people are hesitant to cntiaze and tend to rate toward the positive end of the scale For the quabty assurance committee to focus on areas for improvement, they would have to utilize the ratmgs of specific professional groups and/or environment The relative tendency to show greater overall satisfachon by more 'urgent' patients follows the same pattem as identified by McMillan et al (1986) The moderate or greater anxiety levels m 55% of patients in our survey supports the premise of McMillan et al (1986) that increased anxiety is assoaated with seekmg medical help The impatience with waitmg by anxious, uncomfortable patients reported by McMillan ei al (1986) was also seen in this study
RECOMMENDATIONS FOR PRACTICE With the vanety of pressures and pnonties that prevail m the ED, patient satisfaction may sometimes seem bke an overwhelming task, a 'pipe dream' But in most cases the patient is not looking for lofty psychosoaal nursmg mterventions nor elaborate techrucal skills From the findings of this study, patients mainly want the basics Apart from the expected techrucal competeiKe and tnage capabibties that are usually managed quite welL a positive attitude from staff was the most sought-after commodity
Action Accordmg to the patients surveyed, a positive attitude can be effectively debvered by the followmg measures 1 2 3 4 5
Limitations Accordmg to McMillan et al (1986), overall satisfachon rahngs by themselves must be viewed as inadequate, as
6
a srrule, look the pahent in the eyes, assess their degree of anxiety, be kmd and gentle, try to identify if they have any mdividual needs that are pressing (l e child home alone, carmot locate husband, etc), ask any fanuly present if they have any questions or concems. 963
KE LewismdRE Woodside 7
give an estimate of how l
Patient satisfaction with care in the emergency department Kathryn E Lewis BN BEd MEd Associate Professor of Nurstng
and Reida E Woodside BN MScN Assoaate Professor of Nurstng. University of New Brunswick. Fredencton, New Brunswick. Canada
Accepted (or pubbcabon 9 December 1991
LEWIS K E & WOODSIDE R E (1992) Journal of Advanced Nurstng 17, 959-964 Patient satisfaction with care in the emergency department This paper looks at the patient satisfaction levels with care m an emergency department (ED) settmg Speafic aspects of nursmg care, information given to patients, auxibary persormel and ED environment are exammed m the light of the current literature on the subject Recommendations for practice are provided to assist the nurse and admimstrator m updatmg their accountability to the ED patient
BILL OF RIGHTS
LITERATURE REVIEW
The Pahent's Bill of Rights advises health care professionals that pahents are enhtled to considerate and respectful care (Kosier et al 1991) Although this is an ethical and not a legal document, the last decade has shown that consumers are now very aware of their nghts and often do not hesitate to register their complamts formally with the hospital administration or even the press On occasions, the fine bne between ethical and legal implications gives nse to lengthy and costly legal battles Busmesses are much more aware of their accountabibty to their cbents and good pubbc relations with the commuruty mvolved is considered a valuable marketmg strategy Do those m the health care system also subscnbe to this modem concept or are they bngenng behmd with the old ideas of omnipotence and control? The board of one regional hospital m eastem Canada became concemed with the complaints they had received about their emergency department (ED) and comrrussioned a study that would mveshgate the basis of such con^lamts
Patient satisfaction with services
^ , „,
,.
. ,.,
Corrapomkna KELeais.AssociakPn^e!isor Faculty (^Nursmg, Umvasity of New
. Fndentttm, fka Bnmsauk E3B 5A3. Canada
The emphasis on patient sahsfachon is consistent with the trend toward holding health professionals accountable to their consumers' (Roberts & Tugwell 1987) McMillan et al (1986) suggest that the satisfachon factor may impact on whether the person 'seeks medical help, complies with the prescnbed treatment and mamtains a contmumg relationship with a physiaan' bl a study by Hall & Doman (1988), the facets most likely to ebat a pahent's sahsfachon with health care were humaneness and techrucal abibty Other fadors m decreasmg order of pnonty were faabhes, contmiaty of care, access to faabty, mformahon received cost, bureaucracy and attenhon to psychosoaal problems Hall & Doman (1988) felt that this order of pahents' pnonttes was a reflechon of the emphasis that the health care system places on technical versus psychosoaal aspects of care and/or the possibibty that the pahent's lack of knowledge about technical matters resulted m higher ratings by default for that aspect of care Individual needs Current nursing bterature reflects the importance of '°
^L ^
^ c
L
i. u
..
