Introduction
The purpose of this paper is to compare two research studies--one quantitative and the other qualitative--that concern a particular health issue or an issue that is pertinent to nursing. In each case, the study was chosen that addresses patient satisfaction and how we should measure that. The quantitative study, by Berkowitz (2016), concerns the complexity of measuring patient satisfaction when there is no simple way to go about it. The qualitative study, by Grondal, Wilde-Larsson, Karlsson and Hall-Lord (2012) looks at patient satisfaction through the use of interviews with a small number of patients (n=22) and then coding their responses for similarities in categories that would explain their satisfaction.
Quantitative studies generally use numbers to describe the phenomena being studied. They are generally systematic, objective, deductive, they can generalize easily because the population or sample studied is large, and they use numbers to describe the findings (Nursing Online Resources and Research (NORR) (2015). Qualitative studies, on the other hand, generally use narrative with a small number of people to describe the findings and to interpret what is found. Like quantitative studies, qualitative studies are systematic, but instead of being objective, they are subjective. The reasoning used with them is inductive and not generalizable to any population, because of the small sample size and because they are subjective. As mentioned above, the results use words to explain what was found rather than numbers (NORR, 2015).
The Quantitative Study
Background or Introduction
The researcher wanted to investigate how the patient experience becomes patient satisfaction that results in a metric that can then be used as a basis for "payment systems for quality" (Berkowitz, 2016). But she discovered that the patient experience influences the report of patient satisfaction with regard to their care, and that it is much more complex than previously thought. In the study, Berkowitz (2016) discusses the challenges surrounding what is a "lack of consistent terminology and multiple contributing factors" by reviewing the literature concerning this topic, and she gives examples from clinical nursing practice about how "regulation, organizational environments, and research" can clarify the factors that lead to a patient's expression of satisfaction with the care received.
Literature Review
The review of literature is extensive. The Center for Medicare and Medicaid Services (CMS, 2013) has six priority areas that relate directly to quality: "making care safer, making sure that individuals and their families are engaged as partners in their care, promoting effective communication and coordination of care, promoting prevention, promote healthy living as a community, and making quality care more affordable" (CMS, 2013). CMS incentivizes these priority areas by making payment for services dependent on whether these goals were met. But there are significant factors influencing whether these priority areas are met successfully--adequate staffing, a good relationship between nurses and doctors, nurse burnout, functional status, expectations, health outcome, and communication. Some of these are out of anyone's control, but still have a significant impact, potentially, on how a patient will perceive the care he or she has gotten.
It is very difficult, obviously, to measure patient satisfaction accurately when these factors are at work. Berkowitz quotes an example from Price, Elloit, Cleary, Zaslavsky and Hays (2014), who questioned whether providers should be held accountable for an individual patient's quality of care. The authors listed several reasons for this: patients are typically not good at evaluating the care they receive, the concept of patient satisfaction is nebulous and therefore not valid, caregivers may focus on the desires of patients rather than what is good quality care that the patient may not like, scores that the patient gives that are not in the provider's control, and low response rates.
Methodology
Berkowitz reviewed four studies in term of patient experience and patient satisfaction. The first relates to the implementation of technology. In the case of the Veteran's Affairs Administration, a system was set up to enable patients to access their own records online, thereby making them partners in their own treatment. Kaiser Permanente used alerts to communicate with nursing staff to prevent pressure sores and falls, based on the concept of best practices.
Two other studies focused on the work environment and resulting patient experience. Subscales in the Practice Environment Scale of the Nursing Work Index measured the work environment with its perceived quality and staffing ratios. These two things were positively associated with measures of patient satisfaction. Magnet designation was a significant factor in positive patient experience, and the results were shown to be significant with six of the seven Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, 2015) patient satisfaction indicators.
The association between care coordination and and patient satisfaction was also examined. The researchers found that there was a positive result when care was given for chronic illness management, but that is only a small, relatively speaking, population of all patients that it only applies to those with chronic illnesses. The authors report that further research is needed.
Data Analysis
Since this was primarily a review of literature, no data was analyzed by Berkowitz (2016). However, the studies that were reviewed were all of a quantitative nature, and the results of these studies was given. Because of that, the conclusions at which the authors arrived, and at which Berkowitz arrived, are statistically significant and valid from that perspective.
