Patients Satisfaction with the Care They Receive - Research Proposal Example

 An Examination Of Patient Satisfaction In Limassol General Hospital’s Hemodialysis Unit Introduction: In all facets of health care today, it has become a matter of imperative importance to have a systematic collection of consumer/patient feedback through surveys as a means of gathering relevant data, by analysis of which quality assessment and improvement can be achieved to meet the expected Patient satisfaction. Satisfaction in this context is the degree of congruence between the patients’ expectations of care and their perceptions of the care actually received (Risser, 1975). In Cyprus today, an overhaul reconstruction of the entire health system is in progress and eminent changes are due to take place. Among these anticipated changes is public hospitals’ independence from their current state of total dependence for financial support from the Ministry of Health. The implication of this is that once independence is granted, each institution will have to seek its own sources of funding and other amenities as are necessary for it to maintain just as is the case in the private practice. This means that, they will have to equally compete for their resources with other organisations existing in the private sector. However, to be successful competitors, public hospitals have to measure their present quality status and where necessary, to enhance their care provision in all areas. One of the major aspects that have to be measured is the degree of their patients’ satisfaction from the care provided. Chang et al (1984) argued that studies on patients’ satisfaction are an integral part of the assessment of health care quality and forms a justifiable measure. Additionally, Richards & Lambert (1987), suggested that exploring how much satisfaction patients have with the care provided, has been characterised as the “acid test”, through which any system delivering care has to pass. Furthermore, Locker and Dun (1978) asserted that health care, regardless of how high the quality is, according to clinical or other provider-defined criteria, is far away from ideal when the patient is dissatisfied. Therefore, obtaining the patients’ views about their care, the method of choice is to measure their satisfaction (Bond & Thomas, 1992). Apparently, for public hospitals in Cyprus, the issue of patients’ satisfaction can not be ommited, but on the contrary, it must be taken under great consideration. Studies on patient satisfaction must be carried out as soon as possible, and before public hospitals become independent organisations. This research therefore aims at investigating the level of customer/patient satisfaction among the hemodialysis patients in the Cyprus health care system. Its major importance is that it is the first study of this nature to be conducted in limassol General Hospital’s Hemodialysi Unit. The population of this research will include all the patients under the chronic hemodialysis program in the unit. This is basically because the total number of patients significantly small (n= ±100). A smaller number than this used as a sample size may enclose dangers of misleading results. Furthermore, there is a high homogeinity between this population and the critical variables on the study since all the elements all affected by common conditions- end stage renal disease, are under hemodialysis program, and they share the same team of care providers with similar approach and intervention methodologies. The study will strictly be in adherence of the guiding principles of the “Consumer Assessment of HYealth Care Providers and Systems (CAHPS), 2006” in-Centre Hemodialysis survey. Research Intentions: The major objective or intention of the proposed research is to determine the satisfaction level of various aspects of the care provided to hemodialysis patients in Limassol General Hospital. Since 1950 when the first survey on patient satisfaction appeared in USA and later in UK, the importance of patient satisfaction has been recognized and became an established indicator of the quality of care provided in a health setting. It is believed to be the goal of any health care delivery system that as a consequence of the consumers’ movement, satisfaction is a necessary outcome of any transaction in the health care delivery system (Fitzpatrick, 1991), (Larsen & Rootman, 1976). Furthermore, these kinds of surveys are considered to be an important measure of the quality of care, due to the fact that they provide basic information on the provider’s success to meet the patients’ expectations and values on which the patient is the ultimate authority (Donabedian, 1985). The core item topics that will be explored include the doctors’ caring and communication with the patients, the quality of care and operations the dialysis centre offers, and the provision of relevant information to the patients. Global satisfaction rating regarding doctors, nurses, other staff and facilities, complaints made by patients to the hospital’s complaint office, how they rate their health and mental health status, the treatment they receive for their illness, the quality of staff’s behaviour, the physical condition of dialysis centre, the transportation and access as well as the demographics section will be investigated. Being the first of this kind to be conducted in Cyprus hemodialysis facilities, the proposed research will provide a base knowledge for future reference analysis and discussions. The “Consumer Assessment of Healthcare Providers and Systems (CAHPS) in-Centre Hemodialysis survey 2006” have been decided upon to be utilised for the purpose of the proposed research. The particular questionnaire- structured self-reporting, has been selected because it is specifically designed to assess the perceptions of hemodialysis patients, hence, to serve as a tool that will give some insight to the possible weaknesses or strengths of the care provided to them. As soon as the questionnaires will be collected, they will be edited for certainty that they are properly completed and the information contained therein is legible and usable. After that, the raw data will be coded – coding in respect referring to the process that the original data will be transformed into numerical symbols compatible with computer analysis – and transferred to the computer’s database. The database will be edited and checked for any entry errors, coding errors or reporting errors. Research Paradigm: “…Paradigm is a way of looking at the world