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A dissertation on patient satisfaction dives into understanding how happy or content patients are with their healthcare experience. It explores what makes patients feel good about the care they receive and how hospitals or clinics can make it even better.
The concept of patient satisfaction has evolved significantly in healthcare, shifting from a secondary concern to a central pillar. Healthcare providers have transitioned from focusing solely on clinical outcomes to recognizing the importance of patient satisfaction in the care process. This shift is driven by the understanding that a patient's experience and emotional well-being are integral to effective medical treatment.
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In today's global healthcare landscape, institutions prioritize delivering high-quality medical care alongside a patient-centred experience rooted in empathy, respect, and communication. Patient satisfaction is now a critical focus for researchers and practitioners, guiding healthcare improvements and ensuring regulatory compliance.
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Dissertations on patient satisfaction are essential for healthcare providers and institutions, enhancing care quality and patient-centred approaches. Satisfied patients are more likely to return and recommend providers with strong reputations for patient satisfaction. This shift makes the study of patient satisfaction vital in improving the healthcare experience for all.
Chapter 1- Evaluating Patient Satisfaction and Quality of Care Among Adult Cancer Patients in Saudi Oncology Wards: A Sequential Mixed-Methods Study
Evaluating Patient Satisfaction and Care Quality in Saudi Oncology Wards is a comprehensive mixed-methods study focused on understanding patient satisfaction as a key indicator of care quality among adult cancer patients. Through questionnaires and one-on-one interviews, it offers valuable insights into the patient experience at the Saudi Regional Cancer Centre in Riyadh, contributing to enhancing care quality in this critical healthcare setting.
Introduction
Patient satisfaction is an integral aspect of the patient experience and a vital indicator of healthcare quality, particularly in the context of adult cancer patients within oncology wards in the Kingdom of Saudi Arabia (KSA). This sequential mixed-methods study utilizes quantitative research instruments, such as questionnaires and qualitative one-to-one patient interviews, to comprehensively examine the multifaceted nature of patient satisfaction and its relationship with care quality at the Saudi Regional Cancer Centre in Riyadh (SRCC).
Recognized as a priority within the healthcare sector, patient satisfaction has gained heightened importance in the Saudi region, exemplified by initiatives aimed at achieving "Joint Commission International (JCI)" accreditation (Alturki and Khan 2013). It is acknowledged that patient satisfaction is influenced by various factors, particularly interpersonal and structural elements (Donabedian 1980).
Patient satisfaction is intrinsically linked to the quality of care provided by healthcare providers (Donabedian, 1980). Quality of care encompasses factors like access to necessary healthcare services, effective treatment processes, and achieving positive health outcomes. Key determinants of patient satisfaction include the communication skills of healthcare professionals, such as doctors and nurses, and structural aspects, including the size of the hospital and ward (Donabedian 1980).
However, the measurement and interpretation of patient satisfaction remain complex due to its relativity and localization, as suggested by studies like Hobb (2009) and Jagosh et al. (2011).
Quality of care has gained prominence as a focus in assessing healthcare services worldwide (Groene et al., 2008), with patient satisfaction being a central component of this experience. Patient-centredness has garnered considerable attention, emphasizing the therapeutic value of the doctor-patient relationship and integrating patients' religious and spiritual needs into their care (Krupat et al. 2001; Street et al. 2009; Kenny et al. 2010). It's important to note, however, that patient-centredness alone doesn't guarantee patient satisfaction (Kupfer and Bond 2012).
In the Saudi Arabian context, measuring healthcare quality and patient satisfaction is particularly challenging, as Western models do not seamlessly apply. While the KSA's healthcare system is progressively Westernizing in terms of policy, standards of care, and healthcare provider education, it still retains certain unique features such as gender politics, non-disclosure practices, and language barriers between providers and patients, which can significantly impact care quality (Younge et al. 1997; Al-Shahri 2002). Despite these challenges, the KSA's healthcare system is rapidly evolving and seeking international accreditation, making it crucial to explore and adapt patient satisfaction measures to this changing healthcare landscape.
Aims of the Study and Research Question
The primary objective of this sequential mixed-methods study was to evaluate patient satisfaction, viewed as an integral aspect of the patient experience, with a primary focus on its role as an indicator of care quality for adult cancer patients in the oncology wards of the Saudi Regional Cancer Centre in Riyadh (SRCC), Kingdom of Saudi Arabia. This study places a strong emphasis on understanding the clinical effectiveness of care as it pertains to the patient experience within SRCC's oncology wards.
The central research question that arises from this primary objective seeks to explore the contributing and inhibiting factors of patient satisfaction in the unique setting of oncology wards at SRCC: "What factors influence patient satisfaction with care in oncology wards at SRCC?"
To achieve this overarching aim, the study delineated specific objectives:
To assess the relationship between clinical effectiveness and patient satisfaction among adult cancer patients in the oncology wards at SRCC.
To investigate how the accessibility of healthcare services is linked to patient satisfaction within the adult oncology ward settings at SRCC.
To provide a comprehensive description of the demographic and clinical characteristics of adult oncology patients at SRCC.
To examine the impact of interpersonal aspects of care on patient satisfaction within adult oncology wards at SRCC.
To offer practical recommendations for enhancing patient satisfaction in the unique context of oncology ward settings in the Kingdom of Saudi Arabia.
To delve into the qualitative findings and their potential in explaining the initial quantitative results regarding patient satisfaction in oncology settings in the Kingdom of Saudi Arabia.
The specific sub-questions formulated to address these objectives are as follows:
To what extent does clinical effectiveness, including the skills of healthcare professionals, information provision, and availability, influence patient satisfaction among adult oncology inpatients at SRCC in Riyadh?