Researcher's Conclusion
Berkowitz (2016) concludes that more needs to be done to examine the dynamic of patient satisfaction and the patient experience in greater detail. What is already known is that patient satisfaction is related to the experiences a patient has in the healthcare system and with healthcare providers. Communication is a strong part of that. The nurse's work environment can also have positive and negative effects, and that patient experiences may not at all reflect the perception of quality of care. Much depends on patient expectations for care and for outcomes. Influencing perceptions are things such as families, the prognosis given, and the specific treatment applied. What is not always known and which must be examined in greater detail are "the expertise of the nurse, the support of the environment, organizational leadership," and other influences that affect patient satisfaction.
Is the Researcher's Conclusion Supported?
Yes, I believe it is.
Protection of Human Subjects and Cultural Considerations
Since this was a review of literature, no human subjects were used. With regard to the studies that were reviewed, it is assumed that all appropriate considerations were taken.
Strengths and Weaknesses
As with all reviews of literature, some appropriate studies must be left out, given the time associated with the review, and the space given. In a single study, one cannot account for every conceivable variable. These studies provide a case in point--no patient was reported being negative when his typical demeanor is negative, and it would matter not what his or her experience was. But Berkowitz handled the review very well--she reported on the literature as it stands, and has made provision for further study, as noted. All in all, this study is a strong one.
Nursing Practice
The study has implications for nursing practice because quality care is the default position, and since it is measured and used as a part of determining payment received, it lies directly on the nurse to provide as good an experience as possible. But there are also complications, and the nurse must be aware of these, as much as possible. Families of patients, the work environment, communication with the doctor and the patient, the nurse's attitude and condition on any given day--these things affect the patient's perceptions, fairly or not. The only thing a nurse can do is take the work a day at a time, working diligently on behalf of all her patients, and make the experience a positive one, if it is at all possible.
The Qualitative Study
Background or Introduction
This study by Grondahl, Wilde-Larsson, Karlsson and Hall-Lord (2012) is an example of a qualitative study relating to healthcare and patient satisfaction. It details the experiences of 22 patients who were discharged from the hospital. An effort was made to determine what these patients perceived and how that related to patient satisfaction. There was no statistical work done--all of the responses were recorded in interviews, and a content analysis was done to see if there were any similarities between patients and their responses. The aim was to "describe patients' experiences of care quality and the relation to their satisfaction during the hospital stay.
Literature Review
The literature review was discussed in the introduction section. The authors stated at the outset that there is a confusion of terms in the literature between the ideas of patient satisfaction, perceptions of how much quality of care has been provided, and the actual experience of received care. In the literature, the authors found that these ideas are used interchangeably, so that the ways we measure satisfaction or quality of care or patient experiences is not always clear.
According to the authors, it is typical that about 80% or 90% of patients rate their quality of care as either 'good' or excellent,' but it may be because the responses given and to be selected by the patient are limited, and are usually overly optimistic. Patients, in fact, sometimes rated their care as 'excellent' while at the same time they were reporting problems with their care. The authors point out that other studies have shown that quality of care satisfaction is associated with symptom severity, both at discharge and by how much symptoms had improved during hospitalization. Other examples were the positive report of pain management and thus patient satisfaction, when the patient was experiencing high levels of pain. The reasons given for this disconnect were that the patient expected to feel pain and that the patient didn't want to "bother anybody" (Grondahl, Wilde-Larsson, Karlsson, and Hall-Lord, 2012).
Methodology
The study was classified as a qualitative descriptive design. The study was carried out in Norway from May 2008 to April 2009. Before the patients were discharged from the hospital, they were given a questionnaire about how they perceived the quality of their care and their responses on the Emotional Stress Reaction Questionnaire (Larsson and Wilde-Larsson, 2010), which is a way of registering their emotions. The questionnaires were given to 528 possible participants, but they were told that only about 20 participants would be needed. The criteria was that they be discharged from the hospital, and had no further hospitalizations. thirty one people were initially chosen, and the final count was 22. Interviews were then held with the 22 participants.
Data Analysis
After the interviews were finished, they were analyzed using a content analysis. Notes were taken during the interviews, as well as recording them. The notes were descriptions of the settings (they were chosen by the participant) and the participants' emotional responses. The interviews were described verbatim the next day. They were then read and played back at the same time to account for any discrepancies. They were then coded based on the repetition of key words. The codes were then compared, and the responses sorted into categories and subcategories.
