Survey on Patient s Satisfaction on the Service Quality in an Emergency Department in Malaysia

Abstract

Patients' experience in the emergency department in terms of service, communication, waiting time, competence and facility are important indicators in improving quality care. The aim of this study was to explore patient’s satisfaction level on care of five domains; services, communication, waiting time, competence and facility in the emergency department. A cross-sectional study design using PEQ (Patient Experience Questionnaire). Convenience sampling method used requiring participants to complete the questionnaire prior to discharge. Data was analysed with SPSS version 20. Descriptive and Pearson Chi Square was used to determine the association.324 questionnaires returned. Descriptive analysis showed 67.9% were not satisfied with their experiences. The mean service scored 65.90 ± 31.91, communication scored 65.00 ± 35.76, facility scored 63.33 ± 34.53, competence scored 54.89 ± 35.18 and waiting time scored 49.77 ± 32.65. Service has significance association with education and age group. This study has showed the importance of communication skill and a well-organized emergency department right from the triage till discharge to improve the satisfaction level of patients. Hence the department should recognize these needs and increase the provision of training need for staff in order in contribution to improve the communication skill of the healthcare provider.

Keywords

Patient experiences, Patient satisfaction, Emergency department.

Introduction

Patient’s experiences in the emergency department (ED) are a contributing factor to patient’s satisfaction to the services provided by the department. Patients are viewed as consumers’ of health care and there is an emphasis on surveying them and canvassing their opinions on the quality of service provided [1]. Patient satisfaction is defined as a quality outcome of care that underpins a patient’s health care experience [2]. Patient satisfaction deserves attention because it is a potentially significant mediator for a range of important outcomes and valuable component in promoting health and well-being. Satisfaction may also directly impact the financial viability of an institution by affecting consumer choice, with dissatisfied patients choosing to go for other healthcare services. Therefore, this survey of patient experience is a strategy used to monitor and improve quality of health care [3]. It is crucial to inculcate the culture of providing quality care to patient and should put forward as strategic goal in all healthcare organizations [3]. In 2008, previous study showed that only 58.7% of the patients were triaged immediately upon arrival to the emergency department [4]. Besides that, other study reported only 55% of the patients were given discharge instructions [5]. More recent study in Malaysia, they found that only 75% patients were satisfied with their visits in the emergency department [6].

A study in Boston revealed that patients’ were very satisfied with three nursing care attribute; friendliness, comfort measure and information sharing [7]. During the visits to a stressful and frightening situation in an ED, patients appreciate some care and emotional support, otherwise it will consider fail to give adequate treatment if patients leave without any attention given to them [8]. The communication skills among physician and nurses is crucial to keep the patients well informed and feel comfort [9]. The frightening patients felt they were abandoned and neglected because they were afraid of the unknown and need information about their care [10]. Often patients perceived ED teams were respectful and allowed them to talk with interruption but unlikely to engage in decision making [11].

The prolonged ED wait time affect the quality care given to chronically ill patients and increase the adverse event to patients [12,13]. Timeliness of care is actually an issues most patients are concerned [13]. Promptness of service were rated as most important element of ED service [9].In addition, a recent in fact in patients with non-ST segment-elevation myocardial infarct significantly association with prolonged ED stay of more than eight hours and lack of competence to five acute care guideline [14].

Therefore, the competence, professionalism and caring behaviour should be projected so that patients do not leave before being seen [15]. Parent of paediatric patients viewed that the predictor for their satisfaction are how well the physician work with nurses and quality of medical care given to them [13]. Similarly study in Queensland, Australia also indicated the importance of quality and professional care [9].

Patients suggested that EDs should consider to improve the condition of their waiting room to ensure comfort if they are unable to reduce waiting times [16]. In view of the need to explore the patients satisfaction to improve the service, this study aim to explore patient’s satisfaction level on care of the five domains; services, communication, waiting time, competence and facility in the emergency department.

Methods

Study design

This is a quantitative descriptive cross-sectional study design using convenience sampling. The sample size is calculated based on 95% confidence interval and with a margin error that does not exceed ± 5%. Total of 365 (148 male and 176 female) participated in this study.

Setting

This study was conducted in a tertiary hospital emergency department. This department is divided into three areas which consist of red zone (urgent cases) with average of 17 patients per day, yellow zone (acute cases) with average of 67 patients’ per day, and green zone (semi acute) with average of 170 patients per day.

Selection of participants

The eligibility criteria for this study consist of patients above the age of 18. It was a convenience sampling method because of limited time and the fast turn over in patient’s movement.

