CHAPTER 2

LITERATURE REVIEWS

In this chapter, the researcher reviews existing literature and research on patient

satisfaction, and factors related to patient satisfaction including patient characteristics, nurse

communication and waiting time. The relationship between these factors and patient

satisfaction are described with results of previous researches. Furthermore, the health

service in Bangladesh is described. The content are as following:

1. Patient satisfaction

1.1 Definition of patient satisfaction

1.2 Theoretical perspective of patient satisfaction

1.3 Measurement of patient satisfaction

1.4 Patient satisfaction with health care service

1.5 Factors related to patient satisfaction

2. Nurse communication

2.1 Definition of nurse communication

2.2 The concept of nurse communication

3. Relationship between patient characteristics, nurse communication, waiting

time, and patient satisfaction

4. Health services in Bangladesh

Patient satisfaction

Definition of patient satisfaction

Patient satisfaction is a person’s positive feeling of pleasure or disappointment

resulting for comparing a product or services perceived performance or outcome in relation

to his or her expectations (Anand, Kaushal, & Gupta, 2012; Rashmi & Vijakumar, 2010).

Sodani and Sharma (2011) stated that satisfaction is defined as a consumer’s

emotional feelings about a specific consumption experience. It is judgment that a product or

a services feature, the product or service itself, provide a pleasurable level of consumption

related fulfillment.

Consumer satisfaction is the consumer’s view of services received and the results

of the treatment. It has been used by program evaluators to enhance health care providers’

ability to render services that meet consumer’s need (Ibrahim, Chompikul, & Isaranurug,

2008; Campbell, 1999).

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According to the Fitzpatrick, (1991) satisfied patients are more likely to follow

planned care and make better use of health services. Therefore, patient satisfaction was seen

as a substitute indicator justifying and validating health care initiatives. Moreover, several

researches had shown that patients’ satisfaction with nursing care to reflect the increasing

hospital accountability to the public and outcome of their health care experience (Kumari et

al., 2009).

Ware, Snyder, Wright, and Davis, (1983) stated that patient satisfaction in health

care evolving from the concept of consumer satisfaction, but different in many respects, is

considered as a process of interaction between patient expectations and patient perceptions

or actual experiences with health care. Patients can have expectations on many different

aspects of care, and satisfaction with specific aspects of care has independent effects on

patients’ satisfaction (Sohail, 2005; Abramowtitz, Cote, & Berry, 1987).

The concept of patient satisfaction is important to understand and it is well

recognized that patients attending each hospital. It is responsible to spreading the good

image of the hospital and patients satisfaction to attending the hospital that equally

important for hospital management (Prasad, Kumar, Agrawal, & Mohan, 2012; Jawahar,

2007).

In addition, patient’s satisfaction is fundamental importance as a measure of the

quality of care because it gives information on the provider’s success at meeting those client

values and expectations which are matters on which the client is the ultimate authority

(Donabedian, 1988). Therefore, the measurement of satisfaction is an important tool for

research, administration, and planning (Assefa et al., 2011).

Patient satisfaction is related to the extent to which general healthcare and

condition-specific needs are meet. Patient satisfaction is a multidimensional constructs that

includes the degree of patient’s positive feeling on general satisfaction, technical quality,

interpersonal manner, communication, financial aspects, time spend with doctors, nurses,

registration, pharmacist service, accessibility to health care service, convenience,

availability of care and condition of facilities during their health care services (Kumari et

al., 2009; Abramowtitz et al., 1987). Patient satisfaction is an instrument to monitoring

hospital’s quality of care and reducing administrative complexity.

Theoretical perspective of patient satisfaction

Parasuraman et al. (1985, 1988) undertook a series of research projects which gave

birth to the service quality model "SERVQUAL". The SERVQUAL approach begins with

the assumption that service quality (Parasuraman et al. 1985).

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The SERVQUAL model expectations statement related to the service level and patients

believe that they should get the service from health care providers (Parasuraman et al.

1994).The most popular conceptualization of service quality SERVQUAL features of five

dimensions: tangibles, reliability, responsiveness, empathy and assurance (Parasuraman et

al., 1988). According to the model, service quality can be considered by comparing the

service expectations of patients with their perceptions of actual performance by health care

providers. The physical service aspects such as appearance of employees, equipment and

facilities are classified as tangibles. Reliability refers to accurate, dependable and consistent

performance of the service (Service outcome). The remaining three represent aspects of

interaction quality: responsiveness means being prompt and willing to serve the customer,

empathy involves caring and personalized attention as well as understanding customer

needs and convenient access to the service. Lastly the dimension of assurance comprises the

competence, courtesy and credibility of staff which generate customer trust and confidence

(Pollack, 2008).

The SERVQUAL has been used by many researchers to measure quality of health

care service. Research has shown that good service quality leads to the retention of existing

patients and the attraction of new services, reduced costs, an enhanced corporate image,

positive word-of-mouth and, ultimately enhanced satisfaction (Kang & James, 2004). The

study of service quality would enable management to better direct financial resources to

improve hospital operations in those areas that have the most impact on patient perceptions

of health care service quality in healthcare organization (Pakdil & Harwood, 2005). The

concept of service quality patient satisfaction studies of quality improvement has become

more important year by year in the health care industry and the importance of patients’

views as an essential tool in the processes of monitoring and improving quality of health

care services (Thi, Briancon, Empereur, & Guillemin, 2002; Hiidenhovi, Nojonen, &

Laippala, 2002; Lim & Tang, 2000; Pakdil & Harwood, 2005). Patients’ health care service

quality perceptions are believed to influence patient satisfaction positively, which in turn

positively influences the patient’s decision to choose a specific healthcare provider

(Andaleeb, 2001).

Studies in the developing world have shown a clear link between patient

satisfaction and a variety of explanatory factors among service quality has been prominent

(Rao, Peters & Bandeen-Roche, 2006). Moreover, the researcher also believes the links are

important to health care service in Bangladesh. Several studies suggest that outpatient

service quality can be measured using the SERVQUAL framework (Parasuraman, Berry, &

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Zeithaml, 1991), and its refined version in the context of Bangladesh to help for explain and

assess the perception of patient satisfaction with health services (Andaleeb, 2001). Physical

evidence that the hospital will provide satisfactory services can also be important to patient

satisfaction judgments (Devija, Bhandari, & Agal, 2012).