Researchers' Conclusion
The result of the study was that four categories and seven subcategories emerged from the 22 interviews that described quality of care and patient satisfaction. The four categories were 1) desire to regain health, 2) need to be met in a professional way as a unique person, 3) need to be involved, and 4) need to have balance between privacy and companionship (Grondahl, Wilde-Larsson, Karlsson, and Hall-Lord, 2012). Under the first category, the subcategories found were waiting for treatment, being cured, and having hopes of being cured. Under the third category (there were no subcategories for #2), the subcategories were being correctly diagnosed and having successful treatment. Number 4 also did not have any subcategories.
Is the Researcher's Conclusion Supported?
The researchers' conclusion that the interviews gave insight into the nature of patient satisfaction and quality of care was borne out. Of course, that is the advantage of qualitative studies--they often get at information that is inaccessible to numeric attempts. By simply asking the informants what they thought, the researchers were able to differentiate between quality of care and the patient's ultimate feeling about satisfaction, and the patients were indeed quite honest about what it is that they were expecting as patients.
Protection of Human Subjects and Cultural Considerations
Strengths and Weaknesses
One of the obvious weaknesses of the study is the aforementioned sample size. A study that has only 22 respondents is hardly generalizable to other populations, and the chances of researcher bias are much greater with a study of this size. On the other hand, however, the study does have some strength, notably the extremely personal information that was gleaned by asking questions rather than relying on a Likert-type questionnaire where all possible answers are already given.
Nursing Practice
This is really valuable for nursing practice. It is kind of a window into a patient's thoughts, and it tells exactly how patients feel when they first come to a hospital. They want to be treated with dignity and respect as a "unique" person, they want to be partners with the medical staff, they want to be cured, or at least have the hope of a cure. That's it, and that tells everything.
References
Berkowitz, B. (January 31, 2016). The patient experience and patient satisfaction: Measurement of a complex dynamic." OJIN: The Online Journal of Issues in Nursing, Vol. 21, No. 1, Manuscript 1.DOI: 10.3912/OJIN.Vol21No01Man01
Centers for Medicare and Medicaid Services. (2013). CMS quality strategy 2013 beyond. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy.pdf. In Berkowitz, B. (January 31, 2016). The patient experience and patient satisfaction: Measurement of a complex dynamic." OJIN: The Online Journal of Issues in Nursing, Vol. 21, No. 1, Manuscript 1.DOI: 10.3912/OJIN.Vol21No01Man01
Grondahl, V. A., Wilde-Larsson, B., Karlsson, I. and Hall-Lord, M. L. (2012). Patients' experiences with care quality and satisfaction during hospital stay: A qualitative study. European Journal for Person Centered Healthcare, Vol. 1, No. 1. 185-192. Retrieved from http://ubplj.org/index.php/ejpch/article/view/650/693
Hospital consumer assessment of healthcare providers and systems. (2015). Retrieved from http://www.hcahpsonline.org/home.aspx. In Berkowitz, B. (January 31, 2016). The patient experience and patient satisfaction: Measurement of a complex dynamic." OJIN: The Online Journal of Issues in Nursing, Vol. 21, No. 1, Manuscript 1.DOI: 10.3912/OJIN.Vol21No01Man01
Larsson, G. and Wilde-Larsson, B. (2010). Quality of care and patient satisfaction: A new theoretical and methodological approach. International Journal of Health Care Quality Assurance, Vol. 23. 228-247. In Grondahl, V. A., Wilde-Larsson, B., Karlsson, I. and Hall-Lord, M. L. (2012). Patients' experiences with care quality and satisfaction during hospital stay: A qualitative study. European Journal for Person Centered Healthcare, Vol. 1, No. 1. 185-192. Retrieved from http://ubplj.org/index.php/ejpch/article/view/650/693
Nursing Online Resources and Research. (2015). Nursing research/theory: Quantitative vs qualitative. University of Texas at Austin School of Nursing. Retrieved from http://nursing.utexas.edu/norr/html/links/research_qua.html
Price, R., Elliott, M., Cleary, P., Zaslavsky, A., and Hays, R. (2014). Should health care providers be accountable for patients’ care experiences? Journal of General Internal Medicine, Vol 30, No. 2. 253-256. doi:10.1007/s11606-014-3111-7. In Berkowitz, B. (January 31, 2016). The patient experience and patient satisfaction: Measurement of a complex dynamic." OJIN: The Online Journal of Issues in Nursing, Vol. 21, No. 1, Manuscript 1.DOI: 10.3912/OJIN.Vol21No01Man01
