Journal of Nursing Management, 2008

Patient satisfaction with nursing care in Jordan

MOHAMMAD ABEDRABO ALHUSBAN
1

MSN, RN

and RAEDA FAWZI ABUALRUB

PhD, RN

Staff nurse, Al-Mafraq Governmental Hospital, Al-Mafraq and 2Assistant Professor, College of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Correspondence Raeda Fawzi AbuAlrub PO Box 1894 Irbid Jordan E-mail: raeda71@yahoo.com

ALHUSBAN M.A. & ABUALRUB R.F.

(2008) Journal of Nursing Management Patient satisfaction with nursing care in Jordan

Aims (i) To assess the level of patients experiences of nursing care and identify important aspects that enhance such experiences; (ii) to assess the level of patients satisfaction with nursing care and identify important aspects that enhance satisfaction; and (iii) to compare the level of patients satisfaction and their experiences according to demographic variables of patients, hospital wards and hospital settings. Design and method A cross-sectional descriptive study was used. The sample of the study was a convenience one (n = 300). The Newcastle Satisfaction with Nursing Scale and a demographic form were used to collect the data. Results The ndings of the study indicated that the level of satisfaction of Jordanian patients with nursing care was moderate and their experiences of nursing care were positive. Female patients were more satised with nursing care than male patients. Gynaecological patients were more satised than medical/surgical patients and patients in the semi-private hospitals were more satised than those in public hospitals. Implications for nursing management The ndings of the study provided the basis for developing strategies that may enhance the level of Jordanian patients satisfaction. Conclusion The ndings of the study provide nurses with information about aspects that enhance or hinder patient satisfaction. Keywords: experience, Jordan, nursing care, patient, satisfaction
Accepted for publication: 23 May 2008

Introduction
Consumers of health care services demand quality care. Patient satisfaction has been used as an indicator of quality services provided by health care personnel. The most important predictor of patients overall satisfaction with hospital care is particularly related to their satisfaction with nursing care (Mahon 1997, OConnell et al. 1999). In recent years, the focus on consumerism
DOI: 10.1111/j.1365-2834.2008.00927.x 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd

in a highly competitive environment has led to increased interest in measuring patient satisfaction with health care (Merkouris et al. 1999, Alasad & Ahmad 2003). Pascoe (1983) dened patient satisfaction as a health care recipients reaction to salient aspects of the context, process, and result of their service experience (p. 189). Pascoes denition of patient satisfaction encompasses both cognitive and emotional evaluation of health care 1

M. A. Alhusban and R. F. Abualrub

services (Peterson et al. 2005). On the other hand, Scarding (1994) dened patient satisfaction as the extent of the resemblance between the expected quality of care and the actual received care. Patient satisfaction with nursing care is important for any health care agency because nurses comprise the majority of health care providers and they provide care for patients 24 hours a day (McDonnel & Nash 1990, Alasad & Ahmad 2003). Information about factors that can enhance patient satisfaction is essential for marketing purposes (Phi et al. 2002). Data about patient satisfaction equips nurses with useful information about the structure, process and outcome of nursing care such as adequacy of stafng, therapeutic needs and patient behaviours (Pascoe 1983, Phi et al. 2002). Patient satisfaction is considered as a requirement for therapeutic treatment and sometimes as an equivalent to self therapy. Satised patients help themselves healed faster because they are more willing to comply with treatment and adhere to instructions of health care providers, and thus have a shorter recovery time (Pascoe 1983, Cleary & McNeil 1988, Merkouris et al. 1999).

Background
The health care system in Jordan consists of: (i) public (governmental) hospitals which are mainly funded by the government (Ministry of Health); (ii) private hospitals which are funded by investors; (iii) and semi-private hospitals (teaching) which are funded mainly by universities and partly by the government (Ministry of Health). The public hospitals are nonprot organizations, while private and semi-private hospitals are for-prot organizations. In Jordan, there is no standardized process for granting the licensure exam. Usually, having a degree in nursing is the only requirement to practice nursing in any hospital; however, nursing leaders in Jordan are working on standardizing a licensure exam as a prerequisite for practicing nursing. Few studies in Jordan have focused on the quality of nursing care from the patients perspective. More studies are needed to investigate patient satisfaction with nursing care because such studies present information that is important for nurses to focus on while providing care to their patients. In Jordan, this is only the second study to investigate the level of satisfaction of Jordanian patients and their experiences of nursing care. It also identies satisfying factors that are important for them. While the rst study was conducted in a semi-private hospital, the present study was conducted 2