or a perspective on phenomena that presents a set of interrelated philosophical assumptions about the world. The perspective guides research and practice…” (Doordan, 1998). As indicated earlier, the proposed piece of research study will follow the survey approach using a structured self reporting questionnaire that falls in the paradigm of positivism inquiry which will eventually distinguish the reality as it exists to put emphasis on rational and scientifically empirical investigation contexts. Positivism originated from the pure or natural sciences with a presumption that there is existing knowledge which is extractable through systematic measurement and objective observation. This survey research is characterised as positivist because the questions are mainly closed, decided in advance and anticipated to obtain data that can be compared. Great importance will be given to explanation or measurement and not on the people’s description of their experiences. When research is well planned and carefully implemented, positivism asserts that the findings can be generalised to other situations in a wider context. The research can also be replicated to see whether the findings are confirmed. To prevent the findings from being affected by issues or variables that are not part of the research study, the study will be carried out under cautiously controlled conditions. The researcher will approach the study systematically and objectively, and remain separate from what is under investigation, implying that the ‘etic’ position will be adhered to. Focusing on patient satisfaction, which is a real human attribute, the present study will comply with the ontological assumption seeking the philosophical understanding of what the nature of reality is, as the positivism paradigm accepts a single tangible and objective reality. Furthermore as the epistemological assumption questions the relationship of the researcher to what is being researched, the positivism paradigm accepts that the researcher is independent from what is being researched and does not influence the research findings. Therefore, as satisfaction can only be portrayed by the person - the patient- the researcher has to remain independent from what is under research in order to ensure the validity, credibility and reliability of the research findings (Polit & Beck, 2004). In order to follow the positivism research paradigm, the study will use a set of orderly discipline procedures to acquire information, initiate with the definition of the research question, continue with the selection of the concepts on which it will focus, and finally, critically analyse the information gathered to provide an answer to the research question. Thus, the researcher will logically progress through a series of steps, strictly following the pre-specified action plan in order to avoid any potential bias by the researcher. Furthermore, a researcher following the positivism paradigm must be methodical, perceptive, objective, critical, committed to detail, rational, inquisitive, structured, and detached. Moreover, in positivist research, representation and generalisation are the key issues relating to sampling. The main concern is that the selected sample will accurately reflect any variations in the population from which the sample was drawn, and is free from bias. This is based on the notion that data will be empirical, measurable and reproducible in future research studies. Sampling is therefore a key aspect of the research design. In the case of the proposed research a census sampling frame will be followed. That is because the total number is relatively small (n=± 100), and therefore, representation and generalisation will be achieved. Research Approach: For the purpose of the proposed research, the descriptive survey research approach will be utilized. Surveys are designed to obtain information regarding the prevalence, distribution, and interrelationships of variables within a population. Moreover, surveys are effective in collecting information on people’s actions, knowledge, attitudes, intentions, opinions and values. They can be applied to many populations, and can focus on a wide range of topics. Such gathered information can be used either for descriptive or analytical purposes. Statistical techniques can be used to determine validity, reliability, and the statistical significance (Polit & Beck, 2004). In addition, use of a survey is a competent way to collect information from a great number of respondents utilizing large samples of a population. They are relatively easy to administer and there is a reported economy in data collection due to the focal point provided by standardized questions, only questions of interest to the researcher are asked, recorded, codified, and analyzed and thus time and money is not spent on unnecessary questions (Dempsey & Dempsey, 1996). For the purpose of this study, a survey research approach using a self reporting questionnaire will be carried out, using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) in-Centre Hemodialysis survey, 2006. The questionnaire has been specifically designed to assess the experiences of patients suffering from End Stage Renal Disease and undergoing hemodialysis. The proposed questionnaire is a product of the Agency for Healthcare Research and Quality (AHRQ) CAHPS’ program, and according to the authors, the complete kit is in the public domain and therefore there are no charges for using it, and permission for such use is not required (CAHPS, 2009). However, in the case that researchers want to use the name “CAHPS”, they must use the questionnaire as it is predetermined by CAHPS. The authors of the questionnaire assessed its reliability and validity by two different approaches; cognitive testing and psychometric testing. Field tests and psychometric analyses provide information about the items’ reliability and validity. Many existing questionnaires about health care have been tested primarily or exclusively using a psychometric approach. However, the CAHPS team believed that the combination of both cognitive and psychometric approaches is essential in order to produce the best possible survey instrument. The cognitive testing bases its assessments on feedback from interviews with people who are asked to react to the survey questions while psychometric testing consists of analyses of data collected through the questionnaire. Cognitive testing provides useful information about respondents’ comprehension of the questions, their ability to answer