Nursing care responsiveness from the client's view

Abstracts

A expectativa criada pelo indivíduo na hospitalização e a percepção que ele tem do cuidado que recebe quando hospitalizado são aspectos que definem seu grau de satisfação. Assim, surgiu o conceito responsividade no campo da avaliação em saúde. O objetivo deste estudo é mensurar a responsividade do serviço de enfermagem de uma unidade médico-cirúrgica de um hospital universitário público, na visão do cliente, por meio de um instrumento que aborda duas categorias: Expectativas e Percepções. Trata-se de pesquisa quantitativa que utilizou entrevistas. Para análise dos dados realizou-se o cálculo da taxa de satisfação relativa e do intervalo, o que possibilitou a classificação do serviço de enfermagem. Correlacionam-se as características socioeconômicas com as experiências prévias de internação dos entrevistados. Os resultados demonstraram que o serviço de enfermagem está com uma representação Adequada. Alguns fatores foram considerados responsáveis pelo fenômeno da alta satisfação, como viés de gratidão e de aquiescência.

Serviço Hospitalar de Enfermagem; Qualidade da assistência à saúde; Indicadores de qualidade em assistência à saúde; Satisfação do paciente

ORIGINAL ARTICLE

Nursing care responsiveness from the client's view

Responsividad del servicio de enfermería en la visión del pacient

Ana Vanessa Deffaccio Rodrigues^I; Dagmar Willamowius Vituri^II; Maria do Carmo Lourenço Haddad^III; Marli Terezinha Oliveira Vannuchi^IV; William Tiago de Oliveira^V

^IRN. Student of the Masters Program at State University of Maringá, PR, Brazil. [e-mail]

^IIRN. Master. Nursing Service Quality Advisor for the Londrina University Hospital, Londrina, PR, Brazil. [e-mail]

^IIIRN. Ph.D.. Professor of the Nursing Department at Londrina State University and of the Londrina University Hospital. Londrina, PR, Brazil. [e-mail]

^IVRN. Ph.D.. Professor of the Nursing Department at Londrina State University and of the Londrina University Hospital. Londrina, PR, Brazil. [e-mail]

^VRN. Student of the Masters Program at State University of Maringá, PR, Brazil. [e-mail]

^{Correspondence}

ABSTRACT

The expectation that individuals have when admitted to hospital, and their perception of the care they receive while in hospital, are aspects that define their level of satisfaction. Thus, the concept of responsiveness arose in the field of health evaluation. The objective of this study is to measure the responsiveness of nursing care from the client's point of view at a medical-surgical unit of a public university hospital, by means of an instrument that examines two categories, Expectations and Perceptions. This quantitative study was performed utilizing participant interviews. Data analysis was performed by calculating the relative satisfaction rate and interval, which allowed for rating of the nursing care provided. A correlation was made between the sociodemographic characteristics and the participants' prior hospitalization experiences. The results showed that nursing care has an Adequate representation. Some factors were considered responsible for the phenomenon of high satisfaction, such as the biases of gratitude and acquiescence.

Descriptors: Nursing Service, Hospital; Quality of health care; Quality indicators, health care; Patient satisfaction

RESUMEN

La expectativa creada por el individuo hospitalizado y su percepción del cuidado que recibe mientras está hospitalizado son aspectos que definen su grado de satisfacción. De ese modo surgió el concepto de responsividad en el campo de evaluación en salud. Este estudio objetivó mensurar la responsividad del servicio de enfermería de una unidad médico-quirúrgica de hospital universitario público, en la visión del paciente, mediante un instrumento que aborda dos categorías: Expectativas y Percepciones. Investigación cuantitativa que utilizó entrevistas. Datos analizados por cálculo de tasa de satisfacción relativa e intervalo, lo cual posibilitó la clasificación del servicio de enfermería. Se correlacionan las características socioeconómicas con las experiencias previas de internación de los entrevistados. Los resultados demuestran que el servicio de enfermería se califica con una representación de Adecuado. Algunos factores fueron considerados responsables por el fenómeno de la alta satisfacción, como sesgos de gratitud y de adhesión.