How do the organization and accessibility of healthcare services impact the satisfaction of adult oncology inpatients at SRCC in Riyadh?
What are the socio-demographic characteristics of adult oncology inpatients receiving care at SRCC in Riyadh?
How do interpersonal aspects of care influence the satisfaction of adult oncology inpatients at SRCC in Riyadh?
How do socio-cultural communication factors factor into the satisfaction of adult oncology inpatients receiving care at SRCC in Riyadh?
The Significance of the Research
This research holds significant value for several reasons:
(a) It marks one of the pioneering studies in the Kingdom of Saudi Arabia (KSA) to employ a patient-experience framework within a hospital context to investigate patient satisfaction.
(b) Beyond the boundaries of Western contexts, where patient satisfaction research has been more prevalent, there exists a noticeable gap in international research using the mixed methods approach. This study seeks to bridge this gap, offering insights beyond the Western sphere, especially within the Gulf Cooperation Council (GCC), encompassing Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates, along with other Arab nations. It aims to shed light on the intricacies of the doctor-patient and nurse-patient relationships, particularly in the context of religious beliefs, cultural norms, and patriarchal influences.
(c) By exploring the dynamics of healthcare relationships in the KSA, this study contributes to the broader understanding of these relationships within the GCC and other Arab countries. The findings will provide valuable insights into how religious beliefs, cultural norms, and patriarchal influences shape these interactions.
This study is poised to exert a lasting influence on future practices, educational strategies, and research endeavours related to patient satisfaction and experiences with healthcare providers in oncology wards across the Kingdom of Saudi Arabia.
1.4 Patient Satisfaction and Quality of Care:
This section clarifies the definitions of key terms, including quality of care, clinical effectiveness, patient experience, and patient satisfaction. It sets the stage for precisely understanding these fundamental concepts in the research context.
Quality of Care
Quality of care is a multifaceted concept that lends itself to examination from various angles (Chassin and Gavin 1998; Heath et al. 2009). Campbell et al. (2000, p. 1614) define it as the ability of individuals to access the necessary health structures and care processes, along with the effectiveness of the care received. On the other hand, Lohr (1990) characterizes it as the extent to which health services contribute to desired health outcomes for individuals and populations while aligning with current professional knowledge (Lohr 1990, p.65).
When assessing the quality of care, different dimensions can be considered based on the aspects of care under scrutiny. Donabedian's influential framework (1980) delineates quality of care into three components: structure, process, and outcomes. Structural components encapsulate the care delivery context, encompassing factors like facilities, equipment, and organizational characteristics. Process components involve all the activities that constitute healthcare, from diagnosis to treatment. Outcome components encapsulate the consequences of healthcare on patients or populations. The Donabedian care-assessment model has been widely adopted across international healthcare settings to evaluate patient satisfaction concerning care quality (Ware et al.1989; Campbell et al. 2000; Kringos et al. 2010; Khamis and Njau 2014). This model serves as a vital framework within the context of the present study. It is worth noting that quality care indicators can vary significantly in their validity, as will be elucidated further in the subsequent sections of this study.
Clinical Effectiveness
The concept of clinical effectiveness, while closely intertwined with quality of care and patient experience, primarily pertains to the efficiency and competence of healthcare practitioners. Clinical effectiveness can be succinctly defined as the practice of "the right person carrying out the right procedure based on evidence, in the right manner, at the right time when the patient requires it, at the appropriate location, resulting in a positive clinical outcome or health improvement" (NHS QIS 2005). Detailed methods for gauging and evaluating clinical effectiveness will be explored further in Chapter 2 of this study. Existing literature suggests a positive correlation between patient experience and clinical effectiveness (Doyle et al., 2013). However, in the context of the Kingdom of Saudi Arabia, there is a dearth of evidence regarding assessing patient experience, including satisfaction, from the perspective of clinical effectiveness.
Patient Experience and Patient Satisfaction
Patient experience has emerged as a fundamental component of quality care (Tsianakas et al. 2012; Beattie et al. 2015) and is generally defined as the patient's perception of the entire healthcare process. Within the realm of patient experience, this study zeroes in on patient satisfaction, a pivotal construct at its core. Patient satisfaction is "a healthcare recipient's response to prominent aspects of the context, process, and outcomes of their service encounter" (Pascoe 1983, p.186). It is intrinsically intertwined with the quality of care (Cleary et al. 1989; Stewart 2001; Batbaatar et al. 2015). It is a vital indicator of care quality, albeit inherently complex to assess (Cleary 1998; Al-Rubaiee 2011). Various factors, including personal attributes, attitudes, and past experiences, influence individual patients' responses to the quality of healthcare they receive (Oberst 1984; Blanchard et al. 1990). Even if a hospital boasts exceptional organization, an ideal location, and state-of-the-art equipment, low patient satisfaction can signal a failure to provide effective healthcare (Donabedian 1988; Draper et al. 2001; Turhal et al. 2002; Barlesi et al. 2005).
Enhancing patient healthcare experiences is a central objective of improvement initiatives (Umar et al. 1995; Alturki and Khan 2013; Mohamed et al. 2015). While patient satisfaction is intricate and challenging to measure in healthcare, patient surveys and self-reported outcomes have proven effective tools in hospitals. They are the gold standard for quality assessment in hospital-based care settings (Ervin 2006; Lynn et al. 2007; Groene et al. 2008; Copnell et al. 2009). Nonetheless, certain studies (Sait et al. 2014, Stavropoulou 2010; Al-Sakkak 2008) have indicated that many patients may report satisfaction with care that, in reality, is ineffective. Al-Sakkak (2008) and Stavropoulou (2010) suggest that patients' low literacy levels and insufficient understanding of surveys may lead them to offer opinions on healthcare quality without fully grasping the care they received.