Therefore, the SERVQUAL concept could help hospitals identify the healthcare

service characteristics that are considered important by patients. The measures of

satisfaction are important tools for research, administration and planning. Patient

satisfaction can also be used to evaluate the process of health care. In this way, hospitals can

improve their level of quality and the effectiveness of the model can be monitored with

resources which most heavily influence of patient satisfaction.

Measurement of patient satisfaction

Measurement of patient satisfaction is expected to play an increasingly important

role in the growing push toward accountability among health care providers overshadow by

measures of clinical processes and outcomes in the quality of care equation. Patient

satisfaction regarding outpatient and ambulatory care play a significant role in hospitals’

strategies and tactics in delivering patient services (Afzal, Khan, Rizvi, & Umer, 2012).

Patient satisfaction is measured over a wide range of health service dimensions including

availability, accessibility and convenience of services, technical competence of the

providers, interpersonal skills, and the physical environment where services are delivered

(Nabbuye-Sekandi et al., 2011; Grogan, Conner, Norman, Willits, & Porter, 2000).

In the related to present study, the measurement of outpatient satisfaction is using

service quality (SERVQUAL) as the research instrument, the instrument being validated for

use in the hospital environment. The SERVQUAL is a simple, but a very powerful

measuring tool (Andaleeb, 2000). Service quality instrument developed in a multi-

dimensional measurement scale called SERVQUAL. The SERVQUAL first developed by

Parasuraman et al., (1985, 1991) which has played an important role in the service

environment and also found applications in research on satisfaction with hospital services

(Cronin & Taylor, 1994). Consequently, this study modifies the SERVQUAL to examine

the factors deemed important by patients that influence their satisfaction with health care

services in a hospital (Devija et al., 2012).

The ten dimensional developments were simplified into five dimensions of service

quality by Parasuraman et al., (1994). The SERVQUAL was designed to measure quality

expectations and perceptions about quality of services using 22 items and using Likert type

of scale in representing five dimensions, namely: 1) Tangibles-physical facilities, equipment

15

and appearance of personnel, 2) Reliability-ability to perform the promised service

dependably and accurately, 3) Responsiveness-willingness to help consumers and provide

prompt service, 4) Assurance-competence, courtesy and security, and 5) Empathy-caring

and individualized attention that used reorganized version by the study of (Chakravarty,

2011).

The SERVQUAL is an instrument to measure the difference between the

expectations and perception of the patients about the services and their experience. There

are discrepancies or gaps regarding the executive perception of service quality and the tasks

associated with health care service delivery to patients (Parasuraman et al., 1994). The

SERVQUAL has been used by many researchers to measure quality of service in the service

industries like aviation, banks, hotels, hospitals, fast foods, retail stores etc. The potential

application of the SERVQUAL scale can help other organizations in assessing the

perceptions of service quality (Buttle, 1996). It will also help the managers to identify the

areas of service delivery that need special attention and decide action to be taken to tackle

these issues (Hirmukhe, 2012). Many researchers have researched service quality and

considerable findings and progress has been achieved in the measurement of service quality

(Zeithaml, Berry, & Parasuraman, 1988). Professional services, which those are provided by

professional such as doctors and nurses in healthcare services (Farid, 2008). The service

providers have a need to know and distinct between having clients who are satisfied with

their performance or to deliver the maximum level of perceived service quality and several

researchers have tried to clarify this relationship. Parasuraman et al., (1988) proposed that

higher levels of perceived service quality resulted in increased patient’s satisfaction which

was strong support for SERVQUAL validity.

Alasad and Ahmed (2003) examined satisfaction of patients with nursing care at a

major teaching hospital in Jordan. Data obtained from 266 in-patients of three wards

showed that patients in the surgical ward had a lower level of satisfaction than patients in

the medical or gynecological wards. With respect to the conditions of developing countries,

Andaleeb (2001) proposed and tested a five dimensional instrument for assessing perception

of patients availing of hospital services in Bangladesh. The results indicated that a

significant relationship is found between the five factors and patients’ satisfaction. Based on

the application of a modified SERVQUAL instrument, a study found that a significant

relationship between service quality dimensions and patient satisfaction in the South Korea

health care system (Choi et al., 2005 cited in Ramez, 2012).

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The issue of patient satisfaction has gained increasing attention from the

executives across the healthcare industry. The measurement of patient satisfaction through

patient satisfaction surveys has helped organizational leaders incorporate patient

perspectives as a way to create a culture where service is deemed an important strategic goal

for healthcare facilities. However, despite their many efforts and successes with satisfaction

measurement, evidence shows that more work in this area is still needed (Yeddula, 2012).

Patient satisfaction with health care service

Patient satisfaction is an important component of the health care industry in this

competitive modern era. It is used as an important indicator of quality care and is frequently

included in healthcare planning and evaluation (Akhtari-Zavare, Abdullah, Hassan, Said, &

Kamali, 2010).

Access means that the health care services are unrestricted by geographic,

economic, social, culture, organizational or linguistic barriers. According to Newbrader and

Rosenthal (1997), access as the ability of people to use health services unimpeded by

financial or social constraints or by lack of facilities or providers.

Accessibility has a number of key dimensions, including physical, information and

economic accessibility (Osmani, 2003). Physical accessibility pertains to distance to health

providers including travel time and travel cost and waiting time at health centers.

Information accessibility implies that people should have informed choice regarding the

sources, types and quality of services. It to be economically accessible, services must be

affordable on the basis of equity in financial contribution. For increase access to government

health services, they should also be of good quality because of increasing competition from

private and NGO sources (Sohail, 2005).

Ross, Steward, and Sinacore (1993) measured patients satisfaction with access to

care includes availability of service, technical quality of care, interpersonal care,

communication and financing of care. Several studies confirmed the association between

accessibility level and the satisfaction level.

According to Bangladesh Bureau of Statistics [BBS] (2007), only 49% of the

clients have access to qualified care, a small proportion of around 9% seek health care from

public health services. In the public sector, performance evaluation is the primary tool for

assessing the quality and accessibility of health care delivery system. In this respect, clients’

opinions on aspects of care have gained prominence over the past few decades in the West,

and only recently in the context of developing countries (Sohail, 2005). Several studies

confirmed the association between accessibility level and the satisfaction level. One of the

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studies towards MCH services satisfaction among mothers attending the Maternal and Child

Health Training Institute in Dhaka, Bangladesh revealed that good accessibility was related

to high satisfaction while poor accessibility was related to low satisfaction (Win & Panza,

2010).