1.1.
nursmg care systems that sahsty patients by meeting ttieir 959
KE Lewis and RE Woodstde
individual needs — needs from the pahent's pomt of view (Allanadi & Golden 1988, Lucas et al 1988, Rempusheski etal 1988, %>itzer 1988) Blairrfa/ (1982) felt that pnmary nursmg care on an episodic basis was an appropnate model for the emergency d^artment Rempusheski et al (1988) also reported on quabhes of the nurse-|>atient mterachon that ebated sahsfachon Indeed, Yoder & Jones (1981) report that 'the sahsfachon of psychological needs plays a tremendous role m the emotionai comfort of patients and m the restorahon of homeostasis to physical processes m the body' Gibbon (1988) and Vosburgh (1988) noted the importance of nursmg care of family members whose well-being plays a valuable role m pahent recovery Gibbon (1988) identified 'stress m relahves' as takmg overt and covert forms and pomted out nurses' responsibilihes for addressmg this important problem
would agree to complete a two-part queshormaire relating to their use of the ED, their demographic data and their sahsfachon with care Measurement The pahents' sahsfachon levels were measured by the use of a three-pomt Likert-type scale which asked them to rate as very satisfadory, satisfactory or not satisfactory detailed aspects of nursing care, information they received and their overall opiruon of the visit In addihon, patients were given the opporturuty to make comments about aspeds of the visit that parhculariy pleased or displeased them, as weU as any suggeshons they might have for improvmg nursing care
FINDINGS
Of the 152 patients who rated their nursmg care, 87 4%971% were sahsfied or very satisfied There was slightly Triage more dissahsfachon expressed with nurses regardmg their The tnage dassificahon of emergency department pahents concem for those accompanying the pahent than for the was found to be assoaated with their level of sahsfachon other aspect of care (see Table 1) (McMillan et al 1986) Emergency category pahents were Forty-three patients made positive open-ended comapparently more sahsfied than their urgent and non-urgent ments related to nursing care or mterachons with counterparts As it is unlikely that non-urgent pahents will nurses Another five pahents made negahve open-ended be treated much more quickly, due m part to finanaai comments related to nurses restramts, McMillan el al (1986) suggest improvmg The open-ended comments showed that a positive attitheir waitmg area (providing proxmuty to refreshments, tudefromnursing staff is noted and very much appreciated magazmes and pnvacy), and advising them of the estiFour of the negahve comments related to the pahent's mated treatment time They recounted that mcreased perception of the nurse's athtude and one to a combination anxiety is assoaated with seekmg medical help and that an of attitude and lack of follow through of care mcreased number of consumers want 'a quick diagnosis' Pahent suggestions for ways to improve nursmg care m and 'fast treatment by the emergency department physthe ED related to mcreased staff dunng busy tunes (5), ician' People generally dislike waitmg and it is worse when improvmg their athtude (4), providmg better follow you are anxious and uncomfortable (McMillan et al 1986) through of care (2) and providmg information more McMillan et al (1986) reported the inadequacy of sahs- readily (2) fachon surveys which concentrate only on the 'overall sahsfachon' factor They felt that one facet of a posihve or r^gahve expeneiKe may be overshadowed by a greater Information given to patients negahve or posihve one Thus, it becomes impossible to Pahents were asked to rate their satisfachon with the smgle out speafic areas that need improvement They also mformahon they received regarding their health problem pointed out that sahsfachon surveys are biased toward and ED visit Those who responded were quite sahsfied the posihve as most consumers are hesitant to cnhaze except for a perceived lade of mformahon related to the However, pahents may be openly negahve m their waihng time (see Table 2) conversahons with fnends Auxiliary personnel
METHOD A systemahc survey of ED pahents was earned out by askmg every fifth pahent who registered dunng 24 predetermined day, evenmg, night and hobday shifts if they 960
Pahents were asked to rate their sahsfachon with the ED recephorust, orderbes, ambulance dnvers, fracture room attendants and X-ray staff A large number of patients did not answer parts of this queshon because they were not
Pattent satafactton wtth emergency departments
Table 1 Patient satisfaction ratings of con^nents of nursmg care (in percentages)
Satisfaction ratmgs CompOTients of nursmg care
Very satisfactory
(H = 152)''
'FcHty^eight pahents did not respond to this queshon
Table 2 Patients' sahsfachon with mformahon received dunng their ED visit (m percentages)
Amount of tune spent with patient Skill with medicahons and treatments Knowledge of problem and care Concem for patient's pnvacy Explanations given about care Recognition of individual quabties and needs of pati«tt Mort to understand patient's problem Concem for those with patient Overall canng and compassion Made difference m how patient felt Watchfulness of patient's condition Ease of obtammg nurse when needed
Not
Satisfactory
sahsfactory
471