The literature review in Chapter 2 provides a detailed exploration of 'satisfaction' and various methodologies for assessing and measuring patient healthcare experiences. It also examines the numerous factors that can influence patient satisfaction. Notably, evidence suggests a connection between satisfaction and patients' adherence to medical regimens, as well as their compliance with cancer treatments and improvements in health status (Ware and Davies 1983; Borras et al. 2001; Westaway et al. 2003).
As discussed in section 1.6, a notable aspect considered in the current research was the potential interplay between patient satisfaction, disclosure, and patient autonomy—a dimension historically underemphasized in the Kingdom of Saudi Arabia.
Overview of the Study Context
The study is situated in the unique context of healthcare services provided to adult cancer patients within oncology wards at the Saudi Regional Cancer Centre in Riyadh, Kingdom of Saudi Arabia. This context not only reflects the intricate dynamics of healthcare delivery in a Gulf Cooperation Council (GCC) country but also encompasses cultural and religious considerations that play a significant role in shaping patient experiences and satisfaction. The study delves into the multifaceted relationship between patient satisfaction, clinical effectiveness, and the quality of care within this specific healthcare environment, with a focus on how these elements intersect to influence the patient experience. By exploring this distinct context, the research aims to provide valuable insights for enhancing patient satisfaction and care quality in oncology settings in the KSA.
History and Background of the Kingdom of Saudi Arabia
The Kingdom of Saudi Arabia (KSA) was established as an Islamic state in 1932, marked by the country's unification. It holds a position of significant political influence in the Middle East and the broader Muslim world due to the two holy mosques in Makkah and Madinah. As of the 2010 census, the KSA had a population of 29.9 million, with 73% being Saudi citizens (Central Department of Statistics and Information, KSA 2010). The country also employs many non-Saudis across various sectors, including healthcare.
Riyadh serves as the capital and is the largest city in the KSA, with a population of just over 7 million, constituting approximately 24% of the nation's population (World Population Review 2014). To provide a sense of scale, this population surpasses that of Scotland by nearly 2 million, with Scotland's population standing at just over 5 million (Scotland National Statistics 2014).
Religion plays a central role in Saudi society, with cultural and social norms deeply rooted in the Sunnah, a collection of documents that represent a model for life-based on the actions and sayings of the Prophet Muhammad (peace be upon him). Consequently, daily life in Saudi Arabia adheres to the teachings of the Prophet Muhammad, and the Sunni Hanbali school of Islam is the predominant source of guidance. The monarchy, led by the King and the Royal Family, exerts a strong influence over Saudi politics, effectively governing the state. This results in a cultural unity characterized by a shared Arabic language, commitment to the Sunni Hanbali school of Islam, and a sense of national culture.
The KSA Culture
In the cultural framework of the Kingdom of Saudi Arabia (KSA), Islam serves not only as a religious belief but also as the foundation for a comprehensive social system that shapes various aspects of individuals' lives. However, there are differences in the interpretation and understanding of Islam, leading to a diverse spectrum of compliance with traditional Islamic structures and varying levels of adherence to Islamic principles. This diversity within Islamic culture is attributed to a range of factors, including distinctions between urban and nomadic lifestyles, tribal and non-tribal affiliations, distinctions between city-dwellers and villagers, and individual characteristics such as literacy, open-mindedness or conservatism, as noted by Beling (1980).
The KSA maintains a patriarchal social system characterized by male authority within kinship family groups. In this culture, men hold dominion over women, often viewed as the "inferior gender," largely due to the values attached to the male gender as providers and protectors. The social context in Saudi Arabia places a significant emphasis on the importance of individuals recognizing and respecting the welfare of others. Additionally, Saudi social norms are defined by specific ideals related to dignity and honour, as expounded by Beling (1980).
Healthcare in the KSA
Saudi citizens can access public healthcare services, typically without incurring direct costs. The Ministry of Health, in collaboration with the King Faisal Specialist Hospital and Research Centre (KFSH&RC), universities, and certain segments of the military, is responsible for administering the Saudi Arabian Health System (MOH 2006). Notably, the Saudi healthcare workforce comprises a relatively low percentage of Saudi nationals, significantly relying on healthcare professionals from other countries, including India, the Philippines, South Africa, the United States, and the United Kingdom (Al-Dossary et al. 2008).
Saudisation
It's important to note the concept of 'Saudisation' at this juncture. The Saudi government has been actively addressing the disparity between foreign and Saudi nationals in the workforce for over a decade (Ministry of Planning 2002b). This issue is not unique to Saudi Arabia and is also prevalent in several other Gulf Cooperation Council (GCC) states like Qatar and the UAE, where large expatriate populations have grown due to the influx of migrant labourers, filling skill gaps in key employment sectors. While the UAE and Qatar have non-national populations as high as 70-85%, Saudi Arabia's population imbalance, at 27%, is relatively more moderate. Nonetheless, the government has recognized the need to address this issue.
The Saudisation program was introduced with the primary aim of expanding educational and employment opportunities for Saudi nationals, ultimately reducing the reliance on foreign workers and reinvesting the nation's income (Looney, 2004). The Saudisation process has been gradual, and in 2011, the Ministry of Labour in Saudi Arabia launched the Nitaqat ('zones') program to accelerate the replacement of expatriate workers with Saudi nationals in the private sector (Ministry of Labour 2009). Companies are categorized under this program based on their success in nationalizing their workforce, with penalties imposed on those failing to meet Saudisation targets (Ministry of Labour 2009). Despite introducing the Nitaqat program, the transformation remains a slow process. Saudi patients continue to receive healthcare in a multicultural environment, predominantly from non-Saudi (and often non-Arabic speaking) healthcare professionals.
