Satisfaction with nursing care in the emergency department of an urban hospital in the developing world: A pilot study.

ARTICLE IN PRESS International Emergency Nursing ■■ (2015) ■■–■■

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Satisfaction with nursing care in the emergency department of an urban hospital in the developing world: A pilot study Jullet Buchanan RN, MSN (Student), Pauline Dawkins RN MPH (Lecturer), Jascinth L.M. Lindo RN, MPH, MSN, PhD (Lecturer) * The UWI School of Nursing, The University of the West Indies, Kingston 7, Jamaica

A R T I C L E

I N F O

Article history: Received 12 August 2014 Received in revised form 31 December 2014 Accepted 4 January 2015 Keywords: Emergency department Nursing care Patient satisfaction Jamaica Patient satisfaction with nursing care quality questionnaire

A B S T R A C T

Introduction: Nurses form the largest group of the workforce in hospitals and as such the quality of nursing care is a critical indicator of patient satisfaction. Objective: To determine the level of patient satisfaction with nursing care in the emergency department of an urban teaching hospital in Jamaica. Methods: This descriptive cross-sectional study used a convenience sampling technique to recruit 142 adult patients who accessed nursing care in the emergency and intermediate areas of the emergency department. Data were collected using a 22- item questionnaire adapted from the Patient Satisfaction with Nursing Care Quality Questionnaire and managed using SPSS® version 19.0 for Windows®. Results: The response rate was 77.6%; most respondents (62%) were female, and educated at the secondary level (42.3%). The mean satisfaction score was 32.60 (±7.11) out of a possible 42. Most (59.9%) patients reported that they were very satisfied with nursing care in the emergency department. Satisfaction with nursing care was associated with clients’ education. Perceived health status and empathy of nursing care offered were associated with patient’s satisfaction with care (p = 0.05). Conclusions: Patients were highly satisfied with nursing care in the emergency department studied. Client’s education, perceived health status and empathy of care were predictors of satisfaction. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction Patient satisfaction with nursing care is the most important predictor of overall satisfaction with their hospital care (Otani and Kurz, 2004; Sharma and Kamra, 2013). Highly satisfied patients are essential to the sustainability of any health care organization and dissatisfied clients are unlikely to recommend the facility to their network of family, friends and associates (Ellis-Jacobs, 2011; Lee and Yom, 2007; Shirley and Sanders, 2013; Ting and Yu, 2010). Nursing care is a core factor in the measurement of patient satisfaction given the high levels of nurse–patient contact and nurses’ role as the liaison between patients, doctors and other members of the health team (Dzomeku et al., 2013; Otani and Kurz, 2004; Otani et al., 2009). The patients’ perception of nursing care remains the strongest predictor of behavioral intention and include the likelihood of returning to a particular hospital and to recommending it to others (Aiken et al., 2012; Al-Mailam, 2005; Otani and Kurz, 2004).

* Corresponding author. UWI School of Nursing, The University of the West Indies, Mona, Kingston 7, Jamaica. Tel.: +876 381 2795 / +876 970 3304; fax: +876 927 2472. E-mail address: [email protected] (J.L.M. Lindo).

The staff of emergency departments and registered nurses in particular, are primarily responsible for the patients’ impression of the facility because they work in an area where patients have their first contact with the healthcare facility and which acts as the portal to the rest of the hospital (Dougherty, 2005). As such, satisfaction with emergency services has the potential to enhance healthcare facilities’ financial growth in the long term (Shirley and Sanders, 2013; Stuart et al., 2003). Additionally, where patients are satisfied, they will be more compliant with treatment and readmission will be less likely (Lee and Yom, 2007). High levels of patient satisfaction have also been associated with fewer malpractice litigations within healthcare institutions (Lee and Yom, 2007). The measurement of patient satisfaction is affected by many variables and can be complex (Turris, 2005). For example, the persistent shortage of nursing staff which results in inadequate nurse to patient ratio to meet all the demands, socio-demographic characteristics and the patient’s health status are all factors which affect satisfaction (Kutney-Lee et al., 2009; Soleimanpour et al., 2011; Soufi et al., 2010). Further, patients’ perceptions of the individualized care they received are important in the evaluation of patient satisfaction (Suhonen et al., 2012). Crow et al. (2002), in a systematic review, highlighted the disagreements on the value and reliability of patient satisfaction surveys in the literature, including that many were fraught with

http://dx.doi.org/10.1016/j.ienj.2015.01.001 1755-599X/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Jullet Buchanan, Pauline Dawkins, Jascinth L.M. Lindo, Satisfaction with nursing care in the emergency department of an urban hospital in the developing world: A pilot study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.01.001