48-0 46 7 43 3 45 7 43 7 44 3
510
428
62
38 7
48 7
12 6
518
415
46 3 413
45 5 48 9
44 5
469
6-4 82 98 86
454
50 4 48 9 45 7 47 4
66 29 78 86 89 86
Satisfaction rating Information received (« = 200)
Very satisfactory
Length of wait Diagnosis Medicahons Tests Treatments Prevenhon Self-care Complications
applicable to them Although these staff members usually are not diredly under the supervision of the nursing department, often there are overlaps m onentations, contmumg educahon workshops, evaluations or mstances where nurses role model for other staff m the department It IS important for nurses to take a leadership role m the funchon of their units Results of this study showed that pahent satisfachon with auxiliary staff was generally high However, the athtude of recephonists was rated as unsahsfactory by 8 5% of pahents, whereas the next highest was 15% for X-ray staff This was also bome out by four negahve comn^iits i ^ u t the recephtHiists m the open-ended questums Althcnigh these are not highly relahve to the
Not
No
Satisfactory
satisfactory
answer
200
275
22 5
25 0 24 5 14 0 15 0
37 0 22 5 14 0 23 0
30 0 30 5
65 175 115
105 265 180
75 15 15 25 60 50 85
515
70 5 59 5 77 0 510
62 0
overall number of participants, the receptionists were of particular note because they play a key public relahons role man ED Emergency department environment Again, the ED environment may not be diredly under the supervision of the nursing department but nurses can and do have sigruficant input mto its control The study showed that the majonty of patients were satisfied with the ED environment Many pahents chose not to answer this queshoa possibly mdicahng a neutral athtude or because they felt it was unimportant Abo, some pahents did not use the waitmg room 961
KELewtsandRE Woodstde
Open-ended queshons yielded a anall number of posi1 hve and negahve comments Four pahents commented on what they f)erceived as a lack of pnvacy dunng registrahon and/or care Specific suggeshons regardmg the ED environment were also offered by pahents Induded m these were requests for refreshments, more toys for children and a 2 rockmg chair for fussy babies
faffing Almost half the patients surveyed felt that the department was well staffed Over one-quarter of the pahents felt the ED was not well staffed enough Many pahents assoaated long waits with madequate staffing
Overall satisfaction Pahents' overall sahsfachon with their emergency department visits was abnost evenly divided between very satisfactory and sahsfadory by the urgent and nonurgCTit category patients The emergency patient category (« = 1) m the study is statistically inadequate for comment In the former two categones, findmgs mdicate that the more urgent the tnage category, the more sahsfied the pahent Pahents' overall satisfachon was highest m pahents who perceived themselves as havmg 'no' and 'moderate' fear/anxiety, followed dosely by pahents with 'severe' fear/anxiety Patients with 'slight' fear/anxiety had more complamts Somefromthis category also refused to parhapate in the survey The 'paruc' category (« = 3) was too small for accurate analysis
3
In the 'very satisfactory' category, overall sahsfachon ratings matched with the total specific ratmgs for less than half of the respondents, l e only 24 of the 52 respondents who reported bemg very sahsfied m the overall also reported being very satisfied with the nurse, dodor, environment, auxiliary staff and waits For the 'satisfadory' category, less than one-third of respondents showed a match between overall and specific (nurse, physiaan, etc) aspects of care It must be noted that some sj)ecific aspeds were rated as 'very satisfadory' and others as 'not sahsfadory', resultmg m an averaging effed For those 18 not sahsfied with overall care, no mstances showed dissahsfaction with all speafic aspects of care One instance of overall dissatisfaction was related to nursing care exclusively, for six others, the nursmg care was mduded with other unsahsfactory fadors, and for 11, the nurse was not mduded m their dissahsfachon
DISCUSSION Although satisfadion was expressed by a high percentage of pahents m this survey, McMillan et al (1986) pomt out that 'health care literature well documents the fact that consumers report sahsfachon levels that are generally, if not always biased toward the completely sahsfied end of the scale' Therefore, afrer the lrutial glance, one must take the dissahsfachon of pahents more senously than might be thought Family members
Gibbon (1988) and Vosburgh (1988) state that posihve mvolvement by nurses with family members contnbutes to pahent recovery In the bght of this, it is mterestmg to note Overall satisfaction/specific satisfaction that the onergency department nurses m our study had a Pahents' 'overall sahsfachon' scores for the entire visit 12 6% dissahsfachon rating m relahon to their concem for were compared to their speafic scores for 'nursmg care', those accompanymg the pahent This rate is sbghtly higher 'physician care', and other aspeds such as environment, than the other dissatisfachon ratmgs for nurses This may auxibary staff, overall waihng time, and time spent in the mean that the nurses m this emergency department may waihng room However, before this companson was made, need to place more emphasis on the pahent's fmmly Gibbon (1988) found stress m relahves takmg forms those pahents who rated everything as 'very sahsfactory' across the board were deleted This deasion was based on such as 'fiustrahon or anger, overadivity or impaired the premise that m some cases pahents did not appear to concentrahon' He identified three groups of relahves, difi^enhate their satisfadioa some answenng queshons 'those who constantly ^ek infomiahon from nurses, those who attempt to do so, aruifinally,those who avoid contact that did not even apply to them. Ccmipansons based on the ronainmg resporwlents with niffses' Gibbtm's (1988) sugge^ion for mtervenhcm mdude the flowed only a loose matdi betw^»t the sp^ifk sahsfac^vmg of otfomudion and lndusion of rdatives m tlw care hon ratmgs and the overall sahsbchon ratings 962