Healthcare within the KSA
A substantial body of literature has raised concerns about the level of care provided to patients in the Kingdom of Saudi Arabia (KSA). Criticisms encompass issues such as fluctuating healthcare facilities, limited access to cancer treatment drugs, substantial communication challenges, resource constraints, and difficulties in implementing necessary organizational changes (Almuzaini et al. 1998; Al-Eid and Manalo 2007; Elkum et al. 2007; Brown et al. 2009; Shamieh et al. 2010). Additionally, healthcare costs in the KSA have risen since 1990, leading to resource shortages and disparities in healthcare quality (Akhtar and Nadrah 2005; Al-Ahmadi and Roland 2005; Walston 2008; WHO 2009).
These issues can be partially attributed to the significant socio-economic and infrastructural transformations the KSA has undergone in the past three to four decades. This transformation, along with a shift in its epidemiological profile from infectious diseases and nutritional deficiencies to the era of degenerative and man-made diseases, including cancer, heart conditions, and cerebrovascular diseases, has contributed to these challenges (Younge et al. 1997, p. 309).
The Doctor-Patient Relationship and Disclosure
The healthcare system in the Kingdom of Saudi Arabia (KSA) faces a pressing issue characterized by suboptimal doctor-patient relationships, which significantly impact the patient experience, particularly patient satisfaction (Elzubair 2002). The quality of the doctor-patient relationship has a profound influence on patient satisfaction, as suggested by Weber et al. (2014), who noted that satisfied patients are more likely to adhere to medical instructions, seek follow-up care, and maintain longer-term professional relationships with their healthcare providers. Conversely, poor doctor-patient relationships yield opposite outcomes and are equally dissatisfying for doctors (Vermeire et al. 2001; Al-Sakkak et al. 2008; Stravropoulo 2010). Patient satisfaction has become a critical concern in healthcare systems not only in Saudi Arabia but also in other Arabian Gulf health systems.
In the KSA, doctors' attitudes and behaviours have historically been shaped by their cultural background (Aljubran 2010). Patients are often perceived as vulnerable and fragile rather than as individuals with their own strengths and coping abilities in the face of illness (Younge et al. 1997). Doctors sometimes fail to uphold what would be considered privacy standards in Western contexts, disclosing a patient's medical condition to their relatives without the patient's knowledge (Younge et al. 1997; Al-Amri 2010). At the core of this issue lies the relationship between disclosure and patient autonomy, which has historically been viewed differently in the KSA. Traditional cultural norms dictate that physicians should initially inform the patient's family about serious illnesses, such as cancer, with the patient being informed only if the family consents (Mobeireek et al. 1996; Al-Amri 2010). Consequently, the next of kin has access to critical information irrespective of the patient's awareness of their health status (Al-Amri 2010). This not only affects the doctor-patient relationship but also implies that findings from earlier research surveys on patient satisfaction within the KSA context should be interpreted with caution, as patients may lack essential information about their care. Consequently, previous literature on patient satisfaction may be biased and may not adequately represent patient populations actively participating in medical decisions and their care.
Globally, there is a widespread consensus in the literature that patient autonomy is a crucial component of quality patient care (McCormack 1992; Gaston and Mitchell 2005). However, this model of disclosure and patient autonomy has not been traditionally practised in the KSA. A decade ago, research by Mobeireek et al. (1996) indicated that the KSA had a considerable distance before patients, as the actual recipients of fully informed care, could actively engage in decision-making about their treatment. More recently, Mobeireek et al. (2008) documented a growing recognition of patient autonomy among physicians. Weber et al. (2014) suggest that the key driver for these changes is the rising personal wealth in the KSA, which has raised patient expectations for higher quality care, including increased attention to the doctor-patient relationship to ensure patient satisfaction in delivering quality care. Similarly, research by Aljubran (2010), in the context of the rapidly evolving KSA society, indicates that patients increasingly expect greater autonomy and now demand full disclosure about their diagnosis and prognosis. This cultural shift underscores the growing need to treat patients holistically, recognizing them as individuals and considering their perceptions of care satisfaction.
Indeed, evidence suggests that patients, particularly those with breast cancer, generally prefer to be fully informed about their cancer status and involved to some extent in decision-making regarding their treatment (Beaver et al. 1996; Andersen et al. 2009; Mendick et al. 2010; Nicholas et al. 2013; Sait et al. 2014). Several studies have proposed that adopting patient-centred care would help eliminate the undesirable but common practice of withholding medical information from patients (Younge et al. 1997; Al-Ahwal 1998; Elzubair 2002; Aljubran 2010). Patient autonomy and disclosure in KSA patients represent only two of the potentially influential aspects related to patient satisfaction.
Patient satisfaction within the KSA will undoubtedly be influenced by how changes in the doctor-patient relationship are managed, especially with evolving patient demographics. Cultural and communication challenges also play a significant role in shaping the understanding of this relationship, both for patients and medical staff.
Cancer Prevalence and Care of Oncology Patients in the KSA
The issue of patient satisfaction in the Kingdom of Saudi Arabia (KSA) is particularly pressing in oncology wards, given the recent rise in cancer rates. Although historically, the KSA has had lower age-standardized incidence rates (ASR) for the top five types of cancer affecting both males and females compared to the USA, Ibrahim et al. (2008) suggest that these differences will diminish. The incidence of cancer in the KSA is projected to increase over the next two to three decades due to factors such as an ageing population, the adoption of sedentary lifestyles and Western diets, and an increasing number of smokers (Jazieh 2012). A recent publication addressing the burden of breast cancer in KSA anticipates a 350% increase in incidence and a 160% increase in mortality over ten years by 2025 (Ibrahim 2008). This substantial increase may be attributed to an expected prevalence of reproductive factors associated with an elevated risk of breast cancer, including early menarche, late childbearing, fewer pregnancies, and the use of menopausal hormone therapy, as well as increased detection through mammography, similar to trends seen in developed countries (Parkin and Fernandez 2006; Zahl et al. 2008).