ARTICLE IN PRESS J. Buchanan et al./International Emergency Nursing ■■ (2015) ■■–■■

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methodological issues. Further, wording of questionnaires can affect responses and higher satisfaction was shown for items with personal referent (Crow et al., 2002). “The lack of conceptual clarity and unresolved measurement challenges” are two issues which affect standardization of the measurement of patient satisfaction (Turris 2005, p. 295). 2. Measuring patient satisfaction The Service Quality Model has been used to evaluate patient satisfaction with nursing care in the emergency department (Parasuraman et al., 1985). This model examines five gaps in the provision of service, but focuses on the customer gap, which is the difference between service perception and expectations (Parasuraman et al., 1985). Clients’ perceptions and expectations are formed based on dimensions of quality which are embedded in the concept of nursing care and for the purpose of this study encompass reliability, responsiveness, assurance and empathy. Reliability is the capacity of the institution to perform the service as dependably and accurately as promised, while responsiveness deals with the readiness to assist clients as quickly as possible. The assurance dimension represents the knowledge and politeness of workers and their ability to garner trust and confidence from clients while empathy deals with the caring and individualized attention that the organization gives to its clients (Gupta and Singh, 2012; Parasuraman et al., 1988). The dimensions of quality were incorporated into the Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ) to measure respondents’ satisfaction with nursing care (SpenceLaschinger et al., 2005). PSNCQQ was found to have good psychometric properties and were easily administered due to its short length and specific questions (Ksykiewicz-Dorota et al., 2011; Maqsood et al., 2012; Milutinovic et al., 2012; Spence-Laschinger et al., 2005). In addition, the PSNCQQ has good utility in various countries across different hospital types and settings (Ksykiewicz-Dorota et al., 2011; Maqsood et al., 2012; Milutinovic et al., 2012; Spence-Laschinger et al., 2005). This instrument provided valuable support to nursing administrators as improvements can be made to specific areas of the nursing care delivery system. 3. Background Like in many other health care settings, the majority of patients in Jamaica have their first contact with the hospital through the emergency department (ED). Patients and family members in the Jamaican ED settings have expressed concern with aspects of care such as long waiting time and the management of the flow of information (French et al., 2013). Only 70% of patients expressed satisfaction with the care they received; however, the study was primarily focused on the process of triage and may not have accounted for the dimensions required for a reliable measure of patient satisfaction (French et al., 2013). This study sought to determine the levels of patient satisfaction with nursing care in the emergency department of an urban hospital in Jamaica using an adapted version of the Patient Satisfaction with Nursing Care Quality Questionnaire [PSNCQQ] (Spence-Laschinger et al., 2005). This tool which has good psychometric properties to measure the four dimensions of patient satisfaction with nursing care was employed with a view to elicit information which could be used in the training of nurses. This training could be used to improve the patient experiences with nursing care in the emergency department. 4. Methods A descriptive cross sectional study design of 142 adult patients or their relatives visiting the emergency and intermediate areas of the emergency department of an urban tertiary level teaching

