HOSPITALS are challenged to improve patient satisfaction scores as they have become a means to compare quality of service between different facilities. Health care organizations have used patient satisfaction measures for more than 40 years to plan marketing strategies. Patient satisfaction is considered a widely accepted measure of health care quality and as an outcome indicator to evaluate hospitals.1,6 When organizations look for evidence of quality care, measures of patient satisfaction are being used for performance improvement, quality management, and strategic planning.7,8 As a result, scores on patient satisfaction surveys have emerged as an important indicator of quality of care and are being used as a method for benchmarking hospitals.3,9-11 These scores are receiving more attention now because consumers can compare the patient satisfaction scores of most hospitals on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national database online when choosing where to receive care.
The expanded use of patient satisfaction scores and their association with quality care ratings has challenged hospital management to understand factors that affect these scores. There is a strong relationship between patient satisfaction, the overall quality of care received during hospitalization, and the likelihood to recommend the hospital to family and friends.10,12,14 The HCAHPS survey reflects this as a component of patient satisfaction with the question, "Would you recommend this hospital to friends and family?"15
Quality of care may mean something different to patients than what it means to nurses,13 with the patient's perception of quality affected by the extent that the care expected is actually received.16 Learning the expectations and desires of hospitalized patients can help us understand what quality care means to them.3,5 This study was done to identify these expectations from the responses to a hospital-generated patient satisfaction survey completed at discharge from an inpatient midwestern hospital birthing center. Data came from all surveys completed over the course of one year. The survey consisted of statements to which patients responded using a Likert-type scale. The analysis was performed to determine (a) which components of satisfaction were most important to patients who had care in the birthing center; (b) how these components related to the patients' responses to the survey question, "Would you recommend the hospital birthing center to others"; and (c) how wait times for nurse response to requests affected overall satisfaction scores. These results can help focus patient care activities in a way that may improve patient satisfaction scores.
PATIENT SATISFACTION AND POSITIVE OUTCOMES
Patient satisfaction has been linked with improved outcomes because it can predict a wide variety of health-related behaviors such as compliance with treatment and utilization of services.17,19 A positive correlation exists between a patient's satisfaction with care, their intention to return for further care, and whether or not they will recommend the facility to others.12,19 As a result, patient satisfaction is considered an important measure of quality of care by professional accreditation agencies and both state and federal governments. In addition, staff should try to create an atmosphere where patients are satisfied with care and will want to return to develop organizational loyalty.4,15 Since patient satisfaction has been linked to both quality of care and patient loyalty, it can impact the success of an organization; so, it is essential for both administrators and practitioners to understand the factors that affect patient satisfaction.16,18
Most hospitals collect patient satisfaction information, but there was no national standard to compare hospitals until 2009 when the federal Medicare program began requiring acute care hospitals to survey patients on certain questions. Results had to be publicly reported on the HCAHPS Web site or the hospital would incur a financial penalty.6,18 Consumers can access the HCAHPS Web site to compare patients' perspectives of care between hospitals. Patient survey findings are used for performance improvement, quality management, and organizational strategic planning.7,8,20
FACTORS AFFECTING SATISFACTION WITH CARE
Unlike businesses such as hotels and banks, satisfaction ratings can be difficult to apply in health care because factors such as patients' past experiences, emotions, values, and perceptions of duties have an impact on their expectations and opinion of services.8,21 Satisfaction is affected by the degree of agreement between the patient's preconceived expectations (formed before hospitalization) and perceptions of the actual care. Expectations are such a strong component that patients will even answer survey questions that do not apply to their experience. For example, Roszell, Jones, Lynn found that patients who never used the call light answered survey questions regarding response, suggesting that they had preconceived ideas on how quickly the nurse should respond. Satisfaction is based on expectations and they differ among patients. Discovering patient expectations can allow us to target services and improve satisfaction with care. In actuality, patient preferences may be reflected in patient satisfaction surveys more than quality of care.2,3,22 There are some common themes found in the literature on patient expectations. Hospitalized patients want effective personal care and a quick response.23,25,26 This study included data on expected and actual wait times reported by patients for a response to their call light requests and then linked these data to quality of care factors.
Patient satisfaction in this study was tied to response wait time, communication, and service. This was similar to the patient satisfaction components from the HCAHPS survey-communication with physicians and nurses, pain management, responsiveness of hospital staff, and education.7,27 Other studies have found that satisfaction is strongly influenced by the interpersonal skills of the nurse. Patients report that nurses should be gentle, caring, technically competent, and efficient and provide patient-specific teaching and information, maintain continuity of communication, and explain time delays.4,6,8,28
Response wait time
Response wait time is defined as the amount of time required for a nurse to respond to a call light request. Patients are vulnerable when hospitalized, and they rely on the call light as a vital communication link and a way to have some sense of control over their circumstances. When the patient is unfamiliar with the surroundings or confined to bed because of his or her condition, the call light is a lifeline.26,29 Rapid response by nurses to calls for assistance is of major importance to patients, and conversely, a delay in answering the call light is a major frustration for them.10,29,30 Since wait time can influence patient satisfaction,6 we anticipated response wait time to emerge as a factor in patient care surveys.