Notably, the highest increase in cancer cases in the KSA is projected for the next two decades (WHO 2009). Therefore, there is a need for research to examine, inform, and contribute to improving the quality of care to meet the growing demand. In this context, the present study addresses patient satisfaction within the current framework of quality of care in oncology ward settings in the KSA.
The most recent Saudi Cancer Registry (SCR) reports on cancer prevalence and rates indicate 13,706 reported cases in 2010 (Saudi Cancer Registry 2010). This distribution is relatively even in terms of gender, with 48% of those affected being male (6,579 cases) and 52% female (7,127 cases). Men showed an increased rate of cancer (up to 1.5 times the normal rate) after the age of 64, with median ages of 51 years for women and 58 years for men. The report also revealed a geographical discrepancy, with Riyadh (central), Tabuk (northwest), Makkah, and the Eastern Province having the highest rates, measuring 115.00, 92.00, 77.00, and 116.00 cases per 100,000 population, respectively, in 2010 (Saudi Cancer Registry 2010). Additional information from the Saudi Cancer Registry's 2010 report is presented in the figure provided in Appendix 1.
It has been reported that resources for cancer control in the KSA are insufficient and primarily directed toward treatment, with limited focus on prevention and early detection through screening (Rastogi et al. 2004). Recognizing the challenges posed by cancer and to alleviate suffering and improve the future quality of life, the "Improving Cancer Care in the Arab World" initiative was launched in 2010 in Riyadh. This initiative, a high-profile collaboration between the National Guard Health Affairs Oncology Department and the Arab Medical Association Against Cancer, involves several national and international organizations. The initiative addresses various aspects of comprehensive cancer care and control, including the role of service organizations. It has established a ten-year strategic planning process dedicated to implementing improvements in services, planning, and exploring other issues affecting medical reform.
This extensive initiative addresses funding, detection, screening, medication access, and human resource development. It also involves the establishment of population-based registries across all Arab countries as part of a newly developed National Cancer Control Program aimed at enhancing oncology care in general. By shedding light on the relationships between doctors, patients, and nurses in the KSA, the current study contributes to understanding how these relationships operate within the KSA and, by extension, in Arab countries with distinctive cultural beliefs.
Personal Rationale for the Study
As a former head nurse in an oncology unit in the Kingdom of Saudi Arabia, my experience placed me at the forefront of healthcare. I encountered a diverse range of patient care scenarios daily. This hands-on involvement allowed me to observe areas that, in my view, could be enhanced to improve the quality of care provided to cancer patients. Specifically, I strongly believe in considering each patient's unique circumstances and complexities. By prioritizing patient-centred care, we can eliminate obstacles to top-quality healthcare and empower patients by valuing their opinions, emotions, and perspectives.
However, it is crucial to acknowledge the significance of patient-centred care before effective implementation can lead to positive impacts on healthcare quality. Therefore, there is a need for further research in this field to expand our knowledge base and to explore the intricate relationship between patient experience, patient satisfaction, and the quality of care. These personal insights and experiences have been a driving force behind my motivation to conduct this research. Furthermore, my experiences and expertise were invaluable assets during the execution of the present study.
Research Methods
A sequential mixed-methods approach was adopted to investigate the factors influencing patient satisfaction as an indicator of the quality of care, utilizing quantitative and qualitative methods. To execute this Mixed Methods Research (MMR) process, a sequential explanatory mixed-methods model was followed, encompassing an initial quantitative and a subsequent qualitative phase.
Decisions regarding the study design were thoughtfully considered. Employing mixed methods was motivated by the intricate nature of patient satisfaction, which can be assessed quantitatively and qualitatively. As mentioned earlier, patient satisfaction is a "psychological" concept, which is easy to comprehend but challenging to define, making the qualitative approach particularly valuable. In line with the recommendations of Al-Rubaiee (2011), assessing patient satisfaction benefits from a multidimensional measurement approach that includes global questions using direct measures combined with open and close-ended questions. Furthermore, Hudak et al. (2000) suggest that merging interview data with various survey questions can lead to a deeper understanding of patient satisfaction.
Consequently, a mixed-methods approach was employed to harness the strengths of both quantitative and qualitative methods. Typically, a quantitative approach is commonly used in clinical trials to measure factors like pain and disability. On the other hand, qualitative data is instrumental in shaping policies and practices, usually involving data collection aimed at describing and explaining the meanings individuals attach to a particular phenomenon. In the present study, the overarching goal was to examine patient satisfaction in oncology wards using a mixed-method design. This approach facilitated the collection of diverse data for an in-depth analysis concerning the research aims and questions.
As detailed in Chapter 3, some adjustments were made to ensure that the patient satisfaction questionnaire was valid within the specific context of the Kingdom of Saudi Arabia.
In brief, the quantitative phase involved participants completing a patient satisfaction questionnaire to provide data on its correlations with other variables related to the quality of care, such as clinical effectiveness and accessibility. Subsequently, the qualitative phase consisted of conducting semi-structured interviews to explore the quantitative findings further and to elicit patients' perspectives.
Outline of Thesis
The present study is structured into six chapters.