hospital in Jamaica was used to examine the patient satisfaction levels with nursing care. This referral hospital provides a wide range of generalist and specialist health care services to the people of Jamaica and the English-speaking Caribbean. The emergency department which manages approximately 48,000 patients/year is divided into three areas including the emergency area for Level 1 & 2 clients, intermediate area -Level 3 and Ambulatory Care for Level 4 & 5. Patient seen in Level 4 & 5 were excluded as they have limited or no contact with nursing staff and are usually seen and discharged by the doctor. The emergency department register showed that 2,430 patients were seen in the emergency and intermediate area over a six week period (the proposed period of data collection). Using Raosoft sample size calculator (Rasosoft Inc., 2004), allowing a margin of error of 5%, 95% confidence level and a hypothesized 78% patient satisfaction level (Soleimanpour et al., 2011), the calculated sample size was n = 238. A non-response rate of 10% was also factored (yielding n = 262). A pilot study was undertaken, using 70% (n = 183) of the recommended sample size. Study participants who were over 18 years, received nursing care and agreed to participate in the study were sampled conveniently. Critically ill patients and children were excluded from the study. Critically ill patients (and/or relatives) were too distressed emotionally and physically to be included. 4.1. Data collection Data were collected using an adapted version of the Patient Satisfaction with Nursing Care Quality Questionnaire [PSNCQQ] (Spence-Laschinger et al., 2005) with permission from the developers of this tool. The adapted PSNCQQ measures four dimensions of nursing care: assurance, empathy, responsiveness and reliability. These were based on the Service Quality Model (Parasuraman et al., 1985). The modified PSNCQQ instrument is a 22-item questionnaire scored on a 5-point Likert scale. Response options ranged from 5 being “excellent” to 1 being “poor”. The questionnaire included 14 patient satisfaction questions plus 3 items relating to overall perception of the quality of care and services, nursing care received and perception of their own health. There was also a question on the likelihood of recommending the hospital to family and friends. Specific socio demographic questions which the literature suggested could influence patient satisfaction were also included (Soufi et al., 2010). 4.2. Data collection process Data were collected continuously on weekdays (24-hours per day) over a 6-week’s period during May to June, 2012. The medical and nursing staff who worked in the emergency and intermediate areas were asked to advise the research team about patients who met the inclusion criteria. One hundred and eighty-three patients or relatives in the emergency and intermediate areas at the time that the researcher or data collectors were present and who met the inclusion criteria were asked to participate in the study; in instances where patients were unable to complete interview (e.g. altered mental status), the patient’s relative was allowed to complete the interview. A total of 111 patients and 31 relatives agreed to participate in the study. Those who refused to participate reported that they did not have the time or were just not interested in participating. Questionnaires were interviewer-administered by four data collectors who were trained at the baccalaureate level and had undergone a two hour training session about the study and the data collection process. Data collectors were dressed casually and were not identifiable as nurses based on their attire. This was done to minimize the risk that data collectors were perceived as being a part of the health team,



observing ethical principle of autonomy and the right to refuse participation. The interviews were conducted in a private room following written informed consent and while awaiting discharge whether to another unit or home. These interviews were undertaken after the patients had been managed by the doctor and cared for by the nursing staff. These and other measures were taken to ensure high ethical standards in the conduct of the study and reduce the possibility of bias. 5. Instrumentation 5.1. Reliability and validity The PSNCQQ was reported to have a high Cronbach’s alpha reliability of 0.97 among patients in teaching, community and small hospitals in Canada (Spence-Laschinger et al., 2005). Similarly, excellent Cronbach’s α reliabilities (0.94 and 0.96, respectively) were found when used in surgical clinics in Serbia and several hospitals in Poland (Ksykiewicz-Dorota et al., 2011; Milutinovic et al., 2012). Spence-Laschinger et al. (2005) also reported that the instrument was usually able to forecast what was likely to occur. The predictive validity of the PSNCQQ was checked in several hospitals by testing its ability to forecast projected outcomes such as overall quality of patient care and services and nursing care and intent to recommend the hospital to family and friends (Spence-Laschinger et al., 2005). The Cronbach’s α reliability estimates for the adapted PSNCQQ in this study was 0.91, indicating that the reliability of the questionnaire was high. Quality of the data was assured by pretesting of the instrument, training of data collectors, coding and cleaning of data. The questionnaire was pretested among 10 patients in a similar setting which had a high probability of having the kinds of patients that would attend the emergency department used in the study. Data collection method was similar to those planned for the main study. The result of the pretest was used to modify the wording of question 2 in which “operations” was removed for greater patient understanding and clarity. The phrase “and give you choices” was removed from the question with the descriptor “Recognition of your opinions” as respondents felt that this would be limited in the emergency setting. In addition to modifying questions, others were omitted including questions with the descriptor “involving family or friends in your care”, as respondents felt that due to hospital policy and the acuity of their condition, this was of limited significance. The descriptors “daily routine of the nurses” and “restful atmosphere provided by nurses” were also removed, along with the question relating to where patients were admitted through and accommodation while in hospital because of the physical characteristics of the study site. Additionally, the nurse leaders consulted were of the view that nurses’ ability to control these parameters was limited. “Discharge instruction” was also removed because the majority of patients from the emergency and intermediate areas were usually admitted to another unit and not discharged home. “Coordination of care after discharge” was also removed because this was not one of the responsibilities of the nurses in the emergency department. 5.2. Data analysis The data were analyzed using SPSS ® version 19.0 for Windows®. Descriptive statistics such as measures of central tendency were used to summarize and describe the data. Differences between categorical groups were determined using χ2 test and analysis of variance was applied to continuous data as appropriate. p < 0.05 was considered to be statistically significant. The 14 patient satisfaction items were coded (1–5) based on Likert scales in which respondents’ scores were summarized and ranged from 14 (the lowest possible score)