A recent study from Bangladesh, reported that the most powerful relationship for

client satisfaction with health services was provider behavior, especially respect and

politeness (Assefa et al., 2011; Jorge, Herga & Ahmed, 2001). It also indicated that health

care systems in most developing countries suffer from serious deficiencies in financing,

efficiency, equity, quality and poorly prepared to meet these challenges (Peter & Berman,

2000).

A recent study in India on patient satisfaction about health care services stated that

the overall satisfaction level of patients for availability of services was 97% for seating

arrangements, 95% about cleanliness, 93% for timing, 83% regarding services provided by

the others staff and 85% for availability of sufficient doctors hospital in the department in

OPD (Joshi, Sochaliya, Purani, & Kartha, 2013).

In addition, a study in Maldives revealed that patients were highly satisfied with

component of patient satisfaction such as courtesy 45.8%, quality of care 44.2%, physical

environment 41.8%, and convenience 24.7% and out of pocket cost 23.5%. Even though the

overall satisfaction shows low but in all components patients were satisfied with services

except convenience and out of pocket cost (Ibrahim et al., 2008).

It increasing concentration has been given to the evaluation of patient satisfaction

with care. Furthermore, patient satisfaction is identified as an important dimension for

assessing the quality of health care services. Indeed, quality assurance has evolved as an

internationally important aspect in the provision of health care services (Ashrafun & Uddin,

2011).

Nowadays, important nursing trends and issues like qualified health care service

and patients’ satisfaction are being crucially discussed throughout the world. Many different

institutions have adopted a means to reflect on their service providing. High technology,

humanistic approach, educational backgrounds, communication, and means of transferring

qualified service quality to the patients constitute the vitality of patients’ satisfaction. The

quality of service in health means an inexpensive type of service with minimum side effects

that can cure or relieve the health problems of the patients (Kumari et al., 2009).

The quality of medical services that probe into patient satisfaction can be an

important tool to improve the quality of services. Patient satisfaction is a multi-dimensional

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healthcare issue affected by many factors. Healthcare quality affects patient satisfaction, and

it influences on positive patient behavior such as confidence in hospital care (Afzal et al.,

2012).

Patient satisfaction, as one of the ultimate validates of effectiveness and quality of

care as the patient’s opinion of the care received from nursing staff who working in

hospitals with care services (Fafii, Hajinezhad, & Haghani, 2007). Patient satisfaction is the

most important indicator of high-quality health care and is used for the assessment and

planning of health care (Schmidt, 2003). There is a positive correlation between patient

satisfaction and health care service. Patient satisfaction increases in an organization where

more personalized nursing care is given (Johansson, Oleni, & Fridlund, 2002). In addition,

the study of outpatient department services in Banphaco Community Hospital Samut

Sakhon province, Thailand, revealed that the respondents of 84% had high satisfaction from

convenience during their services (Mandokhail et al., 2007).

Another study of patients’ satisfaction in the Outpatient Department of

Chulalongkorn Hospital by Sriratanabul and Pimpakovit, a significant factor led the

majority of the respondents to feel uncomfortable with the services provided was long

waiting time. There are 83% of the respondents showed positive feelings towards services

provided in the department while disappointed with very long waiting time to receiving

services (Vadhana, 2012).

A study in Nigerian on patient satisfaction with the services provided at a general

outpatients' clinic revealed that high level of satisfaction with the different aspects of care

assessed. On the other hand, bad experiences were reported with the organization of health

center, attitude of record clerks' and consultation process (Kumari et al., 2009).

There is an increasing interest in assessing patients’ satisfaction with medical care

in the United States and other countries. Patient satisfaction studies have, however, received

comparatively little attention in public or government-sponsored settings and in developing

countries in particular. In a study done in Qatar, it pointed to a number of deficiencies in

these dimensions; availability, convenience of services, facilities (physical environment),

humaneness of doctors, quality of care, and continuity of care and delivery of services in

government health facilities in the State of Qatar (Devija et al., 2012).

Physical evidence that the hospital was provided satisfactory services can also be

important to patient satisfaction judgments. Thus, overall cleanliness of the facilities, the

availability of modern equipment, and a general feeling that the facilities are in good repair

can enhance patient satisfaction. Therefore, the relating to customers, the general demeanor

19

of the staff in various service settings can have a significant impact on customer

satisfaction. In the hospital environment, previous studies also shown that the manner in

which the staff interact with patients and staff’s sensitivity to patients’ personal experience

were most important to customer satisfaction. Patient satisfaction should also influenced by

perceived treatment costs. Even with insurance coverage, patients may perceive some costs

to be excessive. Consequently, if hospital costs exceed patients’ expectations, it will

influence patients’ satisfaction with hospital services (Devija et al., 2012).

Therefore, improving service in the health care require hospitals to measure their

own performance in order to improve upon current system of service delivery. A well

design health care delivery system can reduce re-hospitalization, improve quality of life and

provide patient satisfaction (Dzomeku, Ba-Etilayoo, Perekuu, & Mantey, 2012).

Factors related to outpatient satisfaction

Patient satisfaction is an indispensable aspect of quality of care in any healthcare

setup. One of the fastest growing industries in the service sector is the healthcare industry.

Patient satisfaction is affected by the degree of agreement between the patient’s

preconceived expectations (formed before hospitalization) and perceptions of the actual care

(Senti & LeMire, 2011). Factors associated with satisfaction are thought to include the

structure, process and outcome of care as well as patient socio-demographic, physical and

psychological status, attitudes and expectations concerning medical care (Cleary et al.,

1988; Minnick, Roberts, Young, Kleinpell, & Marcantonio, 1997; Williams, 1994).

According to Donabedian (1980), the evaluating of effective medical service

system is described in terms of structure, processes, and outcomes. Structure denotes the

attributes of the settings in which care occurs. It includes organizational infrastructure such

as size, numbers of patients, geographical location of the hospital, equipment money and

patient characteristics such as age, gender, education, and human resources or health

personnel like as doctors, nurses, registration, pharmacy and other staff of the hospital. The

aim of these factors is structure to protect and improve quality health care services with

patient satisfaction by appropriate utilization of process.