in both semi-private and public hospitals. It provides information about the difference in the level of patients satisfaction between public and semi-private hospitals. Such information has implications for nurse administrators in regard to the effect of the organizational setting on the level of patients satisfaction. In addition, the semi-private hospital accessed for the present study was not included in the study of Alasad and Ahmad (2003). The purpose of the present study was to: (i) assess the level of patients experiences of nursing care and identify important aspects that enhance such experiences; (ii) assess the level of patients satisfaction with nursing care and identify important aspects that enhance patient satisfaction; and (iii) compare the level of patients satisfaction and their experiences according to demographic variables of patients, hospital wards and hospital settings. The following research questions were investigated: (i) what is the level of patients experiences of various aspects of nursing care? (ii) what is the level of patients satisfaction with various aspects of nursing care? and (iii) is there a difference in the level of patients satisfaction and their experiences in relation to demographic variables of patients, hospital wards and hospital settings?

Literature review
Patients satisfaction and experiences of nursing care Alasad and Ahmad (2003) conducted a survey using a cross-sectional design to investigate patient satisfaction with nursing care among 266 Jordanian patients. The Newcastle Satisfaction with Nursing Scale (NSNS) was used for data collection. The ndings showed that: (i) females were more satised with nursing care than males; (ii) patients with a high level of education were less satised than patients with a lower level of education; (iii) patients in medical or gynaecological wards had higher levels of satisfaction than patients in surgical wards. Moreover, Ahmad and Alasad (2004) reported on the experiences of nursing care among 225 Jordanian patients recruited from medical and surgical wards in a semi-private (teaching) hospital. These results showed that spending adequate time with patients and showing respect to their family members were perceived by participants as positive experiences. On the other hand, the inadequacy of received information was perceived by participants as a negative experience. Vincent et al. (2004) conducted a cross-sectional study to evaluate the association between continuity of care and the level of patients satisfaction. The study

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was carried out in seven Veterans primary care clinics (n = 21 689). The results showed that as self-reported continuity of care increased so did patient satisfaction. In a descriptive cross-sectional study among 510 Jordanian patients, Mrayyan (2006) found that participants were most satised with nurses availability and least satised with continuity of care. On the other hand, a cross-sectional descriptive correlational study was conducted in Finland to examine the relationship between individualized care and the level of satisfaction with nursing care. The total study sample was 279 surgical patients. The results showed that: (i) patients were generally satised with the individualized care they received from nurses; and (ii) patients who perceived receiving higher individuality of care reported experiencing higher levels of satisfaction (Suhonen et al. 2005). Akin and Erdogan (2007) examined the validity and reliability of the Satisfaction with Nursing Care Scale (SNCS) of the NSNS among 200 medical and surgical Turkish patients. They found that the SNCS has content validity and adequate reliability. Cronbachs alpha was 0.96 and alpha coefcients for the items ranged from 0.43 to 0.89. The results also showed that the overall satisfaction level of participants was reported to be good. In a Japanese hospital, a study was conducted by Tokuanaga et al. (2002) to test if the level of satisfaction differed among two groups of patients: those who requested technical elements of hospital care and those who requested interpersonal elements. The total study sample was 10 350 patients. The results showed that patients who requested interpersonal elements considered kindness and warmth of nurses important for their satisfaction. Whereas, patients who requested technical elements considered skills of nurses important for their satisfaction. Furthermore, Hancock et al. (2003) conducted a study to: (i) identify important elements of nursing care from the viewpoint of nurses, older patients and their family members; and (ii) assess the level of satisfaction of nurses, older patients and their family members. The Caregiving Activities Survey was used to collect data from 232 older patients, 99 family members and 90 nurses. In terms of importance, the results indicated that: (i) carrying out doctors orders was rated highest by all groups; and (ii) providing physical aspects of care was rated as the second highest category then psychosocial care and last of all discharge planning. In terms of satisfaction, nurses, patients and their family members were highly satised with the aspect of carrying out doctors orders and moderately satised with the