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to 42, the highest level of satisfaction. A mean overall score for the scale was also calculated. Items for the assurance dimensions were “information you were given,” “instructions,” “ease of getting information,” “information given by nurses,” “informing family or friends” and “privacy.” “Concerns and caring by nurses” and “attention of nurses to your condition” were the empathy dimensions. The responsiveness dimension questions were “recognition of your opinions,” “considerations of your needs,” “helpfulness” and “nursing staff response to your calls.” The final dimension, reliability, was attributed to “skills and competence of nurses” and “coordination of care.” These were computed to yield a total score for each participant. The scores were then recoded as high, moderate and low. The overall perception of the quality of patient care and services and nursing care received in the emergency department and the perception of respondents’ health were also rated using the Likert scale reflecting a range of 1–5, with 1 being the lowest and 5 being the highest. This indicated poor to excellent quality of patient care and services and nursing care and poor to excellent state of health. 5.3. Ethical considerations Ethical approval was obtained from the relevant internal review board and permission to conduct the study at the hospital was received from the hospital administration. All guidelines for the ethical conduct of the study were observed, respecting the rights of all participants in the study and ensuring that the participants were aware that they had the right to refuse and or withdraw at any time without any adverse consequences (Polit and Beck, 2013). 6. Results 6.1. Description of socio demographic variables and perceived health status The study achieved a response rate of 77.6%, representing 142 of 183 persons recruited; this included 111 patients (78.2%) and 31 family members (21.8%) who were present throughout the management of the patient. The majority (62%, n = 88) of the respondents were females and lived in the urban area. Participants were mainly educated at the secondary (42.3%, n = 60) and tertiary levels (24.6%, n = 35). Eighteen percent (n = 25) were educated at the primary level and 15.2% (n = 22) reported that they last attended technical and vocational institutions. The majority of the patients (or relatives) rated the patients’ overall health status as good (26.8%), followed by fair (22.5%) and very good (20.4%). Approximately 16% felt the patients’ overall health status was excellent, while 15% felt it was poor. 6.2. Quality of care and level of patient satisfaction with nursing care in the emergency and intermediate areas of the emergency department Perception of the overall quality of nursing care was rated as excellent by 57% (n = 81) participants, good by 35.2% (n = 50) and poor by 7.7% (n = 11). The mean satisfaction score of the 14 items related to patient satisfaction was 32.60 ± 7.11 and ranged from 14 to 42. Almost 60% (n = 85) of study participants were very satisfied with the nursing care they received in the emergency department, while 28.2% (n = 40) were satisfied and 12.0% (n = 17) were dissatisfied. Eleven of the patient satisfaction items were rated very satisfied by more than 50% of respondents as illustrated in Table 1. The top three patient satisfaction items were “concern and caring by nurses” (65%), “skill and competence of nurses” (59.2%) and “nursing staff response to your calls” (59.2%). Almost 30% (n = 40) of the study participants were dissatisfied with the item “recognition of your opinions”; 25% (n = 35) were dissatisfied with “instructions” and 20% (n = 29) were dissatisfied with “informing family or friends.”