Instrument

Patient Experience Questionnaire (PEQ) (Appendix 1) was used as an instrument for this study. The questionnaire using 5 point Likert scale consists of two parts. Part A contains demographic data which addressing age, marital status, level of education, ethnic group, gender and working status. Part B consists of 27 questions related to service, communication, waiting time, staff competence and facilities.

Validity and reliability

The questionnaire used in this study is replicated from previous studies in Norwegian and has been tested for reliability and validity [17]. Pilot study was conducted in emergency department, University Malaya Medical Centre to test the reliability and validity. It was done on 30 patients that visited emergency department. Cronbach's alpha coefficients showed the value of 0.94.

Data collection and analysis

Data was collected from April until May, 2012. Each patient was given 15 to 20 min to answer the questionnaire. Data were analysed using the Statistical Package of Social Sciences (SPSS) version 20.0. Descriptive and Pearson’s Chi Square were used to test the association.

Ethical considerations

Ethical approval was obtained from the Research Ethical Committee. Permission was given by nursing administrative, nursing official and Head of Department of Emergency Medicine.

Results

Three hundred and fifty six questionnaires were distributed but only 324 returned which bring to respond rate of 91%.

Experiences on services

In this study, majority patients (83%) felt doctors had main responsibility compare to emergency nurses who are caring for them (62.3%). Whereas 63.6% of them felt the service in ED were well organized, only 57.7% felt problems related to the hospital were taken care in a manner. More than half (57.4%) of the patients showed satisfaction on amount of information given regarding their treatment or condition.

Experiences on communication

Seventy two percent of the patients understood the doctor’s explanation but only 70.1% felt the doctor gave full attention towards them. For nursing section, 62% agreed emergency nurses gave satisfactory answers when questioned; only 61.1% said emergency nurses gave full attention and 55.6% felt emergency nurses were interested in their description. Overall the communication experiences towards doctors (62.3%) were better compare to emergency nurses (46%). This shows patients are more satisfy the doctors compare to emergency nurses.

Experiences on waiting time

More than half (51.9%) was given sufficient information on their triage category, followed by 52.2% was seen within an hour and 47.8% waited more than one hour. 60% were given pain relief on arrival, whereas 65% did not know length of time for lab investigation. Overall only 55% were satisfied with waiting time. This shows patients were not happy with the waiting time in the emergency department.

Experiences on competence

Fifty three point four percent of the patients felt that emergency nurses cared for them and 50.6% of the patients answered that emergency nurses did not have time to speak to them when they needed them. Less than half (46%) of the patients were given complete explanation about their condition and reasons to wait. Whereas only 51.2% of patients were given health teaching and discharge information. Patients answered that 62% emergency nurses did practice good hand hygiene during delivery of care. This made 67.3% patients to have confidence in emergency nurses professional skills.

Experiences on facilities

During their waiting time only 57.4% were satisfied with the cleanness of the toilets, floor and environment, whereas, 66.4% were satisfied with the room where they were seen and 72.5% were satisfied with the equipment used which was in a good condition, but 52.8% were not satisfied because there were no hand-wash gels available for patients and visitors to use to clean their hands after usage of toilet or handling of specimen such as urine.

Total satisfaction on five domains

Among the five domains, patients were more satisfied with services provided (Table 1). For overall satisfaction only 32.1% were satisfied with their experiences in the emergency department. Service scored highest at mean rate of 65.90 with standard deviation of 31.914 (65.90 ± 31.9140), this indicates that patient’s experiences are satisfactory with the service provided compare to communication scored at 65.00 ± 35.762, facility scored at 63.33 ± 34.534, competence scored at 54.89 ± 35.180 and the least satisfactory experience was from waiting time which scored at 49.77 ± 32.652.

Table 1. Total mean score (n=324).

Association between five domains and demographic variables

There is a statistically significant (X²=7.861a, df=3, n=324, p<0.05) association between educations with service (Table 2). Patients with lower education (54.9%) are more satisfied towards the service provided compare to patients with higher education (38.1%) (Table 3). Patients from the age group of more than 50 years old are most not satisfied with the service provided. There is a statistically significant (X²=8.991a, df=3, n=324, p<0.05) association between services with age group (Table 3).

Table 2. Pearson’s Chi Square association between service and level of education (n=324).

Table 3. Pearson’s Chi Square association between service and age group (n=324).