Process denotes what is actually done in giving and receiving health care service

in outpatient department. It includes the patients’ activities in seeking care and carrying it

out as well as technical management and interpersonal management behavior, which

derived from the science and art of disciplines or from the ethics and value of society or

patients satisfaction (Donabedian, 1980). It means the way of care is delivered to the patient

in outpatient department.

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An outcome is the end result of the effects of care on the health status of patient

satisfaction or dissatisfaction with health care services.

Patient characteristics are well known determinant factors of the patient

satisfaction it includes age, gender, education. The expectation of being satisfied had

different levels depending on a person’s needs. If the consequence of receiving the service

satisfied patients that service will be qualified and standardized and met patient’s feeling

and needs. In this research involving patient characteristics factor is affecting on patient

satisfaction as includes:

Age is one of the most important background factors for causing difference of

maturity on thinking, behavior and emotion. People each age have different feeling,

expectation, opinion and attitude toward something when being feeling about health care

service. A study stated that an older age patients scoring more highly satisfied 49% than

young 29% and middle aged patients 39% in health care services (Rahmqvist, 2001; Cohen,

1996). According to Blazevska, Vladickiene, and Xinxo, (2004) there was no statistically

significant difference in comparing the opinion of the different age group patients about

health care quality. Most respondents in each group reported access health care service

quality was very good.

Males and females have different physical and psychological status. People have

different thoughts, attitude, emotion, feeling and behavior because of giving unequal value

and status between male and female. Therefore, the different genders have different feelings

of health care services. Wright, Craig, Campbell, Schaefer, and Humble (2006) showed that

significant differences exist between female and male reporting of satisfaction with health

care services, with males’ having greater levels of satisfaction than females (p < .05). On

the other hand, a study of Al-Doghaither (2004), found that females were more satisfied

(3.82) than males (3.46). The differences between men and women may reflect different

patterns of service utilization, differences in experiences, as well as differing needs and

expectations (Kane, Maciejewski, & Finch, 1997).

Education was a crucial factor of health care services. Being education was caused

of expectation in receiving medical care in the accurate method and technique and need of

information about symptom and treatment program. In addition, education was a divider of

a person’s class level, honor and dignity. When receiving a health care service, people

expected that they would receive the service suited to their dignity. People are having

higher education often higher expected than people having lower education. In the study of

Al-Doghaither (2004) showed that education was significantly associated with health care

21

services. Those with more education were less satisfied than those less education. Another

current study revealed that patients with lower educational levels (illiterate/ primary) were

more satisfied than those with higher levels (secondary/ university). This may be due to that

highly educated people have more critical thinking and high level of expectation in all

aspects of life (Assaf, 2009).

Nurse communication is most important factors which manipulate of patient

satisfaction with health care services in a health care organization. Communication with

patients can greatly affect the healing process. If a patient feels alienated, uninformed, or

uncertain about health outcomes he/she may take longer to heal. Clearly, communication is

vital to delivering service satisfactions in the hospital setting (Devija et al., 2012). Gilbert

(1998) stated that the importance of the nurses listening behaviors was particularly

emphasized and also pointed out that six relational factors were communicated by nurses

listening behavior: trust/ receptivity, depth/ similarity, difference, dominance or power,

formality and composure. In addition, according to Klakovich and cruz (2006) stated that

dimensions of advocacy, therapeutic use of communication and validation factors is related

to health outcomes including quality of life and patient satisfaction with health care service.

Patients are frequently dissatisfied with information receive due to ineffective

communication by the nurse in health care services. The proportion of dissatisfaction

patient is 38% during health care services (Ong, Haes, Hoos, & Lammes, 1995). Buller and

Buller (1987) stated that a positive association between nurse’s expression of behavior and

patients’ satisfaction with health care service. Larsen and Smith (1981) studied the

relationship between nurses’ non-verbal activities and patient satisfaction. A study revealed

that found that a positive relationship between sharing opinions’ and ‘patient knowledge

about illness (Ong et al., 1995).

Waiting time is another important factor in a higher level of patient satisfaction

with better health care services of chronically ill patients (Crow et al., 2002). A study stated

that most common problems were waiting time in 79.2% of patient dissatisfied during their

health care services (Damghi et al., 2013). Waiting time is real or perceived in often found

to influence the patient satisfaction with health care services (Yildirim, Kocoglu, Goksu,

Gunay, & Savas, 2005; Nerney et al., 2001). Patient perception of the time spent with their

physician is also strongly associated with overall satisfaction (Chen et al., 2001).The source

of dissatisfaction with health care services, often noted by patients, and the amount of time

they wait during outpatient department visit. Several studies were documented the

relationship between waiting for service and overall patient satisfaction while longer waiting

22

times being associated with decreased patient satisfaction (Camacho et al., 2006). It was

found that as perceived waiting time increased patient dissatisfaction with health care

services and tends to decrease of satisfaction. Several studies were conducted in outpatient

departments and showed that waiting time may be considerable and may contribute to high

level of patient discomfort with health care service (Thompson, & Yarnold, 1995; Taylor, &

Benger, 2004). According to Katzman (1999) waiting for treatment can be frustrating; given

that time is unproductively spent and people are impatient those do not want to wait for

health care services.

In addition, there are some organizational factors that influence the satisfaction,

health, safety, well-being and quality of care for patient’s satisfaction. The hospital work

environments are impact of the working conditions and may effects on patient’s satisfaction

(Lundstrom, Pugliese, Bartley, Cox, & Guither, 2002).

In a study on patient satisfaction of Johansson et al., (2002) investigated the socio-

demographic background of the patients, their expectations of nursing care, physical

environment, communication and information, contribution and participation, interpersonal

relationship, technical competence, and structural dimensions of healthcare organization.

The findings showed that these eight factors affected patient satisfaction with the offered in

health care systems (Dzomeku et al., 2012).

Patient satisfaction is influenced by numerous factors and only continuous

evaluation can identify the factors which can affect the satisfaction. Patient satisfaction

depends on several aspects and it has been determined that when patient gets medical

assistance needed in sufficient amount and at appropriate cost, he becomes satisfied and

considers the service as accessible. Patients increasingly want to learn more about their

health conditions and they want to participate in the planning, organization and decision-

making of services related to their health (Merkouris, Ifantopoulos, Lanara, & Lemonidou,

1999). The changes that have happened in the patient's roles are also linked to developing

interest in learning more about patient satisfaction (Dzomeku et al., 2012).