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Table 2 Level of satisfaction of study participants with dimensions of nursing care.

Table 1 Level of satisfaction with patient satisfaction items in the emergency department. Question

Concern and caring by nurses Skill and competence of nurses Nursing staff response to your calls Ease of getting information Attention of nurses to your condition Privacy Information you were given Coordination of care Information given by nurses Helpfulness Consideration of your needs Recognition of your opinions Instructions Informing family or friends

Mean scores (SD)

Very satisfied % (n)

Satisfied % (n)

Dissatisfied % (n)

2.57 (0.64) 2.51 (0.64) 2.39 (0.80) 2.45 (0.72) 2.41 (0.76) 2.50 (0.63) 2.38 (0.78) 2.42 (0.72) 2.35 (0.76) 2.34 (0.77) 2.35 (0.74) 2.13 (0.82) 2.21 (0.82) 2.16 (0.84)

64.8 (92) 59.2 (84) 59.2 (84) 58.5 (83) 57.7 (82) 57.0 (81) 56.3 (80) 54.9 (78) 52.8 (75) 52.1 (74) 50.7 (72) 40.8 (58) 45.8 (65) 32.4 (46)

27.5 (39) 33.1 (47) 21.1 (30) 28.2 (40) 25.4 (36) 35.9 (51) 25.4 (36) 31.7 (45) 29.6 (42) 29.6 (42) 33.8 (48) 31 (44) 29.6 (42) 20.4 (29)

7.7 (11) 7.7 (11) 19.7 (28) 13.4 (19) 16.9 (24) 7.0 (10) 18.3 (26) 13.4 (19) 17.6 (25) 18.3 (26) 15.5 (22) 28.2 (40) 24.6 (35) 20.4 (29)

Empathy Reliability Assurance Responsiveness

High % (n)

Moderate % (n)

Low % (n)

56.3 (80) 54.2 (77) 38.0 (54) 9.2 (13)

35.2 (50) 40.1 (57) 51.4 (73) 50.7 (72)

8.5 (12) 5.6 (8) 10.6 (15) 40.1 (57)

6.4. Relationship between intention to recommend and the level of satisfaction with nursing care Of the 79 respondents who reported that they would strongly agree to recommend the department to family and friends, 67.1% (n = 53) were very satisfied, 25.3% (n = 20) were satisfied and 7.6% (n = 6) were dissatisfied with nursing care in the emergency department. On the other hand, of the 11 participants who strongly disagreed that they would recommend the department to family and friends, 9.1% (n = 1) were very satisfied, 27.3% (n = 3) were satisfied and the majority 63.6% (n = 7) were dissatisfied with the nursing care received. The participants’ intentions to recommend the emergency department to family and friends was significantly associated with their level of satisfaction (χ2 = 32.62, p ≤ 0.001). 6.5. Level of participants’ satisfaction with the dimensions of nursing care Table 2 indicated how patients rated their level of satisfaction with the four dimensions of nursing care. The empathy dimension was rated high by 56.3% (n = 80) of participants, while the dimension that was rated lowest by the most participants was responsiveness (40.1%5, n = 57). Three of the four dimensions of nursing care showed significant differences with intentions to recommend family and friends to the emergency department. These dimensions were assurance (F = 3.93, p = 0.05), empathy (F = 23.25, p ≤ 0.001) and reliability (F = 11.69, p ≤ 0.001).

6.3. Relationship between perception of overall quality of care and services in the emergency department and the level of satisfaction with nursing care Fig. 1 shows association between the perception of overall quality of patient care and services in the emergency department and the level of satisfaction. The perception of overall quality of patient care and services in the department which was rated as excellent, good or poor, was significantly associated with the level of satisfaction with nursing care (χ2 = 66.07, p < 0.001). Of the 88 participants who rated their perception of the overall quality of care as excellent, 78.4% (n = 69) were very satisfied with nursing care. This is in contrast to 4.5% (n = 4) who were dissatisfied with nursing care.