Pattent satisfaction mth emergency departments
as much as possible In addihon, relatives need similar onohonal support as do pahents and, at times, even more so The success of the nursmg staff m relahon to technical competence is demonstrated by the high sahsfaction levels given to this aspect of care by patients Hall & Doman (1988) acknowledged that health care professionals place a high emphasis on technical competence, and Spitzer (1988) found that pahents complamed about nurses 'focusing on the equipment and procedure rather than on the patient' 'High touch' care is needed m this age of 'high tech' care To Magill & Scheuerman (1984), this amounts to considerate staff debvermg high quality care This desire on behalf of patients is certainly bome out by the appreaation expressed through posihve comments of the pahents surveyed
Complaints Although the number of complaints about 'follow through of care' was small, this represents a fundamental aspect of nursing care In a study by Blair et al (1982), the pnmary nursmg care model on an episodic basis was shown to be one type of nursmg care appropnate for emergency department use which might address the contmuity problem Spitzer (1988) found that 'explanation of treatment' was a factor important to patient satisfachon However, except for waiting times, the question related to satisfaction with information received from staff was not weU responded to by patients m our survey Perhaps this mdicates their pre-occupahon with physical achon as suggested by Hall & Doman (1988) Some pomted complamts were made about certam staff manbers, l e nurses and receptionists Other comments complimented staff, mdicahng that the problems were bkely to be mdividual and situahonal Spitzer (1988) remmds us that 'nurses are goodwill ambassadors' and, as physiaans are seen apart from the hospital, 'nurses are often seen as responsible for all achvities m the faabty and thus may mcur negative feelmgs' The suggeshons made by patients m the study for the improvement of the emergency department envirorunent were similar to those speafied by McMillan et al (1986) Although the negahve comments made by patients about pnvacy were small m number, the concept is important and refleds one of ttie basic patient nghts
one posihve or negahve aspect of care may be overshadowed by another negahve or posihve aspect Also, they are not specific enough to analyse and improve mdividual aspects of care This is bome out by the findmgs of this study which showed, at best, only a 46% match between the overall scores and the scores for speafic aspects of the visit This view was also douded by patients who gave blanket 'very satisfactory' ratings, which upholds McMillan et al's (1986) condusion that people are hesitant to cntiaze and tend to rate toward the positive end of the scale For the quabty assurance committee to focus on areas for improvement, they would have to utilize the ratmgs of specific professional groups and/or environment The relative tendency to show greater overall satisfachon by more 'urgent' patients follows the same pattem as identified by McMillan et al (1986) The moderate or greater anxiety levels m 55% of patients in our survey supports the premise of McMillan et al (1986) that increased anxiety is assoaated with seekmg medical help The impatience with waitmg by anxious, uncomfortable patients reported by McMillan ei al (1986) was also seen in this study
RECOMMENDATIONS FOR PRACTICE With the vanety of pressures and pnonties that prevail m the ED, patient satisfaction may sometimes seem bke an overwhelming task, a 'pipe dream' But in most cases the patient is not looking for lofty psychosoaal nursmg mterventions nor elaborate techrucal skills From the findings of this study, patients mainly want the basics Apart from the expected techrucal competeiKe and tnage capabibties that are usually managed quite welL a positive attitude from staff was the most sought-after commodity
Action Accordmg to the patients surveyed, a positive attitude can be effectively debvered by the followmg measures 1 2 3 4 5
Limitations Accordmg to McMillan et al (1986), overall satisfachon rahngs by themselves must be viewed as inadequate, as
6
a srrule, look the pahent in the eyes, assess their degree of anxiety, be kmd and gentle, try to identify if they have any mdividual needs that are pressing (l e child home alone, carmot locate husband, etc), ask any fanuly present if they have any questions or concems. 963
KE LewismdRE Woodside 7
give an estimate of how l