aspects of physical care, psychosocial care and discharge planning. Demographic variables and patient satisfaction with nursing care The literature revealed that: (i) older patients were more satised than younger patients (Bodil 1999, OConnell et al. 1999, Phi et al. 2002, Tokunaga et al. 2002, Easter et al. 2003, Venn & Fone 2005, Akin & Erdogan 2007); (ii) men tended to be more satised than women (Bodil 1999, Phi et al. 2002); (iii) highly educated patients were less satised than patients with less education (Bodil 1999, Alasad & Ahmad 2003, Stephen et al. 2003), (iv) patients who stayed longer in the hospital tended to be less satised than those who stayed for a short time (Bodil 1999, Phi et al. 2002, Tokunaga et al. 2002); (v) patients who stayed in private rooms were more satised than others (Phi et al. 2002); and (vi) patients who stayed in medical or gynaecological wards were more satised than others (Phi et al. 2002, Alasad & Ahmad 2003, Akin & Erdogan 2007). On the other hand, other studies revealed that: (i) age was not associated with satisfaction (Barbara et al. 1999, Wallin et al. 2000, Alasad & Ahmad 2003); (ii) gender was not associated with satisfaction (Barbara et al. 1999, Wallin et al. 2000, Stephen et al. 2003); and (iii) women tended to be more satised than men (OConnell et al. 1999, Tokunaga et al. 2002, Alasad & Ahmad 2003, Chan & Chau 2005, Venn & Fone 2005, Akin & Erdogan 2007). In summary, the literature revealed that continuity of care and individualized care were associated with higher patient satisfaction. Nurses kindness and warmth, their skills and amount of information they provided to patients, the time they spent with patients as well as the respect they provided to their relatives and friends enhanced the level of patients satisfaction and their experiences of nursing care. Moreover, the literature revealed the consistency for the associations between patients satisfaction and their education level, length of stay, and the stay in medical or gynaecological wards and private rooms. On the other hand, the literature showed inconsistent results in regard to the association between patients satisfaction and their age or gender. Improving the quality of care in health care organizations is a major challenge that faces health care providers in Jordan (World Bank report 1999). This study provides information about the aspects that enhance satisfaction of Jordanian patients; and highlights the differences in the level of patients satisfaction between public and semi-private hospitals. 3

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M. A. Alhusban and R. F. Abualrub

Methods Sample and data collection

The sample was a convenience one that consisted of 300 medical, surgical and gynaecological patients from three different settings. Patients from three hospitals were included in the study: one semi-private hospital (n = 150, medical, surgical and gynaecological wards); one public hospital (n = 100, medical and surgical wards) and a public gynaecological hospital (n = 50). The purpose of using a combination of public and semiprivate hospitals was to facilitate the comparison of data from both types of institutions. The proposal for this study was approved by the Institutional Review Board of Jordan University of Science and Technology and the three cooperating hospitals. The purpose and signicance of the study were explained to eligible patients. Participation was voluntary and patients were informed that refusing to participate in the study would not affect the care they received in the hospital. Anonymity and condentiality were ensured; (i) no patient names or identifying information was recorded, (ii) all ndings are reported in aggregate, and (iii) questionnaires were destroyed after the data were compiled for statistical analysis. Participants were recruited from medical, surgical and gynaecological wards. The inclusion criteria were patients who (i) were 18 years or older; (ii) could read and write Arabic; (iii) were conscious and well oriented; and (iv) had a length of stay more than 48 hours. The average age of the participants was 37.5 years and ranged from 1881 years. The length of stay ranged from 248 days. The majority of participants were females (n = 219; 73%). The educational level of most participants was high school (n = 165; 55%), followed by bachelor degree level (n = 77; 25.7%). Instruments The NSNS was used for data collection. Permission to use the questionnaire was granted by the director of the Newcastle Clinical Trials Unit, Dr Elaine McCeoll. The NSNS was selected for collecting data for the present study because (i) it was found to be valid and reliable in previous studies conducted in western and middle eastern countries (Jordan) (Walsh & Walsh 1999, Alasad & Ahmad 2003, Ahmad & Alasad 2004); (ii) it can detect differences in the level of satisfaction between wards in the same hospital and different hospitals (Thomas et al. 1996); and (iii) it addresses nursing care rather than other dimensions of the hospital experience (Peterson et al. 2005). The questionnaire consists of three components: 4