Perception of Overall Quality of Care & Services

Level of satisfaction % (n) N = 142

Dimensions

6.6. Influence of socio demographic variables and perceived health status on the level of patient satisfaction with nursing care in the emergency and intermediate areas of the emergency department The only socio demographic characteristic that showed a statistical significant difference was educational level (F = 2.75, p = 0.05).

90 80

78.4

70

62.5

60 50

52.6

Excellent

39.5

Good

40

31.3

Poor

30 17.1

20 10

6.2

4.5

7.9

0 Very Satisfied

Satisfied

Dissatisfied

Level of Satisfaction with Nursing Care Fig. 1. Perception of overall quality of care and services with level of satisfaction with nursing care in the emergency department.



Table 3 Relationship between educational level and dimensions of nursing care. Dimensions of nursing care

Educational level of participants (primary, secondary, tertiary, other) N = 142


χ2

p

10.50 16.81 10.97 7.16

0.11 0.01 0.09 0.31

Participants with primary school education had a higher mean satisfaction score (35.56 ± 5.00) compared to those with tertiary education (31.20 ± 8.67). The majority of primary school leavers were very satisfied with nursing care (76%, n = 19), while majority of tertiary school graduates were dissatisfied (17.19%, n = 6). A statistically significant difference (χ2 = 16.81, p = 0.01) also existed between educational levels and the reliability dimension of nursing care (Table 3). Table 4 illustrates the perceived health status of respondents by the empathy dimensions of nursing care. A statistical association (χ2 = 9.65, p = 0.05) was found between perceived health status and the empathy dimension of nursing care. 7. Discussion 7.1. Interpretation of findings The response rate for this study was relatively high (77.6%) and may be attributed to the interviewer administered data collection method employed. The majority of the participants in the study were females (62%) residing in urban areas and educated at the secondary level and beyond. Based on the Jamaica Health and Lifestyle Survey, these demographic characteristics are representative of the population accessing health care in Jamaica which reported 68% of females among persons seeking health care (Wilks et al., 2008). Additionally, less than 20% of patients or family members present during care rated the patients’ health as poor. The patients and family members present were content with the nursing care delivered in the emergency department as a total of 87% of study participants reported that they were very satisfied and satisfied with the nursing care received. Based on the Satisfaction with Nursing Care questionnaire, 52% of patients were satisfied with nursing care in an Emergency Medicine Outpatient department of a tertiary care hospital in India (Mohanan et al., 2010). Similarly, in Ghana, only 33% of in-patients were fully satisfied with nursing care at a university hospital (Dzomeku et al., 2013). The demographic characteristics of participants in India differ from those in this study as the majority of those respondents had higher levels of education and were mostly males and from rural areas. However, the socio-demographic characteristics of those in Ghana were not described. The level of satisfaction with nursing care in the emergency department was a strong predictor of perception of overall quality of

Table 4 Relationship between perceived health status and dimensions of nursing care. Dimensions of nursing care


Perceived health status of participants (very satisfied, satisfied, dissatisfied) N = 142 χ2