Descriptores: Servicio de Enfermería en Hospital; Calidad de la atención de salud; Indicadores de calidad de la atención de salud; Satisfacción del paciente

INTRODUCTION

In the past few years, many studies^(1-3) have been developed with the objective of learning about patients' perceptions regarding the care received in the hospital. Patients' judgment value regarding the quality of care and health treatments has been a concern to researchers^(4-5).

Patients seek health services while holding a variety of beliefs, attitudes and prior experiences that, along with their knowledge and the information they receive from health professionals, will enable them to define their situation, allowing them to perceive the care they receive⁽⁶⁾.

Under this context, a quality indicator known as responsiveness was developed in the health evaluation field, which represents an alternative to the concept of satisfaction, due to its subjective aspect⁽⁷⁾.

Responsiveness can be defined as the way in which healthcare design acknowledges and responds to individuals' known expectations regarding non-medical aspects of health care. This concept puts two technique elements into practice: measuring what happens when clients interact with the system and measuring how clients perceive and evaluate what happened ⁽⁸⁾.

In face of the relevance of this concept and the importance of measuring how well the nursing service in a public university hospital responds to clients' expectations and perceptions, this present study was developed. Evaluation of nursing service responsiveness is believed to be, according to patients' opinions, crucial for effective and efficient management. Moreover, the information generated from this evaluation process must be used to make the nursing team aware of the need for attention beyond the technical dimension of health care.

The objective of this present study is to measure nursing care responsiveness in a medical-surgical unit of a public university hospital, from the clients' point of view.

METHOD

A quantitative research methodology was chosen. The study was performed in a 48-bed female medical-surgical unit of a public university hospital in the interior of the State of Paraná. Data collection was performed during August and September of 2010 by means of interviews with patients, taking place on different days and shifts.

Inclusion criteria stated that all patients who were interviewed had to be admitted to the hospital for more than 48 hours, since being cared for by all four nursing teams of the unit was mandatory. Being more than 18 years old, able to communicate verbally and being aware about time and space were also necessary components for inclusion in the study.

The sample size was calculated based on the monthly mean of hospital admissions in the previous year, considering a significance of 5%. We interviewed 122 patients, randomly selected by draw. When the selected patient did not meet all the criteria for inclusion, another patient was chosen.

For data collection, an instrument to evaluate the responsiveness of nursing services developed and evaluated in the year 2009 by Brazilian authors⁽⁹⁾ was used, with two distinct approaches; one guided to patients' Expectations and the other guided to Perceptions. Evaluation issues were grouped into the following categories: Structure, Process and Results.

The instrument is composed of a total of 68 affirmatives. Of these, 20 are aimed at evaluating Structure, 44 at Process and four at Results. They are worded in a way to first capture patients' expectations, and afterwards their perception regarding each evaluation item. Structure corresponds to resources needed in healthcare, covering the physical, human, material, financial resources and information systems. Process involves the complexity of treatments and directly depends on patients' access to the service, the interpersonal/ethical aspects, clients' autonomy, social support, the communication/information received by patients and the work process of the nursing team. Results are aimed at analyzing clients' final outcomes regarding health⁽⁹⁾.

The methodology used to measure responsiveness for each evaluation question was the Likert scale, with a numeric variation of one (1) to seven (7), according to the reliability. Number one (1) should be chosen when patients strongly disagree with the question and seven (7) if they strongly agree. The numbers in between would represent the strength of patients' expectations regarding the need for the service to provide resources/conditions (Expectations) and, on the second approach the feelings/impressions about the resource/condition availability (Perceptions). Number zero (0) was chosen when patients had no opinion regarding the question, or when they had not experienced the situation described in the question. All affirmatives assigned a zero were disregarded in the total, with a view to maintaining percentage calculations⁽⁹⁾.