Experience of nursing care Patients experience of nursing care is dened as the cognitive judgment of several aspects of nursing (Pascoe 1983). Respondents rated their experience of nursing care on 26 items, using a seven-point Likert scale (1 = disagree completely, 7 = agree completely) (see Table 1). They indicated how true each item is of their own experience. Responses for each item were summed and transformed to give an overall experience score, with a potential range of 0100, where 100 represents the best possible experience (Thomas et al. 1996). The alpha coefcient for the experience of nursing care scale was 0.91 (Walsh & Walsh 1999). In the present study, the alpha coefcient for the experience of nursing care scale was 0.84. Opinions of nursing care (satisfaction with nursing care) Patient satisfaction with nursing care is dened as the emotional reaction of the patient to several aspects of nursing care (Pascoe 1983).. Respondents rated their satisfaction with various aspects of nursing care, using a ve-point Likert scale (1 = not at all satised, 5 = completely satised). This section consisted of 19 items (see Table 2). Responses for each item were summed and transformed to give an overall satisfaction score of 0100, where 100 denotes complete satisfaction (Thomas et al. 1996). The alpha coefcient for the satisfaction with nursing care scale was 0.96 (Walsh & Walsh 1999). In the present study, the alpha coefcient for the satisfaction with nursing care scale was 0.95. The NSNS indicates a good conceptual match for the denition of patient satisfaction by Pascoes (1983): that is, patients evaluation of health care services is based on both a cognitive judgment of the experience (Experiences of Nursing Care Scale) and an emotional reaction to that experience (Satisfaction with Nursing Care Scale) (Peterson et al. 2005, p. 674). Demographic information This section includes gender, age, level of education and length of stay in the hospital (Thomas et al. 1996). The instrument was translated from English to Arabic by an individual who is procient in both languages, and then back translated from Arabic to English by another individual who is also procient in both languages. The translated versions were reviewed and examined by a committee comprised of four experts, who are interested in the research topic and competent in both Arabic and English. The committee considered the equivalence of terms, clarity and cultural adaptation.

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Table 1 Means () and standard deviations (SD) for Patients Experience of Nursing Care (Total Study Sample n = 300; Mean out of 7) x Gynecological (n = 100) Item 1. It was easy to have a laugh with the nurses *2. Nurses favoured some patients over others *3. Nurses did not tell me enough about my treatment *4. Nurses were too easy going and laid back *5. Nurses took a long time when the they were called 6. Nurses gave me information just when I needed it *7. Nurses did not seem to know what I was going through *8. Nurses turned the lights off too late at night *9. Nurses made me do things before I was ready 10. No matter how busy nurses were, they made time for me 11. I saw the nurses as friends 12. Nurses spent time comforting patients who were upset 13. Nurses checked regularly to make sure I was okay *14. Nurses let things get on top of them *15. Nurses took no interest in me as a person 16. Nurses explained what was wrong with me 17. Nurses explained what they were going to do to me before they did it 18. Nurses told the next shift what was happening with my care 19. Nurses knew what to do without relying on doctors *20. Nurses used to go away and forget what patients had asked for 21. Nurses made sure that patients had privacy when they needed it 22. Nurses had time to sit and talk to me 23. Doctors and nurses worked well together as a team *24. Nurses did not seem to know what each other was doing 25. Nurses knew what to do for the best 26. There was a happy atmosphere in the ward, thanks to the nurses Average 5 5.42 5.07 5.72 4.85 5.42 4.69 5.2 5.67 4.72 5.31 5.24 5.67 4.91 5.41 4.64 4.78 6.03 4.58 5.66 5.52 4 5.86 5.33 5.55 5.43 5.22  x % 71.4 77.4 72.4 81.7 69.3 77.4 67.0 74.3 81.0 67.4 75.9 74.9 81.0 70.1 77.3 66.3 68.3 86.1 65.4 80.9 78.9 57.1 83.7 76.1 79.3 77.6 74.6 SD 1.66 1.88 1.9 1.54 2.1 1.47 1.95 2.05 1.9 1.94 1.66 1.7 1.6 1.94 1.84 2.13 2.04 1.2 1.75 1.51 1.63 2 1.45 1.89 1.37 1.72 0.95 Medical (n = 100)  x 5.16 5.54 4.94 5.1 4.16 5 5.11 5.42 5.79 4.75 5.07 5.25 5.3 4.96 5.33 4.86 2.89 5.6 4.55 5.23 5.51 4.23 5.74 5.74 5.49 5.34 5.16 % 73.7 79.1 70.6 72.9 59.4 71.4 73.0 77.4 82.7 67.9 72.4 75.0 75.7 70.9 76.1 69.4 41.3 80.0 65.0 74.7 78.7 60.4 82.0 82.0 78.4 76.3 73.7 SD 1.5 1.36 1.8 1.69 1.88 1.73 1.72 1.8 1.65 1.61 1.46 1.42 1.4 1.49 1.53 1.66 1.64 1.41 1.89 1.61 1.3 1.88 1.41 1.19 1.37 1.55 0.86  x 4.77 5.18 5.07 5.21 5.05 5.09 4.89 5.03 5.1 4.5 4.86 5.25 5.14 4.7 5.35 4.63 4.42 5.53 4.44 5.2 5.12 3.3 5.51 5.29 5.43 4.97 4.96 Surgical (n = 100) % 68.1 74.0 72.4 74.4 72.1 72.7 69.9 71.9 72.9 64.3 69.4 75.0 73.4 67.1 76.4 66.1 63.1 79.0 63.4 74.3 73.1 47.1 78.7 75.6 77.6 71.0 70.9 SD 1.74 1.82 1.69 1.66 1.7 1.71 1.68 1.72 1.83 1.9 1.69 1.59 1.54 1.73 1.55 1.86 2 1.44 1.78 173 1.6 1.89 1.45 1.7 1.46 1.7 0.92  x 4.97 5.38 5.03 5.34 4.69 5.17 4.9 5.22 5.52 4.66 5.08 5.25 5.37 4.86 5.36 4.71 4.7 5.72 4.52 5.36 5.38 3.84 5.7 5.45 5.49 5.25 5.1 Total (n = 300) % 71.0 76.9 71.9 76.3 67.0 73.9 70.0 74.6 78.9 66.6 72.6 75.0 76.7 69.4 76.6 67.3 67.1 81.7 64.6 76.6 76.9 54.9 81.4 77.9 78.4 75.0 73 SD 1.64 1.7 1.8 1.65 1.93 1.64 1.79 1.86 1.81 1.82 1.61 1.57 1.53 1.73 1.64 1.89 1.91 1.37 1.8 1.63 1.52 1.96 1.44 1.62 1.39 1.67 0.91