p

9.65 7.65 4.92 4.81

0.05 0.11 0.30 0.31

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patient care and services in the emergency department. Eightyeight of 111 respondents reported that their perception of the overall quality of patient care and services in the emergency room was excellent and 78.4% of these were very satisfied with nursing care. In addition, 67% of patients who strongly agreed that they would recommend the hospital to family and friends were very satisfied with nursing care. These results support global findings which concluded that nursing care plays a major role in patient satisfaction and contributes to patients’ perceptions and intentions (Aragon and Gesell, 2003; Ksykiewicz-Dorota et al., 2011; Otani and Kurz, 2004; Senerath and Gunawardena, 2011; Wolf et al., 2003). Otani and Kurz (2004) reported that attributes of nursing care were the most important indicators of overall satisfaction among hospitalized patients in the United States. In a study of 63 hospitals in Norway, patient reported that experiences with nursing services were found to be the most important predictor of patient satisfaction (Bjertnaes et al., 2012). Aragon and Gesell’s (2003; p. 232) examination of the Primary Provider Theory of Patient Satisfaction in the emergency department found that “physician service, waiting time, and nursing satisfaction explained 48%, 41%, and 11% of overall satisfaction, plus 92% and 93% of female and male satisfaction, respectively.” The team reported a positive correlation between satisfaction with nursing services and overall satisfaction with healthcare services; however, in this setting patient satisfaction in the ED was not heavily predicated on satisfaction with nursing care. This study indicated that the top three satisfaction items with which patients were very satisfied were concern and caring by nurses, skills and competence of nursing staff and how quickly nurses responded to patients’ calls. This is in congruence with other studies which found that caring, skills and competence and information given by nurses are important indicators of nursing care (Maqsood et al., 2012; Tang et al., 2013). Conversely, the items that patients were reportedly least satisfied with were recognition of their opinions, giving instructions and informing family or friends. The clients’ perception that their opinions were not recognized by the nurses is an important finding as this is a critical part of the utilization of evidence based practice (Carnwell, 2001; Tang et al., 2013). Suhonen et al. (2012) also found that patients in surgical wards were mostly satisfied with the technical competence of nurses and least satisfied with information giving. Low levels of satisfaction with information and instructions given by nurses have been reported in other settings (Maqsood et al., 2012). Maqsood et al. (2012) reported that nurses had the perception that “information giving” was the role of the physician and may be fearful to provide information because of the power hierarchy between the nurse and the doctor. These views may not be reflective of the significant advancement in the nursing profession. Nurses care for the patients on a 24 hour basis and should be empowered to provide requisite information and instructions to the patients (Maqsood et al., 2012). Furthermore, patients in an emergency department may be frightened, apprehensive and in distress, and desire the emergency staff to pay attention to their needs, provide comfort and regular updates throughout all stages of the emergency visit (Watt et al., 2005). Nurses play a major role in interacting with patients, family members and other members of the health team, and therefore communication skills are critical for functioning in such a high stressed environment as the emergency department. Therefore nurses who work in the emergency department should undergo ongoing communication skills training. Taylor et al. (2006) introduced a communication workshop, a patient education film and a patient liaison nurse as part of their intervention study. They realized significant improvement in patients’ perception about being informed and a 22.5% reduction in patient complaints.


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7.2. Level of satisfaction with nursing care and intention to recommend

7.4. Socio demographic characteristics and patient satisfaction with nursing care

Participants (92.2%) reported that they would recommend the emergency department to family and friends, with 55.6% strongly/ somewhat agreeing and 36.6% agreeing. Intent to recommend the department to family and friends was significantly associated with level of satisfaction with nursing care in the emergency department and this has been seen in other settings (Aiken et al., 2012; Otani and Kurz, 2004). This finding is important to note as it suggests patient satisfaction may negatively affect the financial growth and reputation of the hospital as patients and their family members may choose to utilize other health care facilities (Stuart et al., 2003).

Primary school leavers had the highest mean satisfaction score (35.56 ± 5.00), while tertiary graduates were the ones who were mostly dissatisfied with nursing care. A strong statistical significance was found between levels of satisfaction and educational levels. Previously, it was reported that patients with higher levels of education had lower levels of satisfaction than those with secondary or lower level education (Bleich et al., 2009; Soleimanpour et al., 2011). Patients with higher levels of education may have better access to health information and be more informed about health care and therefore could have higher expectations about the quality of nursing care. High levels of education may bolster participants’ ability to adequately judge the quality of nursing care and appropriately rate their satisfaction with the quality of nursing care at the institution studied. On the contrary, participants with lower levels of education may have different considerations when judging quality of care or they may feel vulnerable in asserting their dissatisfaction. It should be noted that a strong statistical significance was found between the participants’ educational levels and reliability dimension of nursing care. Again, persons with higher levels of education may be better able to judge the technical aspects of nursing care and how care is coordinated.