the questions, and the adequacy of the response choices. Descriptive research provides a precise depiction of characteristics of a particular individual, situation or group. It is a tool of discovering new meaning, describing what exists, determining the frequency with which something occurs, and categorizing information. Additionally, it describes the relevant variables or factors that seem important in a situation and the relationship between the variables. Usually, there is a correlation between two variables e.g. being a female patient, and the expectations on information given from her carers. Nevertheless, by setting information about variables side by side and describing a situation at a given point in time, the findings from a descriptive survey can initiate a useful discussion about current practice. As mentioned earlier, there hasn’t been any other research related to patient satisfaction in Limassol General Hospital’s hemodialysis unit. Hence, it is anticipated that the proposed research will describe the current situation regarding patient satisfaction and at the end useful discussions are expected to emerge so that any potential weaknesses can be identified and necessary improvements made to the patients’ favour. Literature Review: The notion to explore patient satisfaction within the health care services first appeared in USA in the 1950s and later in UK in the 1960s (Bowling, 1992). Through the years the patients’ perspectives have been sought about primary health care, hospital in-patient care, and outpatients departments. The importance of Patient satisfaction has been recognized and has become an established indicator of the quality of the provided health care. It is increasingly getting recognized by professionals, administrators, consumers and evaluators in health care services. Expressions of satisfaction or dissatisfaction are apparently expressions of an attitude, and can be treated theoretically and methodologically as such. This is supported by Fishbein and Ajzen (1975), providing a widely accepted definition of attitude. They claimed that the major characteristic that distinguishes attitude from other concepts is its evaluative or affective nature. It is a general evaluation of feeling of favourableness or un- favourableness towards the object in question. Ware et al (1978) argued that even in studies that do not specifically study patient satisfaction but rather attitudes or perceptions of care, the common feature was that the researchers were in effect seeking people’s evaluations or affective responses to care. Defining patient satisfaction, Risser (1975), suggested that it is the degree of congruence between patients’ expectations of care and their perceptions of the care actually received. Additionally, Stimson and Webb (1975) suggested that satisfaction is related to the perception of the outcome of care and the extent to which it meets patients’ expectations. Moreover, Pelz (1982) defined patient satisfaction as positive evaluations of distinct dimensions of the health care. Finally, Eriksen LR (1995) revealed from the literature that patient satisfaction is the patients’ subjective evaluation of their cognitive and emotional reaction as a result of the interaction between their expectations regarding ideal health care and their perceptions of the actual health care. Most studies on patient satisfaction coincide that satisfaction is a multidimensional assemble, incorporating staff relationships, finances, and care outcomes (Ejaz, et el, 2003); (Gaugler, et el, 2000). Moreover, other studies append that access to and continuity of care, the care giving experience, and the environmental amenities of a particular health care setting are important domains of satisfaction (Bull, et el, 2000); (Castle, 2007). Similarly, in a comprehensive and critical review of the literature on patient satisfaction, (Ware et al, 1983) addressed the question: “what has in effect been studied under the label patient satisfaction?” They concluded that the studies published by that time dealt with a very large number of items that could be grouped according to the constructors that they were implicitly intended to measure. There appeared to be ten such constructors: availability of recourses, continuity of care, accessibility/ convenience, efficacy/ outcomes of care, finances, humanness, information gathering, information giving, pleasantness of surroundings, and quality and competence. Furthermore, Locker & Dunt (1978) suggested that satisfaction with care may influence the quality of life, particularly for patients receiving long term care like hemodialysis. It is widely accepted that chronic illnesses are challenging the coping mechanisms of patients and their families, and more often demand behavioural and emotional changes. Therefore, the quality of care can become synonymous with quality of life, and satisfaction with care is a significant factor for the patient’s wellbeing. Finally, Larsen and Rootman (1976) postulated that satisfaction with care has an influence on whether the patient maintains the patient-care relationship, complies with the treatment regimes and seeks for medical advice. Research Ethics: While researching human beings, researchers must always have in mind that their subjects are real persons, with varied personalities and needs, not just some cold numbers. Through the years, several codes of ethics have been developed and set in effect regarding research on human subjects. Their intention is to ensure the protection of the subjects’ dignity, safety and the worthiness of research. Three basic ethical principles categorically used in research on human subjects include: the respect for human dignity (full disclosure and self determination); the principle of beneficence (freedom from harm and exploitation); and the principle of justice (fair treatment and privacy) (Dempsey & Dempsey, 1996), (Polit & Beck, 2004). In the case of the proposed study, all efforts will be made to meet the highest research ethical considerations. The potential subject’s rights of privacy, dignity, integrity and anonymity will be assured in the strictest possible way. All subjects will receive by hand, during their hemodialysis session, a closed envelope containing the questionnaire together with an explanatory letter. The envelop contents will be explained to them. For those who will give an informed consent, they will be asked to open it at their home, preferably on the following day, in order to avoid any possible unnecessary