According to the methodology used⁽⁹⁾, the need for a numeric value to represent nursing service responsiveness was crucial; to this end, a formula that had already been applied in another study⁽¹⁰⁾ was used to calculate the relative satisfaction rate (RSR) and the GAP. The latter is an English expression considered to be the distance between the RSR and the fully satisfied client⁽¹¹⁾. Calculations are represented by the following formulas:

In this same study⁽⁹⁾, the authors built from a pilot test all combinations of all possible results, including a scale of percentage and acceptability and their representations. This enabled the authors to form GAP categorizations ranging from Insufficient, Regular, Adequate, Good and Great, where a positive value represents service that is below clients' expectations, a zero value means that the service is adequate and meets clients' expectations and a negative value means that the service has exceeded clients' expectations, as shown in Table 1.

Findings related to responsiveness correlated with the education profile and monthly income were demonstrated by interviewees based on the fact that the main reasons for satisfactionare the patients' characteristics, including socio-demographic features⁽¹²⁾. Therefore, for monthly income calculations, the minimum wage of R$ 510.00 was used as a reference.

Regarding previous experiences in other hospitals or in the same hospital in this study, this variable was analyzed since expectations are directly influenced by negative or positive experiences in a way that affects individuals' behavior ⁽¹³⁾ and therefore their perception of the service.

Data were entered in a table and grouped using the Microsoft Office Excel 2010 software, counted according to frequency and simple percentages, and then presented and analyzed in a table.

Data collection began after the project was approved by the Research and Ethics Committee of the institution, by means of registration in the National Information System regarding Research Ethics (CAAE Protocol nº 0124.0.268.000-9). Patients were informed about the research project, and those who agreed to take part in it received guidelines about privacy and anonymity and were then asked to sign a Free and Informed Consent Form.

RESULTS

Analyzing the interviewees' socio demographic profiles, findings demonstrated ages between 18 and 80 years old, and the most common hospital admissions were for individuals between 41 and 50 years (22.9%). Regarding marital status, of the 122 women interviewed, 64 (52.5%) were in a stable union, 30 (24.6%) were widows, 16 (13.1%) were separated and 12(9.8%) were single.

Regarding religious beliefs, 70 (57.4%) identified themselves as Catholic, 43 (35.2%) as Christian, 4 (3.3%) as Spiritualists, 1 (0.8%) as a Buddhist, 1 (0.8%) as a Jehovah's Witness and 3 (2.5%) stated they were not affiliated with any religion. Regarding the color of skin, 81 (66.4%) women considered themselves to be Caucasian, 19 (15.6%) considered themselves to be black, 5 (4.1%) identified themselves as Asian and 17 (13.9%) stated they belonged to other races.

Regarding education, 19 (15.6%) had no education, 37 (30.3%) had an incomplete primary education level (1st to 9th grade), 18 (14.8%) had completed a primary education level, 8 (6.6%) had an incomplete secondary education level, 29 (23.8%) had a complete secondary education level, 6 (4.9%) had an incomplete higher education level, and 5 (4.1%) had a complete higher education level. Monthly income varied between one and above four minimum wages, and most individuals had an income between one and two wages (82.0%).

Results demonstrate that responsiveness of nursing services, as viewed by the patients in this study, was unrelated to education degree and/or monthly income; results also demonstrated that Expectations regarding nursing services were equal to Perceptions regarding the service received. In other words, the GAP was 0% (Table 2 and 3).

Responsiveness of nursing services in the hospital of this study was rated as Adequate; in other words, the interval between total satisfaction and relative satisfaction was equal to zero (GAP= 0%). This means that patients' perceptions regarding the conditions/resources met their expectations in all three categories (structure, process and results), both in previous experiences in other hospitals and in the hospital in this study (Table 4).

DISCUSSION

Expectations created by individuals at the time of hospitalization and the perceptions they have regarding health care while they are in the hospital are aspects that will define their degree of satisfaction. The nursing team performs an essential role in providing health care to hospitalized individuals, since they spends the majority of the patient's stay dealing with the patient, providing specific care for them from the day they are admitted until the day they are discharged⁽⁶⁾.

This present study established the difference between patients' expectations and perceptions in a female surgical-medical unit of a public university hospital regarding the nursing service, and it demonstrated that for most evaluation items, the GAP was equal to zero, which qualifies the nursing service as adequate.