Chapter 1, the introduction, precedes the current section. In Chapter 2, an extensive literature review is provided, covering topics relevant to the thesis's objectives. These encompass quality of care, including Donabedian's model, patient satisfaction, definitions, influencing factors, and measurement approaches, as well as KSA-specific studies on patient experience and satisfaction.
Chapter 3 outlines the selected research methodology and methods and furnishes the rationale for adopting a sequential mixed-methods approach.
Chapters 4 and 5 are dedicated to presenting the research findings. Chapter 4 elaborates on the results derived from the quantitative phase of the study, while Chapter 5 expounds upon the findings from the qualitative phase.
Integrating the diverse threads in a mixed-methods approach can be a particular challenge. This integration is skillfully accomplished in the final discussion and conclusions presented in Chapter 6. This chapter consolidates and assesses all the findings, deliberates on the successes and limitations of the research, and offers recommendations for future investigations.
Chapter 2 - Literature Review
A literature review is a systematic overview of existing academic research on a specific topic. It summarizes key findings, identifies gaps, and helps shape research questions by placing the study within the broader scholarly context. It serves as a crucial compass for researchers, ensuring their work is informed and contributes to the relevant academic discourse.
Introduction
This review begins by describing the methodology used in the literature search strategy and the narrative synthesis method used to combine or pool the results of research studies with various research designs (Coughlan et al., 2013). Then, the chapter discusses the literature on (a) quality of care and the use of the Donabedian model to define it; (b) patient satisfaction, which is a concept based upon the attitudes of a patient towards their care and evaluation of the quality of care and (c) the assessment of patient satisfaction and quality of care in the KSA.
In the third section, which follows the discussion of quality of care and patient satisfaction, a thorough appraisal of the selected literature regarding patient satisfaction in oncology settings in the KSA. A careful assessment of the most robust evidence and a detailed exploration of important and relevant themes emerging from the studies are then offered. The review concludes by identifying the limitations of existing patient satisfaction studies. These limitations are subsequently used to help formulate the research question adopted for the current study and help to articulate the research question and the research design.
Methodology for Literature Review
The methodology for a literature review involves systematically searching, selecting, and analyzing existing research to address specific research objectives. It includes defining criteria for source inclusion, data collection, quality assessment, and structured organization of findings. This methodical approach ensures a rigorous and comprehensive synthesis of the relevant literature.
Narrative Synthesis
This chapter provides a narrative synthesis of existing relevant literature in the KSA and beyond, focusing primarily on publications from the last three decades, as there is little published material on the topic from before 1980. The method of narrative synthesis has been chosen from among the different methods for conducting a literature review identified by Popay et al. (2006) because it relies primarily on words and text to explain, interpret, and summarise the synthesis of findings from multiple studies which inform the research question. Narrative synthesis is a particularly useful method for facilitating evidence-informed policy development internationally (Snilstveit et al. 2012). Popay et al. (2006 p. 5) define narrative synthesis as an:
Approach to the systematic review and synthesis of findings from multiple studies that rely primarily on using words and text to summarize and explain – to ‘tell the story’ – of the findings of multiple studies.
The narrative approach to synthesising research evidence involves critical appraisal of large bodies of evidence, which can employ different research designs, including qualitative and/or quantitative, or a combination of both - mixed methods. The narrative approach is particularly relevant to synthesise diverse evidence from various study designs, as is the case here. Notably, unlike the commonly used specialist synthesis methods, narrative synthesis has not been well developed. For example, one weakness of narrative synthesis mentioned in the literature is the lack of transparency (Dixon-Woods et al. 2005) and clarity on methods and guidance for conducting such a synthesis (Mays et al. 2005).
However, within the past decade, extensive work by Popay et al. (2006) has culminated in published guidance on the conduct of narrative synthesis. This guidance shows researchers precisely how to conduct narrative synthesis systematically and transparently by focusing on the synthesis of evidence, the effectiveness of interventions, and factors determining the implementation of interventions. This guidance has been tested by other researchers and found to be robust and transparent (Arai et al. 2007; Rodgers et al. 2009). It has, however, been emphasised that researchers should ensure their narrative synthesis aims to produce a reflective account rather than simply providing a summary of research findings (Rodgers et al.2009).
Applying this guidance to the current research ensured effective implementation of the technique. Specific tools to assist in the synthesis were adopted, and the narrative synthesis was followed. First, the approach involved setting out the adopted search strategy and describing the reasons for including particular articles. Second, theories were developed, and a preliminary synthesis of the most robust research evidence was performed. This was followed by an evaluation and a reflective account of those articles selected for inclusion. Finally, conclusions and recommendations are offered. The process is shown in the flow diagram in Figure 1.
Figure 1 - Integrative narrative synthesis process (adapted from Popay et al. 2006)
Literature Search Strategy
The selection criteria used for this review were applied in two stages. A final selection followed the initial selection of studies after evaluating quality. As previously mentioned, the literature search was kept within the date range of 1980-2014, as there is little published material before 1980. This also covers the period during which there was a substantial socio-economic change in the KSA, as discussed previously.
Multiple databases were searched, including Science Direct, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Knowledge (multiple databases, including Medline), and Google Scholar. Combinations of search terms were used through the Boolean operator, including: ‘patient satisfaction AND quality of care’, ‘patient satisfaction AND Saudi’, ‘Saudi patient satisfaction’ AND ‘quality of care, Saudi Cancer patient satisfaction AND quality care’, ‘quality health care AND Saudi’, ‘Doctor Communication AND Saudi AND cancer care’, ‘Communication AND Saudi Cancer care’. This search strategy facilitated the capture of all articles about quality care issues in health care, both globally and in the KSA, with a specific focus on oncology patients. In addition to this database search, other documents and reports were accessed via the Saudi Ministry of Health and Saudi Cancer Registry websites. 93 papers were retrieved following this search (see Appendix 2 for the search and screening process).