Finally, there are several factors that directly or indirectly affect patient

satisfaction with health care services. Those include socio-demographic factors such as

those that describe the propensity of family members to use services- including family

composition such as age, gender and marital status. Social structure includes education,

employment, social class and ethnicity. Health beliefs are attitudes, values, and knowledge

that people have about health and health services that might influence their succeeding

perceptions of needs and use of health resources for medical care. In addition,

23

organizational factors, information, work environments, physical facilities, health status,

cost of health services and accessibility to health care service factor affect in patient

satisfaction.

Therefore, in this study nurse communication is a very important factor which has

an effect on patient satisfaction during health care services. It includes advocacy,

therapeutic communication and validation that are part of nurse’s service in outpatient

department. It is well documented that waiting time also impacts patient satisfaction. It

includes doctors, nurses, registration, and pharmacy counter health care service factors. It is

important for nurse administrator, policymaker to note that the present study to determine

factors on patient satisfaction with health care service and it may also prove useful for

planning and evaluation as well as identify areas to improvement health care service and

avoid unnecessary delay.

Nurse communication

Definition of nurse communication

Nurse communication refers to patient’s perception regarding nurse

communication with three dimensions of advocacy, therapeutic communication and

validation factors that are part of nurse’s service in outpatient department. The patient can

consider the ability and experience of the nurse, suggestion of how to take care of oneself,

clarification of diagnosis and care during their visit.

Communication is fundamental and vital to all healthcare functions.

Communication is a means of transmitting information and making oneself understand by

another or others. Communication is the creation or exchange of thoughts, ideas, emotions,

and understanding between nurses and patients. It is essential to building and maintaining

relationships in the workplace. Although nurses spend most of their time communicating

(e.g., sending or receiving information), one cannot assume that meaningful communication

occurs in all exchanges (Guo & Sanchez, 2005).

In addition, communication is a strongly dependent on the culture, the social

status, and reciprocal relationships of the patients. The exchange of information with the

aim of understanding is the central characteristic of communication (Usher & Monkley,

2001; Vivian & Wilcox, 2000).

Furthermore, interpersonal or therapeutic relationships are continuous processes of

communication; consequently communication can be seen as a prerequisite for relations

(Rundell, 1991; Tuckett, 2007). Verbal and nonverbal expressions make up communication,

24

with verbal expressions in the form of language being viewed as basic. In interactional

situations all kinds of behavior are communicative and convey messages between nurse and

patients (Fleischer, Berg, Zimmermann, Wuste, & Behrens, 2009; Daubenmire, Searles, &

Ashton, 1978). According to Davies (1994), communication can occur through facial

expression, eye contact, body posture and touching, as well as through speech. The

successful communication demands an accordable cognitive effort and awareness of the

patients of communication (Larsson & Starrin, 1990). All behavior can convey messages

and all patients’ behavior has a communicative meaning and message.

The concepts of nurse communication

Nurses are the frontline caregivers to the patient in the hospital of every country.

Nurse can play an important role to communicate with patients who seeking medical care

services. Nurse communication is crucial role in all of medical fields during their patient

caring in health care center. Professional nursing practice requires the ability to

appropriately and effectively communicate with patients. The quality of interpersonal

communication is related to health outcomes, including quality of life and patient

satisfaction (Klakovich & Cruz, 2006; Coeling & Cukr, 2000).

Patient-centered communication is respectful and responsive to a health care

user’s needs beliefs, values and preferences. Patient-centered communication is important to

ethical, high-quality health care. It is often easy to see the link between effective

communication and high-quality health care. Patient satisfaction increases when

communication is clear, understandable and respectful (Thanh, 2011). On the other hand,

gaps or lapses in communication between health care professionals and patients, or among

health care professionals can lead to medical errors and unexpected outcomes (American

Medical Association [AMA], 2006).

The nurse-patient relationship is primarily mediated by verbal and non verbal

communication. Like communication relationships are unique situations and are mutually

constructed whereby the professional nurse-patient relationship is responsive and inter

subjective (Aranda & Street, 1999). It is this interpersonal relationship that makes the

difference between nursing and caring (Tuckett, 2005). The essential aspect of nursing

relationships is dependent on the skills of the nurse like non-judgmental listening and the

ability to convey warmth and understanding (Gastmans, 1998). The importance of

communication and interaction for nursing has been an often stated point by nurses and

nursing scientists since Florence Nightingale in the 19th

century and continuing until today.

25

The main intention of communication and interaction in the health setting is to influence the

patient’s health status or state of well-being (Fleischer et al., 2009).

In addition, effective communication is a fundamental element of nursing care that

is integral to the provision of quality patient care (Bowles, Mackintosh, & Torn 2001;

Wilkinson & Tappen, 1999). Social interaction mediated through effective communication

is a critical factor affecting quality of life. For those residing in long-term care (LTC) and

complex continuing care (CCC) facilities, opportunities for socialization occur primarily

during interaction or communication with staff. The effectiveness of a communication is

enhancement intervention, based on a theoretical framework, in enhancing nurse-patient

interactions so that they optimized nurse relationships with patients, and patients’

satisfaction (McGilton, Irwin-Robinson, Boscart, & Spanjevic, 2005).

There are seven dimensions of relational communication: comprised of calm,

comfortable, caring, interested, sincere, accepting, and respectful (Finch, 2006). Although

not all seven communication dimensions were viable within the contexts of patient’s

perspectives of communication with nurses, patients did report more satisfaction with nurse

patient interactions when nurses were composed, immediate, receptive, and shared values

(Fleischer et al., 2009). Between nurse-patient communication in the health care setting,

may often some barriers in these situation. Longest, Rakich, & Darr (2000) classify the

barriers into two categories including environmental and personal. Environmental barriers

are including competition for attention and time between nurse and patients. Multiple and

simultaneous demands cause messages to be incorrectly decoded. The patient hears the

message, but does not understand it. Due to inadequate attention paid to the message, the

patient is not really “listening.” Listening is a process that integrates physical, emotional,

and intellectual inputs into the quest for meaning and understanding.