discomfort. The explanatory letter and the questionnaire will be written in a simple and plain language so that every respondent clearly understands the contents. Alongside the information regarding the purpose and importance of the study, the letter will explain that participation will solely be on the subject’s good will to contribute or not. They will have the right to refuse participation in the study without any fears of incurring penalties or prejudicial treatment. Furthermore, it will be explained that if they may so decide, they can terminate their participation at any point, or refuse to give information, or to ask for clarification about the purpose of the study and/or on specific questions. Moreover, the explanatory letter will state the aims of the study, the procedures that will be followed, and the significance of their participation. As was mentioned earlier, every effort to preserve human rights of anonymity and confidentiality will be made. Thus, the explanatory letter will be anonymous and will not contain a consent form as it will disclose the recipient’s identity. Instead, it will be stressed out in the letter that the return of the questionnaire will be regarded as consent by the participant, and that the provided information could be handled by the researcher. Additionally, no names will be written or asked for in any part of the questionnaire or the envelopes. In the case of low response rate, a reminding letter will be circulated to all the potential participants since it will not be possible to only address the non participants as a way of encouraging them to respond. The questionnaire design will be in such a way that the completion time will be set to the minimum time possible, written in plain and understandable language that will be physically easy to complete in order to avoid any possible discomforts and constrains to the potential participants considering that they are chronically ill persons. Finally, fulfilling the legal implications arising from data collection within the hospital’s premises, the researcher will apply to the proper department of Ministry of Health (since Limassol General Hospital is governmental) for official consent. Furthermore, consent will be asked from the director of the hospital as well as from the director of hemodialysis unit. Anticipated Data: The aim of the study is to investigate the level of patient satisfaction and/or dissatisfaction as expressed by the patients in the above mentioned areas. Moreover, it focused to provide research based evidence upon which to discuss the ways in which patient satisfaction with the provided care can be improved. It is anticipated that with the selected research approach, the research will provide objective and precise data that could be enumerated, analysed and able to generalise. Furthermore, through the descriptive framework it is expected that new knowledge will emerged as this is the first time hemodialysis patient satisfaction will be researched in this particular hospital. Moreover, concepts will be described and relationships will be identified so as to provide a basis for further discussions and research (Burns & Grove, 1997). The selected questionnaire has been designed to produce three global ratings which are: a) the overall rating of medical staff, b) the overall rating of the hemodialysis centre staff, and c) the overall rating of the hemodialysis facility. To compute the respondents’ assessment of the above global ratings, scales of 0 to 10 will be used. Furthermore, this will produce three composites which are groups of questions that will measure the same dimensions of health care. Composites will be used because they will make the reports feasible, comprehensive and concise. In addition, psychometric analyses indicate that composites are reliable and valid measures of subject’s experiences. These composites are: a) The nephrologists’ communication and caring, b) The quality of hemodialysis unit care and staff, and c) Providing information to patients. The response scale of the composites varies with some dichotomous (Yes/No) scale responses and others with 4-point response scale (never, sometimes, usually, always). By the end of the proposed research, an extensive report is expected to be the final product along with a number of report abstracts. These report abstracts will be disseminated to the authorities of LGH’s hemodialysis unit, the staff working in the unit, the hospital’s administrative authorities as well as to other people working in the same field around Cyprian health facilities. Presumably, this will significantly contribute to the decision making processes about the service provision, stimulation of proposals for service restructuring and could also be used to evaluate the effects of respective policy changes. Conclusion: Patients’ perspectives, and particularly their satisfaction with the care they receive, are acting as a “mirror” where every health care delivery system has to emphasize on. Looking at this “mirror” will help health care providers to acknowledge the optimum service they should provide. Consequently, this study will identify any potential weaknesses or strengthens. As the Cyprian health care system is under reconstruction, researching the patients’ satisfaction will contribute in the overall system’s evaluation. The proposed research will study for the first time in Cyprus the satisfaction of hemodialysis patients, a particular clinical area which is especially distinctive. A descriptive survey research approach will be followed using a readymade self-report questionnaire. The proposed questionnaire has been constructed specifically for patients undergoing hemodialysis care. All efforts will be made to meet the research ethical considerations. The potential subjects’ rights of privacy, dignity, integrity and anonymity will be assured in the strictest way possible. Furthermore, as the population under investigation are chronically ill persons, further special precautions will be considered to avoid any further discomfort to them than they are already experiencing. It is anticipated that analysis of the data collected by the end of the study will reveal the real situation concerning the issue of patients’ perception of satisfaction. It is expected that a base knowledge for further investigation will be elicited and probably this will initiate changes in the existing system. Bibliography 1. Avis, M., Bond, M., & Arthur, A. (1995). Satisfying solutions? 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