Inclusion and exclusion of documents
Following the initial search, the next stage of the selection process was to narrow down the articles by reading through the abstracts and removing those not directly related to the current study. The inclusion and exclusion criteria used for this selection are shown in Appendix 3. After this secondary review was complete, 69 articles were selected for full review. The importance and value of hand searching during systematic reviews is demonstrated by Armstrong et al. (2005), who uses the same criteria as described for the current study. Therefore, 21 additional articles were selected by hand, searching the citations from the initially selected articles and identifying relevant articles. These were subsequently narrowed down to nine. Accordingly, 78 papers were ultimately collated and subjected to a quality appraisal.
Quality appraisal
To determine the quality of these extracted papers, all 78 identified primary studies were further subjected to rigorous quality appraisal using the method devised by Dixon-Woods et al. (2005). This approach does not exclude weaker studies but gauges the overall quality of both quantitative and qualitative papers to be graded together using the following five criteria: (1) aims and objectives, (2) research design, (3) methodology, (4) findings, and (5) interpretations and conclusions (see Appendix 4). One point is given for each aspect, and a research paper’s quality is judged by the total score obtained out of five. Of the 78 papers, those obtaining the highest quality appraisal rating were included in the final review. These papers were scored in the following way: 3, if they omitted a robust explanation of the methods used, such as the sampling strategy or the instrument definition; 4, if only a clear interpretation of the results was missing; and 5, if they addressed study aims methods and findings. Due to this screening, 58 papers were selected for use in this review.
Overview of studies
This section presents an overview of the studies reviewed. The details of the 58 papers that were selected and critically reviewed can be found in Appendix 5. Appendix 5 includes a summary of the study aims, sample population, methods, key findings and limitations of the studies for each paper. A preliminary synthesis helped develop theories regarding patient satisfaction; further critical review allowed the exploration of relationships within and between studies. This iterative process identified several common themes and allowed for categorising several identified variations. The rest of this chapter presents the narrative synthesis of the research on quality of care, patient satisfaction, and healthcare in the KSA.
Quality of Care: Definition and Measurement
Quality of care is an increasingly important concept in health care. However, it has proved difficult to measure and quantify given its highly subjective nature (Cleary 1998; Campbell et al.2000; Ladhari 2009; Beattie et al. 2014). Therefore, there is a need for a working definition that can capture the multidimensional nature and reflect the differing perceptions of what comprises quality of care. The Institute of Medicine IOM (2001) define quality as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’ (IOM 2001, p.65). This definition suggests that if patients can access the services they need and if the services provided are useful, then quality is guaranteed. Therefore, this working definition is adopted in the current study.
The traditional method of measuring health care quality was assessing if the care or treatment being provided had achieved its goal, for example, whether the illness was cured or did the patient recovered. Today, a more holistic approach is taken to the issue of quality of care. Quality of care is ultimately how patients reflect upon their experiences in a health setting and if they positively construct them. Therefore, quality of care is ultimately determined by the patient, which is crucial to a patient-centred approach (IOM 2001). Quality of care usually involves more than successfully treating a patient and is related to the overall experience of a patient (Tsianakas et al.2012; Manary et al. 2013; Beattie et al. 2015). An important theme that emerged in the literature review was the wide range of components of care and the differing extents to which they have received attention. This raises the issue of the identity of the indicators we must consider as essentially linked to quality measurement to assess patient satisfaction.
The most frequently identified quality dimensions in literature are safety, effectiveness, efficiency, patient-centeredness and timeliness (IOM 2001; WHO 2006; Copnell et al.2009; Beattie et al. 2015).
Donabedian model
The Donabedian model (1980) provides a framework for understanding the quality of care in a healthcare setting. It does not claim to offer how an organisation can improve the quality of care or even present a definition of what quality of care is. Rather, it should be seen as a way of helping to evaluate it. The Donabadian model offers a way of analysing a healthcare environment or a treatment method to determine what can be done to understand the level of quality of care of patients. Information on patients’ satisfaction with the quality of care can be assessed with the help of information captured under three domains: (1) process, (2) structure, and (3) outcome. The information captured under these domains is all particular to the domain. Structure is the context and environment in which the care is provided. This can include the buildings, equipment and staff. Process refers to the various actions and initiatives taken in treating a patient and includes all the actions involved in the care of a patient, from diagnosis to aftercare. It includes clinical and interpersonal aspects of care while delivering medical treatment or intervention. Outcome refers to the series of consequences and effects of the treatment on a patient. This is possibly the most important of all the concepts in the Donabedian Model. It is ultimately the main criterion for a patient’s level of satisfaction with the care received.
The Donabadian model privileges the interaction between staff and patients as a key factor in quality of care. The different information from every domain is assessed, and this allows a researcher or a health professional to conclude as to what can be done to provide an improved level of care. The outcomes of the patients are then examined. Usually, one particular outcome is examined to measure the structures and process. The aim is to determine how they can be changed to improve the quality of care. The model is often used to modify structures, such as facilities and processes, and patient interpersonal relations to deliver higher-quality care. The model has also been used to improve the information flow among the various departments in a healthcare setting (Fenny et al., 2014).