7.3. Level of satisfaction and the dimensions of nursing care Concerning the dimensions of nursing care, the results illustrated that the reliability, empathy and assurance dimensions were the three aspects of nursing care with which study participants in the emergency department were most satisfied. The reliability, empathy and assurance dimensions were given high/moderate ratings by most participants. On the other hand, responsiveness was rated high/moderate by the least number of participants. The findings about the reliability and assurance dimensions were supported in a gap analysis study that examined the relationship between patient satisfaction and quality of services which concluded that reliability and assurance dimensions were strong predictor of patient satisfaction (Sudhakar et al., 2012). However, the same study found that the empathy dimension was only a moderate indicator of patient satisfaction. In another study to evaluate the difference between quality service that is expected and what is actually provided, the researchers concluded that reliability was a significant determinant of overall satisfaction with nursing care and intent to recommend others to the hospital (Chou et al., 2005). On the other hand, responsiveness was rated high/moderate by the least number of participants. In a cross sectional study in Iran to determine the service quality gap, Aghamolaei et al. (2014) found that the highest expectation score and the lowest perception score of participants were for responsiveness. In a study to examine responsiveness as a determinant of service quality in a government hospital in Africa, de Jager et al. (2010) had similar findings. Patients had high expectations of the responsiveness dimension; however, the perceived performance was given low scores, signaling that they were not satisfied. Aghamolaei et al. (2014) suggested that hospitals should invest in service quality improvement programmes for staff. The dimensions of nursing care were also analyzed to determine their association with participants’ intention to recommend family and friends to the emergency department. The assurance, empathy and reliability dimensions were found to be strongly associated with participants’ intention to recommend others to the department. This is more than likely associated with the level of satisfaction with these dimensions of nursing care. In previous studies, empathy was found to be a highly significant predictor of intent to recommend others to hospitals (Chou et al., 2005). Additionally, there was an association between the empathy dimension of nursing care and perceived health status (p = 0.05). Participants may have linked the concern, caring, and the attention of nurses to their conditions with a perceived feeling of well-being. Previous patient satisfaction studies have concluded that patients’ perceptions of their health status had a significant positive influence on patient satisfaction with nursing care (Bleich et al., 2009; Soufi et al., 2010). Potentially a feeling of improvement at the end of care allowed patients to feel satisfied about the care that they received.

8. Limitations of the study The study used a convenience sample to examine patient satisfaction levels with care provided by nurses in a single emergency department in Jamaica, and therefore is limited in its ability to predict patient satisfaction in other emergency departments in the country. Bias could have been introduced because the questionnaires were interviewer administered. Furthermore, the emergency room staff was aware of the conduct of the study and this may have influenced their actions. Critically ill patients were excluded from the study requiring the emergency department staff to participate in identifying eligible participants for the study. While this is important for patient safety, objectivity may have been compromised. Patients may be reluctant to express dissatisfaction with nursing care received for fear of retribution, although this was addressed in the informed consent process. It is notable that one fifth of the questionnaires were completed by family members, who may have different expectations and perceptions from the patient. Finally, the work of Turris (2005) highlighed the importance of interpreting studies relating to patient satisfaction with caution given the complexity of the concept.

9. Conclusion and recommendations In the study, responsiveness was rated high/moderate by the least number of participants. Patients who visited the emergency room were therefore dissatisfied with the nurses’ response to their calls, nurses’ helpfulness, and consideration of their needs and the recognition of their opinions. Patients visiting the emergency department expect that they will meet helpful staff, their needs will be considered and that they will be cared for quickly. These are areas which must be further explored in order to improve the quality of care in the emergency department. Participants were satisfied with the empathy dimensions of nursing care underscoring the importance of the technical and caring aspects of nursing care. Satisfaction studies can give useful information to nursing administrators and nursing care providers about aspects of care which require adjustment to ensure the provision of high quality nursing care in the emergency room.



Acknowledgements We acknowledge the unfailing support, guidance and wisdom of Dr. Eulalia Kahwa and express appreciation to the participants of the study, the data collectors and all the staff in the Emergency Department.

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