On the other hand, personal barriers arise due to an individual’s frame of reference

or beliefs and values. One may also consciously or unconsciously engage in selective

perception or be influenced by fear or jealously. Personal barrier is lack of empathy, in

other words, insensitivity to the emotional states of nurses and patients (Guo & Sanchez,

2005).

National organizations have identified health care communication as an essential

element of public health and a core component of the health care system. For example,

Healthy People 2010 has included health communication not only as one of its focus areas,

but indicated that it also affects each of its 10 leading health indicators (Public Health

Foundation [PHF], 1999). The Joint Commission on Accreditation of Health Care

26

Organizations, the National Committee for Quality Assurance [NCQA] (2004) and others

have developed standards that require health care organizations to recognize individuals’

right to and their need for effective communication. Lastly, the National Quality Forum

[NQF] (2004) is list communication as both a practice for improving patient safety as well

as a national priority for health care quality measurement and reporting.

There was agreement on the importance of communication is one of the most

important determinants of patient satisfaction. Anderson, Barbara, & Feldman (2007) stated

that patient satisfaction rating was highly influenced by a core communication and follow

up care in outpatient department. The core qualities appear to be the most important, namely

communication, access, interpersonal skills, care coordination follow up care. The quality

of medical care processes, quality of healthcare facilities and quality of other staff followed

in order to importance.

In reaching conclusion, communication is documented as a valuable indicator of

quality of health care service from patient’s perspective. Nurse communication is

constitutes patient and part of the quality health care service and predominantly influence

patient satisfaction with health care service. Nurse communication is patient’s perception

regarding with three dimensions of advocacy means clearly conveying diagnostic and other

relevant information in a way that supports patient wish and decisions; therapeutic use of

communication by the nurse means demonstrating interpersonal behaviors that assist

patients in achieving healthy emotional and behavioral outcomes, empathetic, and respectful

of the patient; and validation factors means listening carefully and verifying that intended

from nurse’s service in outpatient department. The patient can think from ability and

experience of the nurse, suggestion of how to take care of oneself, clarification of diagnosis

and care. In addition, these three dimensions a profile of nurse’s strength and weakness can

be identified, increasing the specificity of health care services that build on strengths while

improving weakness in this issue.

Relationship between patient characteristics, nurse communication,

waiting time, and patient satisfaction

Patient characteristics such as age, gender, and education were significantly

associated with patient satisfaction with health care services. According to previous study

stated that the patient characteristics may influence patient’s satisfaction with health care

services (Hall & Dornan, 1990). The age was the strongly associated with satisfaction and

showing that older patients were more satisfied than younger patients with health care

27

services (Rahmqvist, & Bara, 2010). Another study revealed that men were less satisfied

than women with heal care services and also patient with lower education was more

satisfied than high education (Assaf, 2009). In contrast, the high educated people have

more critical thinking and high level of expectation in all aspects of life related to health

care services (Hall, Milburn, & Epstein, 1993).

Nurse communication refers to patient’s perception regarding nurse

communication behaviors to patients both verbally and nonverbally with service in

outpatient department including advocacy, therapeutic use of communication and validation

aspects that intended from nurse’s service in outpatient department. The patient can

consider from ability and experience of the nurse, suggestion of how to take care of oneself,

clarification of diagnosis and care.

Professional excellence is associated with the care provided by doctors and nurses

who form the major part of manpower in the field of health care. Research has also

indicated that good communication between patient and provider of health care is a vital

factor for patient satisfaction (Mohanan, Kaur, Das, & Bhalla, 2010). Previous research

supports that nurse communication is an important issue in perceived care. The patient

education was an important component of patient satisfaction with nursing communication

the most effect on patients’ overall satisfaction with a hospital service (Senti & LeMire,

2011). Most patients prefer a patient-centered communication style and use of patient-

centered communication may improve patient satisfaction that control of chronic disease.

There was strong evidence for the use of teams in health care to increase patient

satisfaction. Therefore, the relationship between nurse communication and overall patient

satisfaction is good indicator of health care organization.

The relationship between the nurse and the patient is often seen as a therapeutic

relationship in itself that is based on partnership, intimacy and reciprocity. Its purpose is

different from a social relationship that it has a focus on the patient’s well-being as a

priority, and the nurse and patient do not need to have anything in common or even like

each other. This relationship can last only five minutes in an accident and emergency

department or primary care practice, or can continue and develop for months or years

during chronic illness management. It can be intensely personal when breaking bad news, or

quite superficial such as when directing a patient to the appropriate clinic room. However,

all of these scenarios are nurse-patient encounters that impart to the patient something of the

support and meaningfulness of their engagement with health care (Arnold & Boggs, 2006).

28

Nurse communication in nursing profession with health care organization is

reinforces the nurse client relationship. It makes the nurse appear more humane to a patient.

Therapeutic communication in nursing can help to cut through barriers of cultures and

gender, establish a connection and help deal in a situation where empathy is needed with the

patient. Patient satisfaction is clearly link to a patient-centered approach. In a study of sore

throats in general practice, satisfaction with the consultation predicted the duration of illness

and was strongly related to how well the doctor deal with the patient’s concerns (Little et

al., 1997). Doctors’ information giving is also related to patient satisfaction. Physician

nonverbal behaviors showing immediacy (distance between the patient and doctor forward

learn of body orientation) are associated with higher levels of patient satisfaction. More

recently, a large UK general practice study reported that if patients do not receive a patient-

centered consultation they are less satisfied (Hawken, 2005).

Communication with patients is vital to delivering service satisfaction because

when hospital nurse takes time to answer questions of concern to patients, it can alleviate

many feelings of uncertainty. In addition, when the medical tests and the nature of the

treatment are clearly explained, it can alleviate their sense of vulnerability. This component

of service is valued highly as reflected in depth interviews and influences patient

satisfaction levels significantly (Andaleeb, 2000).

There are two concepts identified as important in interaction and relationship,

“being authentic” and “being a chameleon”, that meaning the necessity of two divergent

behaviors in interaction and relationship. Therefore, nurses have to be authentic and

adaptive to the patient and situation. The professional relationship is a important

characteristic of nursing interactions and can have positive or negative effects on the

nursing experience of patients (Breeze & Repper, 1998).