*All these negative items were reversed during analysis to be positive items.

A modication was made according to the committee recommendations. Moreover, the instrument was pilot tested with 30 patients from medical, surgical and

gynaecological wards before the study was conducted. The ndings of the pilot test indicated that the instrument was clear, understandable and reliable. 5

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Table 2 Means () and standard deviations (SD) for patient satisfaction with nursing care (total study sample (n = 300); mean out of 5) x Gynecological (n = 100) Item 1. The amount of time nurses spent with you 2. How capable nurses were at their job 3. There always being a nurse around if you needed one 4. The amount nurses knew about your care 5. How quickly nurses came when you called for them 6. The way the nurses made you feel at home 7. The amount of information nurses gave to you about your condition and treatment 8. How often nurses checked to see if you were okay 9. Nurses helpfulness 10. The way nurses explained things to you 11. How nurses helped put your relatives or friends minds at rest 12. Nurses manner in going about their work 13. The type of information nurses gave to you about your condition and treatment 14. Nurses treatment of you as an individual 15. How nurses listened to your worries and concerns 16. The amount of freedom you were given on the ward 17. How willing nurses were to respond to your request 18. The amount of privacy nurses gave you 19. Nurses awareness of your needs Average  x 3.25 3.96 3.65 3.87 3.44 3.39 3.47 % 65 79.2 73 77.4 68.8 67.8 69.4 SD 1.2 0.9 1.2 0.9 1.2 1.3 1.2 Medical (n = 100)  x 3.15 3.68 3.5 3.71 3.38 3.27 3.3 % 63 73.6 70 74.2 67.6 65.4 66 SD 1.06 0.97 1.03 1 1.05 1.14 0.96 Surgical (n = 100)  x 3.2 3.7 3.5 3.6 3.4 3.1 3.2 % 64 74 70 72 68 62 64 SD 1.08 0.96 1.02 0.93 1.15 1.26 1.16  x 3.2 3.79 3.54 3.72 3.39 3.24 3.31 Total (n = 300) % 64 75.8 70.8 74.4 67.8 64.8 66.2 SD 1.1 1.0 1.1 1.0 1.1 1.2 1.1