Discussion

Health care institution should prioritise patients need in ordered to provide quality care. Measurement of patient satisfaction is influenced by many variables including communication between practitioner and patient, length of stay, waiting times, demographics and socioeconomic status [18]. It is also a critical step toward understanding and improving the quality of care [19]. In this study, the ED consist of 18 physician and 122 nurses and patients’ overall satisfaction toward service given by them in the emergency department were rated quite low (32.1%) as compare to previous studies ranging from 50 to 90% of ED patients were happy with the services given [9,11,12]. This is supported by a study in Australia where they reported that patients were very satisfied with total care received in the emergency department [20]. By providing good services, it would increase patient satisfaction and help them during long waiting hours [21].

Besides that, good communication skill also can improve patient satisfaction [6,22]. Result from this study showed that patients are satisfied when communicates with the doctors and emergency nurses. It is most important for both doctor and emergency nurse’s to have good communication skill as it is an important domain for all global rating in patient care [21,23]. However, a study conducted in Scotland reported about 21 out of 42 issues was raised as a result of poor communication between practitioners and patients in the emergency department [24]. Therefore, one of the main targeted areas in good communication skills among practitioners is by providing adequate information to the patients. Adequate information related to diagnostics, treatment and reasons for delays must be given. It is important to remember that patients do not simply want to be given a diagnosis but they want to know what the diagnosis means and the underlying cause of their condition. If family members are present, they too should be provided information and treated as respectfully as the patient. This is especially true for families of patients in critical condition, because the family is likely to be very anxious and seeking information about the loved one [25].

Furthermore, this study have identified that patients are dissatisfied about long waiting time in ED due to delay laboratory results and triage category. This is supported by a study in Iran which those who waited longer were less satisfied [16]. Thus, providing adequate information on their waiting reasons and giving education regarding triage service system will increases patients’ satisfaction in their lengthy hours [26]. To achieve improvement in their overall services, healthcare institutions needs to focus attention on their practices involving triage system, registration time, patient flow, physical environment, laboratory testing, admission processes and policies, workload assignment, staffing and others [27].

Nursing care in ED differs from that in hospital wards in many ways. In the ED, patients arrive in need of more or less urgent attention, causing large variations in patient flow. The duration of visits to the ED is often short and decisions have to be made quickly [2]. Therefore, healthcare providers should successfully project competence, professionalism and caring attitude to achieve patient’s satisfaction [15]. Good nursing care and competence emergency nurses can leave significance impact on patients’ satisfaction. As shown in this study, more than half of the patients have confidence in emergency nurses professional skills. This is supported by other studies which showed quality of care and patient satisfaction level is increasing when emergency nurses are competent and expert [1-5].

Long waiting time with a poor environment facility and poor cleanliness can cause dissatisfaction among patients visiting the ED as shown in our results. A study in Sweden also reported patients and caregivers did not have access to something to drink during their visit to the ED and there was a lack of newspapers for relatives to read while waiting for the patient [2]. Therefore, setting up a good triage system and creating a neat environment are among factors that can reduce dissatisfaction among patients during a long waiting time [16]. Unable to reduce waiting time can be improved with providing good waiting area for patient’s comfort during the lengthy stay [16].

Findings from this study showed that there are association between education level and age with patients’ satisfaction level. Patients with lower education level are more satisfied towards the service provided. This result similar with a study in Iran which reported that patient satisfaction level was lower in those with higher educational levels [16]. Then, elderly patients are most not satisfied with the service provided in the emergency department. Older patients are vulnerable because multiple diseases, poor eyesight and hearing [2] which require additional evaluation time in the emergency department [23]. Therefore, busy, crowded, noisy ED environment and the periods of waiting for various services can increase discomfort and distress for elderly people [28-30]. Other studies suggest that care of older patients in EDs needs improvement and standards of care should be developed by focusing on triage, trolley waits, pain relief and attitudes towards ageing [31,32].

The limitation of the study is patients have short experiences in visiting emergency department. Further study should be conducted on selected sample that has visited more than once to the emergency department.

Conclusion

This study found that only 32.1% found good experience with emergency department. This finding has raised the importance of communication skill to patient’s satisfaction. Patients were satisfied with waiting time if they are informed of the reasons to wait and good facilities are provided where patients can wait with comfort. Patients perceive emergency nurse’s competency as well organized, able to spent time talking to patients and informing patients regarding their conditions and discharge plan. Education and age has an association with satisfaction level towards services provided. This indicates that mid age patients with higher education level have higher expectation on service provided.