Communication
Keeping patients well informed is a vital aspect of nursing care. Patients expect nurses to have knowledge and technical skills needed for their work, but their satisfaction with the hospital is frequently based on communication and the amount of time the nurse spent with them.18,20,30,31 The nurses' teaching skills, ability to answer questions, and ability to keep them updated about their condition are key components of patient satisfaction.6,10 Shaffer and Tuttas27 reported that nursing communication had the greatest effect on the overall satisfaction with the hospital and the likelihood to recommend the facility to others. Dubuque32 found that communication, but between patients and staff was the number-1 factor in patient satisfaction. Nurses who focus on each patient's individual needs and work as a team to develop a plan of care improved the patient's perception of quality of care and satisfaction with that care, highlighting the impact nurses have on patients' perceptions.8,33 Beck and Larrabee13 found that patients and nurses were more likely to agree on what defined quality care when communication was improved. Clearly, communication should be a key element in patient satisfaction.
Service
Patients and their families equate quality of care with more subjective aspects such as personal caring. Today, patients not only want, but expect, the most thorough medical treatment available, as quickly as possible, in a convenient location. It is important to patients to have personal treatment by staff, to feel involved in their care, and to feel that they (and their families) are being catered to.20,31,32 Customer service means that the practice setting should allow time for friendliness; listening; and respectful, professional care for every patient.34
Research reports indicate that the wait time for a response to the call light is a major concern for patients and closely linked to satisfaction with overall care.23,26,29 Patients come to the hospital with an expectation for prompt service.2 The rationale for this study is that expected nurse response wait times, realistic or not, will form the basis of patient satisfaction. Since expectations are a component of satisfaction, this information can guide us in identifying changes to be made in providing care, which could improve patient satisfaction scores.21
The literature provides a great deal of information on patient satisfaction in general, but there is a lack of research on patient satisfaction in hospital birthing centers. The analysis in this study begins to fill that gap by showing which dimensions of care were most important to patients and correlated with the likelihood to recommend the facility to others. This study also demonstrates the impact of patient expectations of how long they should wait for a nurse response to their call light requests (both in general and specifically for pain medication) on overall satisfaction.
METHOD
The sample consisted of 220 women of childbearing age who received care at a midwestern hospital birthing center over the course of one year. All patients were given a patient satisfaction survey at discharge as part of the routine discharge procedure. They were informed that participation was entirely voluntary and that they could leave the survey in their room; place it in a collection box in the hallway; or mail it in the postage-paid, addressed envelope provided. Data came from all of the surveys collected for the year and reflect 14% of the patients who received care (220 surveys were returned from a total of approximately 1550 patients). The work was approved by 2 institutional review boards.
The patient satisfaction survey used in this study was developed by the hospital. The survey had a total of 14 questions. Ten questions used a 5-point Likert-type scale with responses ranging from "1 = strongly agree" to "5 = strongly disagree," and 4 questions used a choice of time intervals for nurse responses with a response of "1 = 0-4 minutes," "2 = 5-10 minutes," "3 = 11-15 minutes," and "4 = 16-20 minutes."
All completed surveys were coded and analyzed with SAS 9.2 (SAS Institute Inc, Cary, North Carolina).35 The survey questions using the Likert-type scale were factor analyzed using principal components and the dimensions of wait time, communication, and service emerged. The time dimension consisted of 2 questions: (1) nursing staff responded quickly to my calls or requests, and (2) the nursing staff responded quickly to my request for pain control, with factor loadings of 0.64 and 0.56. There were 3 questions on communication: (1) the nursing staff helped me to understand my condition; (2) during my stay, the staff made me feel safe; and (3) I felt prepared to care for my baby after discharge, with factor loadings of 0.63, 0.58, and 0.42 respectively. Service questions asked whether the people serving patients' meals were polite and professional and on each shift, whether patients were aware of which nurse was in charge of their care, with factor loadings of 0.61 and 0.60. The internal consistency of these dimensions was measured by Cronbach alpha with results of 0.68, 0.75, and 0.71, respectively.
The key measure of satisfaction on the survey was considered to be the response to the statement, "I would recommend this hospital birthing center without hesitation to family and friends." The correlation of the dimensions of wait time, communication, and service with this key statement on satisfaction were 0.61, 0.64, and 0.44, respectively, supporting the validity of these measures relating to satisfaction with the birthing experience.
In addition, an independent variable was created using reported call light waiting times. This variable was coded into 2 levels-those who reported that they "did not wait longer than expected" and those who "waited longer than expected" for service. Responses were coded as "waiting longer than expected" if patients' expected wait time was shorter than their reported actual wait time. This variable was then used to compare the three dependent variables of wait time, communication, and service with t tests, which are reported in Table 1.