3.7 3.92 3.73 3.51 3.9 3.34

74 78.4 74.6 70.2 78 66.8

1.1 1.0 0.9 1.2 0.9 1.2

3.46 3.8 3.44 3.27 3.74 3.35

69.2 76 68.8 65.4 74.8 67

1.15 1.02 0.99 1.13 0.85 0.96

3.3 3.6 3.3 2.9 3.7 3.3

66 72 66 58 74 66

1.11 1.07 1.17 1.17 1.01 1.15

3.49 3.78 3.5 3.24 3.77 3.33

69.8 75.6 70 64.8 75.4 66.6

1.1 1.0 1.0 1.2 0.9 1.1

3.43 4.43 3.99 3.71 3.69 3.9 3.65

68.6 88.6 79.8 74.2 73.8 78 73

1.1 1.3 1.0 1.1 1.0 1.0 0.8

3.23 3.24 3.87 3.43 3.44 3.61 3.47

64.6 64.8 77.4 68.6 68.8 72.2 69.4

0.98 1.16 0.79 1.06 0.94 0.91 0.78

3.0 2.9 3.3 3.4 3.2 3.4 3.3

60 58 66 68 64 68.4 66

1.18 1.3 1.09 1.15 1.05 1.12 0.84

3.2 3.18 3.72 3.51 3.44 3.64 3.47

64 63.6 74.4 70.2 68.8 72.8 69.4

1.1 1.3 1.0 1.1 1.0 1.0 0.8

Results
Research Question 1, what is the level of patients experiences of various aspects of nursing care? was addressed by the use of descriptive statistics. The maximum scores for patients experiences and satisfaction were calculated out of 100. The scores were categorized into three levels: (i) a score less than 60% indicated below good level of experience or low level of satisfaction with nursing care; (ii) a score between 6080% indicated good level of experience or moderate level of satisfaction with nursing care; and (iii) a score of more than 80% indicated a above good level of experience or high level of satisfaction. The means 6

and standard deviations for the items of patients experiences with nursing care as well as item scores out of 100 for the total sample across wards are presented in Table 1. The average mean of experience with nursing care for the total sample was good ( = 5.1; SD = 0.91; x score = 72.9%). Participants in gynaecological wards had a better experience with nursing care when compared with participants in medical and surgical wards. In gynaecological wards, participants indicated that they had a above good level of experience with aspects such as nurses told the next shift what was happening with my care. On the other hand, participants indicated that they had a below good level of

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experience with aspects such as nurses had time to sit and talk to me. The average mean of experience with nursing care in medical wards was also good ( = 5.16; SD = 0.86; x score = 73.7%). In medical wards, participants indicated that they had a above good level of experience with factors such as nurses made me do things when I was ready, and doctors and nurses worked well together as a team. Conversely, participants indicated that they had a below good level of experience with aspects such as nurses explained what they were going to do for me before they did it, and nurses took a long time to respond when they were called. The average mean of experience with nursing care in surgical wards was good ( = 4.96; SD = 0.92; score x 70.9%). In surgical wards, participants indicated that they had a good level of experience with aspects such as nurses told the next shift what was happening with my care and doctors and nurses worked well together as a team. On the other hand, participants indicated that they had a below good level of experience with aspects such as nurses had time to sit and talk to me. Research Question 2, what is the level of patients satisfaction with various aspects of nursing care? was also addressed by the use of descriptive statistics. The average mean of satisfaction with nursing care for the total sample was moderate ( = 3.47; SD = 0.8; x score = 69.4%). Participants in gynaecological wards were more satised than participants in medical and surgical wards ( = 3.65; SD = 0.8; score = 73%). In x the gynaecological ward, participants indicated that they had high levels of satisfaction with aspects such as how nurses listened to your worries and concerns. On the other hand, participants had a moderate level of satisfaction with aspects such as the amount of time nurses spent with you and the type of information nurses gave to you about your condition and treatment. The means and standard deviations for the items of patient satisfaction as well as item scores out of 100 for the total sample are presented in Table 2. The average mean of satisfaction with nursing care in medical wards was moderate ( = 3.47; SD = 0.78; x score = 69.4%). Participants indicated that they had a moderate level of satisfaction with all items of the scale such as the amount of freedom you are given on the ward and nurses helpfulness. The average mean of satisfaction with nursing care in surgical wards was also moderate ( = 3.3; SD = 0.84; x score = 66.2%). Participants indicated that they had a moderate level of satisfaction with aspects such as how capable nurses were at their jobs. Conversely, participants indicated that they had low levels of

satisfaction with aspects such as how nurses helped put your relatives or friends minds at rest. Research Question 3, is there a difference in the level of patients experiences of nursing care or their satisfaction in relation to demographic factors of patients, hospital wards, and hospital settings? was addressed by the use of t-test, analysis of variance (A N O V A ) and Pearsons correlations. A N O V A and t-tests were used for the categorical variables. Pearson correlation was used for the continuous variables (age and length of stay). Female patients ( = 3.53) were more satised with nursing care x than male patients ( = 3.32) (t = )2.0, P = 0.04). They x also had better ( = 5.14) experience of nursing care x than male patients ( = 5.04), but the increase in the x mean score was insignicant (t = )0.86, P = 0.39). Analysis of variance was performed to investigate if there was a difference in the level of patients experiences and satisfaction with the nursing care in regard to education level, hospital wards and hospital settings. There was no statistical difference between patients education level and reported means of experience and satisfaction. Participants in the gynaecological ward had higher levels of satisfaction than participants in medical and surgical wards (F = 4.39, P = 0.01). The post Hoc Test (Tukey) showed that the signicant difference was between the gynaecological ward and the surgical ward at P = 0.009. There was no statistical difference between selected wards and the reported mean of patients experiences. The results of A N O V A also showed that participants in the semi-private hospital had higher levels of both experience and satisfaction with nursing care than participants in public hospitals. There were no signicant correlations between patients age or their length of stay and levels of experiences and satisfaction. The results of A N O V A showing the relationships between selected wards and hospitals and the reported means of patients experiences and satisfaction are presented in Table 3.