References

1. Jennings N, et al. A survey of patient satisfaction in a metropolitan emergency department: Comparing nurse practitioners and emergency physicians. Int J NursPract. 2009;15:213-218.
2. MuntlinA, et al. Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement. J ClinNurs. 2006;15:1045-1056.
3. Roslinah A, et al. Is the contact time between patient and health care personnel in ministry of health hospitals Malaysia appropriate? Malaysian Journal of Public Health Medicine. 2010;10:14-22.
4. Goransson KE and Rosen A. Patient experience of the triage encounter in a Swedish emergency department. IntEmergNurs. 2010;18:36-40.
5. Vashi A and Rhodes KV. “Sign Right Here and You’re Good to Go”: A content analysis of audiotaped emergency department discharge instructions. Ann Emergency Med. 2011;57:315-322.
6. Saiboon I, et al. A study of patients’ satisfaction with the emergency department (ED) of Hospital UniversitiKebangsaan Malaysia (HUKM). Med & Health. 2008;3:7-13.
7. Blank FS, et al. A comparison of patient and nurse expectations regarding nursing care in the emergency department. J EmergNurs (United States). 2014;40:317-22.
8. Gordon J, et al. The patient experience in the emergency department: A systematic synthesis of qualitative research. IntEmergNurs. 2010;18:80-88.
9. Mahmoud I, et al. Satisfaction with emergency departmentservice among non-English-speaking background patients. Emerg Med Australas(Australia). 2014;26:256-261
10. Jay R. Reassuring and reducing anxiety in seriously injured patients: A study on accident and emergency interventions.AccidEmergNurs. 1996;4:125-131.
11. McCarthy DM, et al. Emergency department team communication with the patient: the patient's perspective.J EmergMed (United States), 2013:45:262-270
12. Liew D, et al. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003;179:524-526.
13. Byczkowski TL, et al. A comprehensive view of parental satisfactionwith pediatric emergency department visits. Ann Emerg Med (United States). 2013;62:340-350
14. Diercks DB, et al. Prolonged  emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association Guideline for management and increased adverse events. Ann Emerg Med. 2007;50:489-496.
15. Thompson DA, et al. Effects of actual waiting time, information delivery and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28:657-665.
16. Soleimanpour H, et al. Emergency department patient satisfaction survey in Imam Reza Hospital, Tabriz, Iran. Int J Emerg Med. 2011;4:1-7.
17. Garratt AM, et al. Five-point scale outperform 10-point in a randomized comparison of item scaling for the Patient Experiences Questionnaire. J ClinEpidemiol. 2011;64:200-207.
18. Thrasher C and Purc-Stephenson R. Patient satisfaction with nurse practitioner care in emergency departments in Canada. J Am Acad Nurse Pract. 2008;20:231-237.
19. Browne K,Roseman D, et al. Measuring patient experience as a strategy for improving primary care. Health Aff. 2010;29:921-925.
20. Wilson A and Shifaza F. An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department. Int J NursPract. 2008;14:149-156.
21. Arendt KW, et al. The left-without-being-seen patients: What would keep them from leaving? Ann Emerg Med. 2003;42:317-323.
22. Byrne G, et al. Patient satisfaction with emergency nurse practitioners in A&E. J ClinNurs. 2000;9:83-93.
23. Wilkins V, et al. The association between care experience and parent rating of care for different racial, ethnic, and language groups in a medical population. Health Serv Res. 2011;46:821-839.
24. Bongale S and Young I. Why people complain after attending emergency departments. Emerg Nurse. 2013;21:26-30.
25. Boudreaux ED and O’Hea EL. Patient satisfaction in the emergency department: A review of the literature and implications for practice. J Emer Med. 2004;26:13–26.
26. Tran TP, et al. Provision of clinically based information improves patients’ perceived length of stay and satisfaction with EP. Am J Emerg Med. 2002;20:506-509.
27. Horwitz LI, et al. US emergency department performance on wait time and length of visit. Ann Emergency Med. 2009;55:133-141.
28. Dinh M, et al. Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors. AustEmergNurs J. 2012;15:188-194.
29. Nash K, et al. Evaluation of the fast track unit of a university emergency department. J EmergNurs. 2006;33:14-20.
30. Gallagher R, et al. Emergency department nurses’ perceptions and experiences of providing care for older people. Nurs Health Sci. 2014;16:449-453.
31. Grief CL. Patterns of ED use and perceptions of the elderly regarding their emergency care: A synthesis of recent research. J EmergNurs. 2003;29:122-126.
32. Nyden K, et al. Unsatisfied basic needs of older patients in emergency care environments - obstacles to an active role in decision making. J ClinNurs. 2003;12:268-274.