These results demonstrate a phenomenon described in the literature as the elevation effect, which occurs when satisfaction rates are reported as positive even when perceptions regarding the service received are negative. This fact has led researchers to question the validity of these studies, since it is unlikely that nursing professionals will always provide perfect health care⁽¹⁴⁾.

Manners dictate social rules, such as the obligation to show respect for authority figures (such as the health professionals or the researcher), andunderstanding criticism as a social inconvenience may be associated with the positive pattern of satisfaction responses ⁽¹⁵⁾.

Methodologically, some factors have been pointed out as being responsible for the phenomenon of high satisfaction, such as the reluctance to express negative opinions, also known as gratitude bias and acquiescence bias⁽¹⁶⁾.

Gratitude bias regards the omission of questions and negative criticisms on the part of clients and is especially common in the evaluation of public services. However, gratitude bias can appear in situations where clients have formed relationships with the professionals providing the service, as in cases where patients have been in the hospital for a prolonged period. Also, it may be reflected in a position of gratitude toward the researcher. In this case, the satisfaction measure is distorted, since it is a source of satisfaction for the client in and of itself⁽¹⁷⁾.

Acquiescence is revealed in the scale used in the instrument. It regards the tendency of an individual to agree with the first item in the scale, regardless of its content. Therefore, the order of the items can influence the level of satisfaction; in other words, taking results to higher levels if items are positively ordered, or to lower levels in the opposite situation. This tendency is more common among elderly clients and individuals with lower incomes⁽¹⁶⁾.

There is little agreement regarding the choice of satisfaction measuring instruments. Many instruments can be identified in the literature and most studies use more than one instrument⁽¹⁸⁾.

In Brazil, as in other developing countries where access to quality healthcare is still a privilege extended to few people, clients would be expected to manifest greater dissatisfaction with the services they receive⁽¹⁶⁾.

In public services, high satisfaction can express clients' concern in losing their right to the service, even when it is of low quality, making clients of the public system a captive client⁽¹⁹⁾. Also, the fact that clients demonstrate satisfaction with the health care provided even when the service provided is of low quality has been related to a lack of information (low expectations) allied to the provision of negative responses (contextual dynamic elements), producing elevated satisfaction levels as an artificial response⁽¹⁵⁾.

It is believed that quality evaluations of nursing care using indicators such as responsiveness can be used to reinforce the natural desire of health professionals to improve health care, at the same time providing a method of understanding the quality of this care⁽²⁰⁾.

There is a study limitation regarding the data collection method used for the interviews, since it is believed that if patients answered a questionnaire, they would feel more comfortable in voicing their true real opinion, in addition to being faster and less tiring for weaker patients. However, this method was chosen since the education background of the patients receiving service from the institution is already known, a fact that was demonstrated in this present study; therefore, there would be a considerable risk for the questionnaire to be inappropriately answered, since it is a complex instrument.

CONCLUSION

This present study aimed to measure the Relative Satisfaction Rate and GAP regarding nursing services provided in a female med-surg unit of a public university hospital, concluding that patients consider the service provided to be adequate and that, apparently, this level of satisfaction is not related to the demographic profile of the population in the institution.

Implementing measures aimed at improving nursing care requires a broader vision of the entire team in order to provide quality management as a target, with a view to making the necessary changes to reach health care service goals that agree with what is expected by clients.

Regarding the need to improve instruments and research methods measuring responsiveness of clients, it is important to remember that this improvement must be guided towards a consequent evaluation that will result in improvements to health service routines, ultimately resulting in significant progress in service management.

The development of further studies is recommended with a view to developing new evaluation instruments and new technologies to measure responsiveness in health services, considering that the more researches are performed, the greater the chance of developing higher quality measuring instruments, in terms of costs and effectiveness.

REFERENCES

Received: 09/23/2011

Approved: 04/19/2012

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Correspondence addressed to:

Ana Vanessa Deffaccio Rodrigues

Avenida Tancredo Neves, 841 – Centro

CEP 86900-000 - Jandaia do Sul, PR, Brazil

Publication Dates

• Publication in this collection
  30 Jan 2013
• Date of issue
  Dec 2012

History

• Received
  23 Sept 2011
• Accepted
  19 Apr 2012