Discussion and implications Experiences and satisfaction with nursing care

Patients experiences of nursing care in the current study were generally positive. Participants had the most positive experiences in regard to aspects such as nurses told the next shift what was happening with my care and doctors and nurses worked together as a team. These ndings are consistent with the ndings of Ahmad and Alasad (2004) and McColl et al. (1996). Such results indicate the importance of collaboration and continuity of nursing care. 7

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Table 3 Analysis of variance showing the relationships between selected wards and hospitals and the reported means of patients experiences and satisfaction with nursing care Gynecological (n = 100) Experiences of nursing care Satisfaction with nursing care 5.22 3.65* Semi-private hospital (n = 150) Experiences of nursing care Satisfaction with nursing care 5.31 3.64 Medical (n = 100) 5.16 3.47 Public hospital (1) (n = 50) 5.00 3.43 Surgical (n = 100) 4.96 3.31* Public hospital (2) (n = 100) 4.87 3.24 7.517 7.707 0.001 0.001 F 2.144 4.395 P 0.119 0.013

*Post hoc test (Tukey) showed the difference between gynecological and surgical ward at P = 0.009. Post hoc test (Tukey) showed a significant difference between semi-private hospital and public hospital (2) regarding experience of nursing care at P = 0.000, and between semi-private hospital and public hospital (1) at P = 0.049*. Post hoc test (Tukey) showed the difference between the semi-private hospital and public hospital (2) regarding satisfaction with nursing care at P = 0.000.

Participants satisfaction with nursing care was moderate. The participants were mostly satised with aspects such as the nurses capability of their job, nurses helpfulness, nurses manner in going about their work and the amount nurses knew about patient care. These factors reect the nurses competences and skills, which mean that satisfaction of patients is mostly affected by the skills and competences of nurses in performing their work. Such results are congruent with the ndings of Alasad and Ahmad (2003). Participants of the present study had the most negative experiences with aspects such as nurses had time to sit and talk to me, nurses knew what to do without relying on doctors. Such ndings are also consistent with the ndings of Ahmad and Alasad (2004), McColl et al. (1996) and Walsh and Walsh (1999). The participants were also least satised with aspects such as how nurses listened to your worries and concerns and the amount of time nurses spent with you. These aspects indicate that the time that nurses spend with patients is not adequate, which might be attributed to heavy workload, inadequate stafng, performing nonnursing activities and nursing shortage. Such results inform nurses, nurse administrators and managers that despite cultural differences, the issues of spending inadequate time with patients and poor nursing autonomy seem to be common dissatisers among patients with different cultures.

Demographic variables and patients experiences and satisfaction with nursing care
Female patients were more satised with nursing care than male patients. Such a result is consistent with the ndings of Alasad and Ahmad (2003), Easter et al. (2003) and Venn and Fone (2005). On the other hand, 8

the results showed that female patients had better experiences than male patients; but the difference was insignicant. Such a result is inconsistent with the ndings of Ahmad and Alasad (2004) who found that male patients had better experiences of nursing care than female patients. It is worth mentioning here that experience of nursing care and satisfaction with nursing care have different operational denitions in the present study. Experience of nursing care was measured by 26 items (cognitive judgment); whereas, satisfaction with nursing care was measured by 19 different items (emotional judgment). The ndings of the study also indicated that patients education level had no effect on their experiences or satisfaction with nursing care; such ndings were consistent with the results of Akin and Erdogan (2007) and Chan and Chau (2005). On the other hand, such ndings were inconsistent with the ndings of Alasad and Ahmad (2003), Barbara et al. (1999) and Bodil (1999). These studies found that patients with higher levels of education had lower levels of satisfaction. The results also showed that there were no signicant relationships between the patients age or length of stay and his level of experience or satisfaction, which is inconsistent with the ndings of Bodil (1999), Stephen et al. (2003), Tokunaga et al. (2002) and Vincent et al. (2004). However, no association between age and the level of patients satisfaction was found by Alasad and Ahmad (2003), Barbara et al. (1999) and Wallin et al. (2000). Such inconsistent results in regard to the associations between the demographic variables of patients and the level of satisfaction call for further research that control for other variables such as the demographic variables of nurses who provide care for those patients and other organizational variables such as nurses satisfaction.

