Patients’ Satisfaction Levels of Nursing Services at a Urology Unit of a University Hospital

Background: Thanks to the advances in science, technology and knowledge in the globalized environment which hosts many people, professions, nursing in particular, are faced with the need to improve business processes to ensure high quality. Therefore, it is important to evaluate the level of satisfaction of patients an important indicator of quality service in the field of health. Objective: The cross-sectional study was conducted to determine patients’ satisfaction with nursing services provided in a urology clinic. Methods: The study was conducted at the Urology Clinic of a university hospital between July 1, 2014 and August 31, 2014. The study population consisted of inpatients, who were admitted to the hospital between the a forementioned dates. Seventy patients were included in the study sample. The data were collected using the Sociodemographic Characteristics Questionnaire and the Newcastle Satisfaction with Nursing Care Scale (NSNCS). The T-test and analysis of variance were used for the analysis of data. Results: The mean score the patients obtained from the Satisfaction with Nursing Care Scale (NSNCS) was 81.02±14.26. There were statistically significant differences between the mean NSNCS scores in terms of the following variables: educational status, economic status, social security status and level of satisfaction with the previous nursing care (p<0.05). The mean NSNCS scores of the patients with moderate economic status were higher than those of the patients with low economic status. The mean NSNCS scores of the patients whose satisfaction with the previous nursing care was low were lower than those of the patients who had no previous hospital experience or whose satisfaction with the previous nursing care was good or moderate. Conclusions: the patients’ level of satisfaction with the nursing services in the urology clinic was good.


Introduction
Renewed and advancing health technologies have increased people's expectations of services provided. Thanks to the advances in science, technology and knowledge in the globalized environment which hosts many people, professions, nursing in particular, are faced with the need to improve business processes to ensure high quality care Şişe [1]. An important indicator of quality service in the field of health is the level of satisfaction of patients. Patient satisfaction is a multidimensional concept involving the presence, continuity and presentation of the service, and service providers' competence communication characteristics and interaction with the patient Aksakal & Bilgili [2]; Özer, Köçkar & Yurttaş [3]; Kayrakçı & Özşaker [4]. As reported by the American Nurses Association, patient satisfaction ranks third among the seven indicators of the quality of health care in organizations. Therefore, patient satisfaction is used as a concrete criterion in the assessment of the quality of health care. Cerit [5]. The measurement and provision of quality of nursing care has been a topic of worldwide interest in the 1970s and 1980s. The first steps aimed at improving the quality of nursing care were taken by Florence Nightingale. Nursing is aware of its responsibility not only for the improvement of the quality of healthcare services regarding patients, institutions, ethics, laws and professional standards, but also for how its performance would contribute to the quality of care and patient satisfaction Tuğut & Gölbaşı [6]. There is a positive relationship between the nursing care provided to the patient and patient satisfaction in this respect Demir et al. [7]. Therefore, in the literature, it is emphasized that regular assessment of patient satisfaction with valid and reliable measurement tools will allow the necessary arrangements to be made to meet patient expectations in nursing practices and thus will positively contribute to the quality of the nursing care Aksakal & Bilgili [2]; Özer, Köçkar & Yurttaş [3]; Demir et al. [7]. In this sense, listening to what patients say about their care and their satisfaction with the care can guide managers when deciding on how to realize.

Aims of the Study
This analytical and cross-sectional study was conducted to determine patients' satisfaction with nursing services who were hospitalized in a urology clinic.

Study Design
The research was carried out at the Urology clinic of a university hospital in the Province of Samsun, a province in Turkey, between July 1, 2014 and August 31, 2014. Answers to the following questions were sought in the study: a) How satisfied were the patients with the nursing services provided in the urology clinic? b) Is there any difference between the patients' satisfaction with the nursing services provided in the urology clinic in terms of their socio demographic characteristics?

Participants, Setting, the Sampling
The study population consisted of patients hospitalized in the urology clinic of the hospital between July 1, 2014 and August 31, 2014. The study was carried out with 70 patients who met the research inclusion criteria without any sample selection in the study population. The research inclusion criteria were as follows: being at least 18 years of age, being literate, being treated at least two days in the urology clinic volunteering to participate in the research, being able to communicate, being open to cooperation and not being diagnosed with a psychiatric disorder.