RESULTS
Patients tended to give lower scores for all statements of the patient satisfaction survey if they reported that they waited longer than expected for any type of call light requests. Table 2 shows the percentages of expected and reported wait times for the 2 types of call light requests-general requests and requests for pain medication. A finding from this study is how long the patients in the study group expected to wait for a response to their call light. Approximately 40% of patients reported that they expected to wait 4 minutes or less, and 93% reported that they expected a response within 10 minutes. In the case of wait time response for general requests, 53.7% of the individuals who were classified as "waiting longer than expected" reported that they expected to wait 4 minutes or less. In the case of wait time response to requests for pain control medication, 55.5% of the individuals who were classified as "waiting longer than expected" also expected to wait no more than 4 minutes.
Table 1 shows a comparison for those who waited longer than they expected and the effect on the 3 factors of wait time, communication, and service. A larger mean represents more disagreement with receiving quality care. All of the comparisons were statistically significant for both general and pain medication requests. When patients waited longer than expected for a response to their requests, they gave a lower score to "wait times" with an effect size of d = 2.19. They also then scored communication and service lower, with effect sizes of d = 0.44 and d = 0.35.
DISCUSSION
This study analyzed an existing patient satisfaction survey to determine which care factors were most important to patients and correlated with the likelihood to recommend the facility to others. We found several dimensions of care to be important. Our results showed that wait time, communication, and services in the hospital birthing center influenced satisfaction with care and correlated with the likelihood to recommend the facility to others. We also assessed the impact on overall satisfaction of patient expectations of general and pain medication wait times for nurse response. We determined that failure to meet patients' expectations of wait time for call light response was associated with lower patient satisfaction scores in wait time, communication, and service.
The most influential factor that emerged in this analysis was wait time for call light response. This factor accounted for the largest amount of survey variability and was correlated with likelihood to recommend the facility (used as a key measurement for overall satisfaction). This finding is consistent with other studies on patient satisfaction.2,10,23,26,29
The second most meaningful factor that emerged was communication by nurses. This factor also had a strong correlation with likelihood to recommend the facility to others. The components of communication from this survey were nurses' explaining patients' medical condition to them and providing education on the care of their newborn. Previous research supports this finding that nurse communication is an important factor in perceived care. In a study by Shaffer and Tuttas,27 patient education was an important component of patient satisfaction, with nursing communication having the most effect on patients' overall satisfaction with a hospitalization and the likelihood to recommend that hospital to others.
The third factor to emerge was service, although it was not found to be as influential as wait time and communication. Attention to the service details of hospitalization emerged as a contributing factor of patient satisfaction in the findings of Rutledge.20 Urden8 reported that satisfaction was closely tied to the expectations of the individual about services and care, which is more general than our findings.
Because wait time has been shown to be an important factor in assessing service, it is important to know how long patients expect to wait for a response. The survey analysis demonstrated that 40% of patients expected to wait 4 minutes or less for a response to their calls or requests and 50% expected a response in 5 to 10 minutes. Failure to meet this expectation was a significant factor that correlated with a lower score on the factors of wait time, communication, and service. For the questions on wait time for requests for pain control medication, the analysis showed that 42% of patients expected a response in 4 minutes or less and 53% expected to wait only 5 to 10 minutes.
Our findings indicated that patient satisfaction was multidimensional and that responsiveness to call lights or requests for care had the strongest predictive value for patient satisfaction with the overall stay in the hospital birthing center. The themes that emerged from the analysis were similar to those described by Urden,8 who suggested that 3 components should be used in patient care surveys-patient satisfaction with nursing care, pain management, and patient education. In the present study, the dimensions of nursing care related to response wait times and patient education through communication were positively correlated (r = 0.61) with likelihood to recommend.
The findings in this study extend our understanding of the relationship between expectations for wait time and patient satisfaction. If institution staff is interested in improving patient satisfaction scores, they may want to have a discussion with new patients about realistic wait times for nurse response. When expectations are realistic and then they are met, overall satisfaction scores should improve. This outcome is supported by Meade et al,24 who concluded that patient satisfaction with nursing care is primarily dependent on patients' perceptions of how well their needs were met. If patients have a realistic perception of wait times, they will then have a better basis for evaluation of the quality of the care they received.
In summary, patients want a quick response when they need help or pain medication. They want their nurse to be knowledgeable about their condition, able to explain it to them, and able to teach them how to care for their infants at home. Our results reinforce that call light wait time is an important factor in patient satisfaction but is certainly not the only factor.
Limitations
The population was limited to patients cared for in a hospital birthing center in a single facility in the midwest. Participation in the study was voluntary and reflected a response rate of approximately 14% of patients. The survey had no identifying information on it; so, demographics could not be determined.
CONCLUSION
Recent government reporting requirements for hospitals receiving Medicare and Medicaid reimbursement have resulted in the expanded importance of patient satisfaction surveys. Instead of using only survey results for marketing and evaluating certain aspects of care, the focus is now on creating a public record of the quality of care. This study adds new insight to factors affecting patient satisfaction for a birthing center and reaffirms some factors that have already been reported in the literature. Meeting expectations is a strong component of satisfaction. Clarifying what to expect in regard to wait times for call light response or pain management has the potential to improve patient satisfaction.
REFERENCES