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Patient satisfaction

Discussion
When comparing wards, the results showed that participants in gynaecological wards had higher level of satisfaction with nursing care than participants in surgical wards; such a result is consistent with the ndings of Akin and Erdogan (2007), Alasad and Ahmad (2003) and Phi et al. (2002). A possible explanation for this result might be because of the fact that the health status of gynaecological patients is better than those in surgical wards. Usually, patients who are admitted to surgical wards are more sensitive to the quality of care they receive because of their reduced health status. Vera (1999) indicated that variation in patients satisfaction and their feelings of vulnerability were related to the levels of care they received. Another explanation might be the gender of patients; all gynaecological patients are females who have higher levels of satisfaction than males as the ndings of this study and other studies have shown. Females were more satised than males because they felt more comfortable discussing health issues with their health care providers and thus received more emotional support which may affect their level of satisfaction positively. When comparing between the hospitals, the results showed that patients of the semi-private hospital had better experiences of nursing care and higher levels of satisfaction than patients in public hospitals. Vera (1999) found that the level of quality of care relied on several factors which were (i) environmental factors such as stafng level and early discharge; (ii) organizational factors such as the type of the hospital; (iii) and demographic factors of nurses and patients. Therefore, a possible explanation for such results might be the fact that the semi-private hospital is a teaching hospital. The semi-private hospital included in this study is accredited by local and national agencies; whereas the public hospitals included in this study are not accredited. Hospitals which seek accreditation are striving to enhance their quality of care as well as patient outcomes. Patient satisfaction data as a measure of care quality are routinely collected and used for accreditation purposes (JCAHO 1991). Moreover, the workplace setting of semi-private hospitals is different from that of public hospitals; for example, there is more emphasis on training and continuing education programmes in semi-private hospitals. Nurses salaries in semi-private hospitals are higher than those in public hospitals which might motivate nurses to work in such hospitals. Furthermore, nurses in semi-private hospitals might have more opportunities to advance their careers

through continuing their graduate education as the semi-private hospital is a university (campus) hospital. The factors that enhance the level of patients satisfaction as indicated by the current study are continuity of nursing care, nurses competences and skills, nurses decision making skills and the adequacy of time provided for direct nursing care. Such results provide signicant implications for nurse administrators. For example, they should (i) develop a system for assessing patient satisfaction regularly to identify weaknesses and areas for improvement; (ii) implement standards for enhancing nursing competencies and skills through continuing education and training programmes; (iii) provide workshops for nurses in the eld of communication and decision making skills to enhance their capabilities to effectively interact with patients and their families; and (iv) provide support systems to minimize the non-nursing activities and enhance the direct patients care. Some of the limitations of the study were (i) the generalizability of ndings is potentially limited as the sample was a convenience one that was only derived from three hospitals located in north of Jordan; (ii) the majority of participants were females; and (iii) the level of patients satisfaction was only measured subjectively which might create a reporting bias. Despite these limitations, the ndings of the study provide the basis for several recommendations to enhance patients experiences and satisfaction with nursing care. Nurses need to (i) increase the time they spend with patients; (ii) provide more information to patients in regard to their treatment and health status; and (iii) enhance continuity of care and maintain patients individuality. Moreover, nurse administrators and managers should (i) capitalize on the importance of continuity of nursing care, and nurses competences and skills by providing regular workshops and continuing education and training classes; (ii) hold workshops to foster and enhance the skills of decision making and effective time management among nurses; (iii) benchmark practice against hospitals where the level of patients satisfaction is high; and (iv) strive to change the organizational structure of public hospitals to be similar to those of semi-private hospitals.

Conclusion
Identifying the level of patients satisfaction with nursing care is a good indicator for the quality of nursing care services. The ndings of the study provide nurses with information about aspects that enhance or hinder patient satisfaction. Nurses can enhance patients experiences and satisfaction by spending more time 9

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M. A. Alhusban and R. F. Abualrub

talking to them, explaining what they are going to do for them, responding to their needs in a reasonable time, supporting their relatives and friends, being more helpful, and being more capable and competent at their jobs.

Acknowledgements
The authors would like to thank the patients who provided information necessary for the completion of the study, and the NSNS team at the University of Newcastle for their permission to use the NSNS questionnaire in this study.

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