Data Collection
The data were collected using the Sociodemographic Characteristics Questionnaire and the Newcastle Satisfaction with Nursing Care Scale (NSNCS). The Sociodemographic Characteristics Questionnaire was developed by the researcher in line with the literature. The questionnaire consists of 12 items questioning the participants' sociodemographic characteristics such as age, gender, marital status, educational status, employment status, social security, place of residence, economic status, presence of a chronic illness, the number of hospitalizations, previous treatment in another hospital and satisfaction with nursing services in the previous hospital. The Newcastle Satisfaction with Nursing Care Scale (NSNCS) was developed by Thomas LH [8] and the validity and reliability studies for its Turkish version was conducted by Uzun [9]. The Cronbach's alpha value of the Turkish version of the scale was 0.95, which indicated that the scale was quite reliable. In the present study, the Cronbach's Alpha value was 0.97. All the items of the 19-item NSNCS are scored on a five-point Likert scale ranging from 1 to 5 (1= not at all satisfied, 2= barely satisfied, 3= quite satisfied, 4= very satisfied and 5= completely satisfied). The scores obtained from all the items are summed and the total score is converted to a score on a scale ranging from 0 to 100 using the following formula: (sum of the scores obtained from all the items) ÷ (maximum possible score to be obtained from the overall scale) × 100. Scores greater than 50 indicates satisfaction with the nursing care. To collect the study data, the Sociodemographic Characteristics Questionnaire and NSNCS were administered to the patients who met the inclusion criteria in the urology clinic through face-to-face interviews. The interviews took about 5-10 minutes on average.

Ethical Considerations
Before the study was conducted, the approval of the Urology Department of the studied hospital was obtained. Permission of the developer of the scale used in the research was obtained. Individuals participating in the research were informed about the research, and their verbal consent indicating that they volunteered to participate in the study was obtained. The individuals who agreed to participate in the study were told that their credentials would be kept confidential and would not be shared with any third party.

Statistical Analysis
The study data were analyzed with the SPSS 17 software package. Descriptive statistics were used to analyze the data. In addition, the independent samples t-test was used to determine whether there was a statistically significant difference between the means in the two groups in terms of the variables such as gender, marital status, social security, economic status, place of residence, presence of a chronic illness, previous treatment in another hospital since these data have a normal distribution, and the analysis of variance was used to test differences between mean values in terms of the variables such as education level, employment, number of hospitalizations, and satisfaction with previous nursing care.  Of the participants, 71.4% were male, 40% were primary school graduates, 22.9% were housewives, 82.9% were married, 92.9% had social security, 80% had moderate economic status, 62.9% were living in the urban area and 52.9% had a chronic disease. Of the participants, 44.3% were hospitalized for the first time, 81.4% had previous treatment in another hospital, and 47.1% were satisfied with the nursing care they received previously. The mean age of the participants was 53.73±17.27 (Table 1). According to the 50 cut-off point, 95.7% of the participants were satisfied with the nursing services. The mean NSNCS score obtained by the participants was 81.03±14.26 (Table  2). "How nurses listened to your worries and concerns" (62.9%), "The amount of freedom you were given on the ward" (61.4%), and "Nurses awareness of your needs on the care and treatment" (62.9%) were the three areas, in which the participants had the highest satisfaction (Table 3). There was no statistically significant difference between the mean NSNCS scores in terms of gender, social security, occupation, marital status, place of residence, presence of a chronic illness, the number of hospitalizations and previous treatment in another hospital (p>0.05). However, there was a statistically significant difference between the mean NSNCS scores in terms of the other sociodemographic characteristics of the patients, such as education status, economic status and level of satisfaction with the previous nursing care (p<0.05) ( Table 4).