For the past three years, miscommunication has been identified as one of the most

frequently root causes of sentinel events reported to The Joint Commission with 82% of the

sentinel events in 2010 identifying communication as the primary root cause. There are up

to 75% of clinical decisions are made without all pertinent clinical information. Differences

in status and discipline may be part of the confounding factors associated with poor

communication (Tschannen & Lee, 2011).

The act of communication between nurses and physicians is a central activity in

healthcare, and a failure to communicate has been linked with poor quality and patient

errors. Effective communication and collaboration among nurses and physicians has been

shown to result in improved quality of care increased patient and professional satisfaction

29

(Boyle & Kochinda, 2004). Ineffective nurse-patient communication has been blamed

largely on nurses’ weak communication skills, but other factors also contribute to the

problem. These include a task-oriented approach to nursing, workplace policies and

practices, lack of time and privacy, and work-related stress (Wellard Lillibridge, Beanland,

& Lewis, 2003; Bowles et al., 2001).

There are some findings that physicians’ and nurses’ communication skills with

patients are the key components to a high level of patients’ satisfaction. In a research done

in Switzerland, physician-patient interaction has been suggested as the vital factor in

predicting patients’ satisfaction (Robert, Coale, & Redman, 1987). Likewise, way of raising

voice, physical feeling, communication and personal behaviors of physicians really

contribute in bringing a higher level of patient satisfaction.

In this study, waiting time is patients who are waiting for receive the services like

as doctors, nurses, registration, and pharmacy counter health care services and their satisfied

or discomfort in waiting for long periods in outpatient department. A review of the literature

on waiting time perception has indicated that people are increasingly concerned with using

their health care service efficiently that patients respond emotionally (Taylor, 1994).

However, Taylor (1994) stated that there are different types of wait while patients can wait

before, during, or after in health care service regarding their care. Patient reactions to

waiting are more strongly influenced of patient’s satisfaction with health care services

(Pruyn & Smidts, 1998; Bielen & Demoulin, 2007).

Dansky and Miles (1997) investigated the relationship between patients’ perceived

waiting and satisfaction with ambulatory health care service and found that the waiting time

for the clinician was the most significant predictor of patient satisfaction with health care

services. Hall and Press (1996) investigated that factors affect patient satisfaction in an

outpatient setting and found that nursing-staff services, physician issues, other staff and

waiting-time are the key issues that drive satisfaction with the outpatient department.

According to Manaf (2006) indicated a positive correlation between waiting time

and outpatient satisfaction with health care service. Research reports indicate that the

waiting time for a response to the call light is a major concern for patients and closely

linked to patient satisfaction with overall care (Senti & LeMire, 2011; Tzeng & Yin, 2009).

Waiting time is increasing attention on the evaluation of the efficiency and delivery of

healthcare while trying to maintain the quality of service patients expect. Therefore, wait-

time in follow-up hospital has important implications, not only for the patient, but also for

the hospital and healthcare system in general. The waiting time influences patient

30

satisfaction and is important in an outpatient setting. Outpatient department is the subject of

recent attention due to their ability to increase efficiency and reduce healthcare costs.

Recent studies have shown that patient waiting time is an important indicator of patient

satisfaction in OPD (Chung, Hamil, Kim,Walters, & Wilkins,1999). Levesque et al., (2000)

showed that patient expectation of time in clinic and actual clinic times are independent

determinants of satisfaction. However, the actual factors associated with increased waiting

time in hospital impact on patient satisfaction (Syed, Parente, Johnson, & Davies, 2012).

Waiting time is found to be varying importance in the four studies, Vukmir

(2006), in his systemic review of the literature on customer satisfaction as it applies to

current medical practice, found that the waiting time and the amount of caring are the most

important determinants of outpatient satisfaction in the outpatient department. The most

important reasons for patient satisfaction with the quality of outpatient care are having to

wait for appointment, the length of waiting time, communication and information received,

duration of consultation, lack of reach ability, lack of continuity, and not being able to

practice in and contribute to decision making.

In contrast, Tam (2007) found that waiting time was not the important determinant

of service quality but it is one of the nine identified factors that were key aspects of the

medical service encounter that influenced patient satisfaction including doctors technical

quality, doctors interpersonal skills, quality of nurses, quality of support staff, efficiency of

appointment system, waiting time, duration of consultation, physical environment and

respect for patients privacy.

The influence of waiting time on the satisfaction, loyalty relationship was explored

in depth by Bielen and Demoulin (2007) in Belgium on radiological outpatients. The results

confirm that waiting time satisfaction is not only a service satisfaction determinant, but it

also moderates the satisfaction with the relationship. Moreover, determinants of patient

waiting time include the perceived waiting time, the satisfaction with information provided

in the case of delays, and satisfaction with the waiting environment. In addition, it was

shown that the waiting time satisfaction was a complete mediating variable in the perceived

of waiting time link outpatient satisfaction with health care service. Thus, it seems that

waiting time is an important to determinant in patient satisfaction. By contrast, recent

studies found that long waiting time was not a significant predictor of patient satisfaction

(Dansky & Miles, 1997).

The patients consider waiting as inactive to wasted or lost opportunity time. It was

found that the patient satisfaction decreased with longer waiting times (Dansky & Miles,

31

1997). The strength of the correlation between waiting time and the patient satisfaction

varies across the literature. A study conducted from the responses of a national cross-

sectional, online survey of patient’s satisfaction revealed that longer waiting times were

associated with lower patient satisfaction. Camacho et al., (2006), found that the increased

waits decreased willingness to return for service. However, most of the studies that were

conducted in primary care outpatient settings find a detectable relationship between waiting

times and patient satisfaction (Yeddula, 2012).

A study stated that longer waiting times were associated with lower patient

satisfaction (p < 0.05); however, time spent with the physician was the strongest predictor

of patient satisfaction. It seems that increased waiting time is an important source of patient

dissatisfaction (Anderson et al., 2007).

In the long run, it recognizes that the patient characteristics, nurse communication

and waiting time is very important to patient satisfaction in health care organization.

Effective and interpersonal communication is one of the parts of nurses that may enhance

the patient satisfaction with health care services. Hospital administrators and policy-makers

are becoming more and more concerned with outpatient communication and waiting time

because it is a measure of organizational efficiency.