Discussion
Assessing the level of satisfaction of a patient with the nursing care is the subject of many studies, addressing continuous improvement of the quality of nursing. In the present study, conducted to determine the satisfaction of the patients hospitalized in the urology clinic with the nursing services, the patients' NSNCS scores ranged from 38 to 95. The mean NSNCS score of the patients was 81.03±14.26 and their satisfaction levels were evaluated as "high" ( Table 2). According to many studies in the literature, the level of satisfaction of the patients with the nursing care services is good Özer, Köçkar & Yurttaş [3]; Demir, et al. [7]; Şişe [1]; Yıldız, et al. [10]; Okgün Alcan, et al. [11]. However, there are also studies in which the level of satisfaction of patients with nursing care is determined as moderate Kayrakçı & Özşaker [4]; Cerit [5]; Tuğut & Gölbaşı [6]; Akgöz, Aslan & Özyürek [12]. This difference is thought to be due to the quality of the nursing care services of the hospitals where the studies were conducted. "How nurses listened to your worries and concerns", "The amount of freedom you were given on the ward", and "Nurses awareness of your needs on the care and treatment" were the three areas of nursing care, in which the participants had the highest satisfaction (Table 3). As the hospitals allow, the amount of freedom that nurses provide in physical and social services can cause individuals to feel at home, which increases their level of satisfaction. Patients who are sufficiently informed, valued, whose needs are recognized and who feel like at home have more confidence in the treatment and care as well as in the health care team. Therefore, nurses play a critical role in evaluating patients from every aspect and in providing care for their specific condition throughout their hospitalization Aksakal & Bilgili [2]; Tuğut & Gölbaşı [6]; Demir, et al. [7].
In the present study, there was no statistically significant difference between the NSNCS scores in terms of age, gender, occupation, marital status, place of residence, presence of a chronic illness, the number of hospitalizations, and previous treatment in another hospital (p> 0.05) ( Table 4). In the literature, factors affecting patient satisfaction are grouped in relation with patient-specific (social status, economic status, education status, patient's lifestyle and past experiences, etc.), service providerspecific (humanistic approach, information given, general quality, technical adequacy, general satisfaction, bureaucratic regulations, financial and physical facilities), and environment and institutionspecific factors (hospital's availability, working hours, hygiene), quality of food services) Tuğut & Gölbaşı [6]; Ejder Apay & Arslan [13]; Fındık Yıldız, Ünsar & Sut [14]. In the present study, the fact that satisfaction with nursing care was affected only by the educational status, economic status and satisfaction with the previous nursing care is believed to be related with the sociocultural structure of the studied population (p< 0.05) ( Table 4). There was a statistically significant difference between the mean NSNCS scores in terms of the participants' education status, economic status and level of satisfaction with the previous nursing care (p<0.05). In the literature, it is stated that the level of satisfaction is high if the expectation level of the patient is low and that if the minimum expectations are met patients with lower expectations and knowledge about the services are more satisfied with the nursing care Aksakal & Bilgili [2]; Kayrakçı & Özşaker [4]; Gadalean L. Cheptea & Constantin [15]. According to a study, the level of satisfaction with the nursing care was higher in individuals with low levels of education. Of the patients included in the present study, 62.9% were illiterate or primary school graduates, and only 20% were high school or higher education graduates (p< 0.05) ( Table 4). Therefore, it can be said that the participants' level of expectation was low due to their low level of education and therefore their level of satisfaction with the nursing care was high. The results of the present study are consistent with those in the literature.
The comparison of the patients' satisfaction levels in terms of their previous hospitalization experiences in any other hospital demonstrated that the satisfaction levels of the patients with previous hospital experience were lower than those of the patients without any previous hospital experience. According to a study, those who had previous hospital experience and were not satisfied with the care services in that hospital were not satisfied with current care services either Yıldız [10]; Arslan & Kelleci [16]. In the present study, levels of satisfaction of those who had a previous hospitalization experience and were not satisfied with the previous nursing care were also found to be low for the current care services. Those who did not have a previous hospital experience were found to have high levels of satisfaction with the current nursing care. The results of the present study are consistent with those in the literature. In a study, it was determined that the economic status affected the degree of satisfaction with nursing. Thus, the mean score the patients with good level of economic status obtained from the "Satisfaction with Nursing Care Scale" was low Koç, Sağlam & Şenol [17]. In the present study, satisfaction of the patients with moderate level of economic status with the nursing care was also low (p< 0.05) ( Table 4). In several studies, patients with social security have been found to have better levels of satisfaction with nursing care services Tuğut & Gölbaşı [6]; Okgün Alcan [10]; Koç, Sağlam & Şenol [17]. In the present study, the mean nursing care satisfaction scores of the patients with social security were high (p< 0.05) ( Table 4).

Conclusion and Recommodation
The level of satisfaction with nursing services was high in the present study. It was determined that the level of satisfaction was affected by factors such as education level, economic status, social security and satisfaction with the previous nursing care. Information obtained as a result of the evaluation of patient satisfaction may provide important evidence to improve nursing care and quality of care services. Therefore, it is recommended to conduct such studies in wider populations and at specific intervals.