Health services in Bangladesh

Bangladesh is a mostly rural, developing country of South Asia and located in the

northeastern part of South Asia and covers an area of 147,570 square kilometers. For

administrative purposes, the country consists of 7 divisions, 64 districts, and 545 upazilas/

thanas (BBS, 2012). Muslims make up almost 90 percent of the population of Bangladesh,

Hindus account for about 9% and other religions constitute the remaining 1% (BBS, 2007).

Bangladesh is the most densely populated country in the world, excluding city-

states such as Singapore, Bahrain, and the Vatican. According to the results of the 2011

primary health care, the population of the country stood at about 149.8 million, with a

population density of 1,015 persons per square kilometer (BBS, 2012). During the past

century, the population of Bangladesh has increased exponentially. Between 2001 and 2011,

about 19.8 million people were added to the population, which represents a 15% increase

and 1.37% annual growth rate. Between the 2001 and 2011 censuses, life expectancy in

Bangladesh increased by about two years for males and by more than three years for

females. Female life expectancy is slightly higher than male life expectancy 69 years versus

67 years (Sabir, Sultana, Bhadra, & Alam, 2009).

32

Health is one of the most happiness for any person and every family. The

constitutional commitment of the Government of Bangladesh is to provide basic health and

medical requirements to all people in the society. The Constitution of the People’s Republic

of Bangladesh ensured that “Health is the basic right of every citizen of the Republic,” as

health is fundamental to human development. Since independence, the government has been

pursuing a policy of health development that ensures provision of basic services to the

entire population, particularly to the under-served population in rural areas. The successive

health plans of the country emphasize primary health care (PHC) as the key approach for

improving health status of the people.

Total health system in Bangladesh is controlled by the Ministry of Health and

Family Welfare (MOHFW), which is divided into two, wings one concerned with

Population and Family Planning and the other concerned with Health. Government

healthcare service network is spread over the country from the capital to village level. The

network service is provided through three approaches such as primary care at upazila (sub-

district) level, secondary care at district level, and tertiary care at division level (Rahman,

Ashaduzzaman, & Rahman, 2005).

The Ministry of Health and Family Welfare is responsible to management over

health services in the whole country. The administration and management of health service

is divided. Under the minister there are two ways Directorates General; one for health, and

another for family planning. They are responsible for implementation of all programs, and

for providing technical guidance to the minister. Each district has a Civil Surgeon to

supervise health activities and a Deputy Director of Family Planning to supervise family

planning activities. A Thana Health Center consists of four functional units: (1) General

administration (2) Inpatient and outpatient services (3) Maternity and child health services

(4) Home service. The union sub-center is the smallest unit of the health administration. The

government aims to provide for a union sub-center in every union for the first contact level

of rural population to obtain health and family planning services.

In 1977, the Nursing Administration (NA) was established under the Health

Branch of the Ministry of Health and Welfare. The Nursing Administration is responsible

for the planning, administration, organization, implementation, supervision, co-ordination,

and evaluation of nursing education programs and nursing services in health facilities. The

Nursing Administration maintains liaison with international nursing organizations (Ruhul,

Fukuda, Nakajima, Takatorige, & Tatara, 1999).

33

Nursing is play a crucial role in upgrading the quality of patient care in hospitals

and bring health care services towards the health care center especially to the vulnerable

areas. In Bangladesh, health care service is mostly curative oriented and hospital based

where the quality of service is a major concern particularly care provided by nurses.

National Institute of kidney Diseases and Urology hospital

The present study will be carried out in National Institute of Kidney Diseases &

Urology (NIKDU) hospital. It is a government specialized hospital under the Ministry of

Health and Family Welfare. The Government of People’s Republic of Bangladesh, it was

certainly a mile stone in the history of nephrology, urology and transplantation in this

country. The institute was formally opened on 18th

April 2001.

National Institute of kidney Diseases & Urology hospital has been set up in the

heart of the Dhaka city and provides modern and scientific management for kidney &

urological diseases. In Bangladesh with a population of about 160 million nearly 20 million

people are suffering from various kidney and urological problems. Every year 15-20

thousand patients develop acute renal failure (ARF), 70% of those can be rescued by

dialysis therapy and further 18-20 thousand patients are developing end stage renal diseases

(ESRD). On the other hand approximately 3 million patients are suffering from various

urological diseases. As a result there is huge number of patients and the existing facilities

are very inadequate to serve them. Fundamental mission of this hospital is continue and

expansion of service and provide quality care to the patients. Although we have knowledge

and experience for modern management of kidney diseases but we have scarcity of

necessary specialties, hospital beds, equipments and laboratory services (MOHWF, 2012).

It is a 116 bed specialized hospital and highest referral centre in the country,

providing the necessary services to people. The outpatient department is the most important

department which deals with day to day patients, most of whom do not require admission

for treatment. The outpatient department (OPD) is normally open from 8:00 am to 2:00 pm

on all days except Friday and government holidays. At present the hospital provides charity

service including area of adult nephrology, adult urology, paediatrics nephrology,

paediatrics urology, kidney transplant, mini-operation theatre, nursing, pharmacy, nutrition

and dietary services. The emergency department is a special unit which provides healthcare

to patients who need both urgent and immediate medical attention. Medical staffs are

supported by an observation room and also an emergency operation theatre in 24 hours.

Respect for patients’ demand and desire is central to any humane health care policy. Patient

satisfaction is widely considered as an integral part of the quality of care. Health care

34

provider organizations wishing to meet those needs more effectively is show the growing

interest in the use of patient evaluations and reports as a complement to other methods of

quality assessment and assurance.

Therefore, it is increasingly important to evaluate patient satisfaction with care.

Patient satisfaction is identified as an important dimension for assessing the quality of

health care services. On the other hand, the researcher cannot find out a single research has

been focusing on assessment and evaluation, constrains faced by patient, and quality of

services of patient satisfaction in outpatient department of National Institute of Kidney

Diseases and Urology hospital in Bangladesh.

In summary

From literature review, patient satisfaction with health care service is a positive

emotional response and patients compare their individual experiences. Patient satisfaction is

really a vital indicator of quality of medical care service. Moreover, it is an important

outcome measure which can reflect strength, weakness, opportunity and threat of the

healthcare system. Identify the factors affecting the patient satisfaction can be use

systematically to improve the services and help to generate ideas towards resolving these

problems. There are few studies on patient satisfaction with health care service in

Bangladesh. Therefore, researcher will study on patient satisfaction and selected factors

including nurse communication and waiting time in Bangladesh.