The Donabadian Model is not the only model of care. The World Health Organization (WHO) recommended the Quality of Care Framework, which is a widely accepted model of care (WHO, 2010). The framework seeks to understand how optimal care for all can be established and particularly tries to measure staff responsiveness. Another model is the Bamako Initiative; this was designed in an African context. Its emphasis is on providing an efficient service to patients by streamlining the system for the delivery of health care (Knippenberge et al.1997). The Donabadian model has certain strengths compared to the mentioned models. It offers a model as to how to evaluate something difficult to measure. By linking the domains of structure, process and outcome, it can offer a holistic approach to evaluating the quality of care. Furthermore, the Donabadian model identifies areas that need to be examined, such as interpersonal relations, that are important in the quality of care.
The Donabedian Model does not try to measure the quality of care; rather, it provides a theoretical framework that allows professionals to examine the factors involved in the quality of care for patients. For example, the Donabedian Model was used to construct reliable findings on patients’ satisfaction in an outpatient setting in Dar Es Salem, Tanzania (Khamis and Njau, 2014). There is a strong relationship between all three domains, as suggested by Donabedian (1980), and all need to be explored together (Khmais and Njau 2014, p. 6). The model has been widely used as the basis for identifying quality in many settings (Tarlov et al., 1989; Irvine and Donaldson, 1993; Campbell et al., 2000; Kringos et al., 2010). The model has been used to generate data and insights into patients’ quality of care and provides concepts useful in identifying factors that influence patients’ satisfaction and has been useful in the current research. In the current study, the Donabedian (1980) model was used to assess factors contributing to patient satisfaction in inpatient settings such as oncology wards in the KSA. It was chosen because it is highly flexible and does not seek to impose a definition of what quality of care is. The flexibility allowed me to establish a model of care adapted to the local context in the KSA and, in particular, to Saudi subject's construction of satisfaction.
Influence of Donabedian’s model
Debates and findings in the literature regarding quality of care demonstrate the widespread influence of the Donabedian model and appear to centre upon organisations’ service structures and processes, plus doctors’ and nurses’ skills and availability (Chassin and Gavin 1998; Copnell et al. 2009). In a study on quality of care in hospitals by Cornell et al. (2009), indicators were first classified based on aspects of care provision (structure, process, and outcome), then according to the dimensions of quality (safety, effectiveness, equity, patient-centeredness, efficiency, and timeliness), followed by the domain of application, including hospital-wide surgical and non-surgical clinics. The study of Cornell et al. (2009) found that while there were many available indicators, there were instances where they were not applicable and inadequately measured the quality of care, and further studies were needed to determine which of the existing indicators were pertinent.
Research suggests that the structural aspects of healthcare have implications for patient satisfaction. Structure of care refers to ‘the organizational factors that define the health system under which care is provided’ (Campbell et al., 2000, pp. 1612). A key domain of a healthcare delivery system is how it is structured to involve service organisations or access to services in the healthcare facility (Donabedian 1980; Davies and Crombie 1995; Campbell et al. 2000; Sizmur and Redding 2009). This includes the ease and rate of the movement of patients from one facility to another, the availability of services, such as screening and testing, the effectiveness and organisation of the schedule that the patients have to follow, and the overall experience of the patients during their time in health care. Patients’ experiences of access to services, which include service organisations and structures, can significantly contribute to patient satisfaction, which is one of the key indicators of quality of care. Hence, assessing access to services represents a further dimension needed to meet the aims of the current study.
Research further suggests that the processes by which healthcare is delivered are related to patient satisfaction. According to Campbell et al. (2000), Donbedian’s care process ‘involves interactions between users and the health care structure; in essence, what is done to or with users’ (p. 1612). Of fundamental importance to processes of care is clinical effectiveness, an important criterion for patient satisfaction (Schuster et al. 2005; Campbell et al. 2009). Clinical effectiveness is the delivery of suitable patient care in a suitable manner by health professionals with the best outcome possible for the patient and their well-being (Doyle et al., 2013).
Studies by Cleary and Edjman-Levitan (1997), Chassin and Gavin (1998), and Campbell et al. (2000) describe a plethora of different quality indicators with little standardisation. A study undertaken by Bredart et al. (2007), using the EORTC INPATSAT32 questionnaire, found that the most relevant quality indicators were the interpersonal skills and availability of nurses and doctors and information provision. The EORTC INPATSAT32 tool is cross-culturally validated and can judge the satisfaction level of patients from different cultures. The difficulty in measuring quality of care was confirmed by some studies to be due to a lack of a standardised definition of what comprises quality and how best it can be measured (Mainz 2003; Groene et al. 2008). Mainz (2003) differentiated quality based purely on structure (number of specialist doctors available, access to equipment and tests, access to specific units, etc.), process (protocols and procedures that were used in treatment and care), and outcome (mortality, health status, satisfaction and patient quality of life). From the consensus in the literature, it is clear that when considering the patients’ perspectives of their care, a range of influencing factors, including social-political, social-cultural, and socio-demographic, must be considered. Given the difficulty of defining and measuring the quality of care, it stands to reason that it would also be difficult to measure patient satisfaction, the construct at the heart of the current study. However, the indicators discussed above in the Donabadian model allow for parameters to be established to allow the issue of patient satisfaction to be explored.
Patient Satisfaction
This section discusses the literature on patient satisfaction, including (1) the varying definitions of the construct of patient satisfaction, (2) the wide array of factors that have been shown to influence it, and (3) the various approaches that can be used to attempt to measure it.
Definitions
The concept of patient satisfaction has evolved over the years as different definitions have been applied. Linder-Pelz (1982) defined patient satisfaction as evaluating distinct healthcare dimensions. Pascoe (1983, p. 189), on the other hand, defined it as a ‘comparative process involving both cognitive evaluation of care and an affective response that may include both structure process and outcomes of services’. Keith (1998, p. 1122) defined patient satisfaction ‘as a complicated multidimensional concept whose measurement and application are anything but simple’. A more recent definition by Al-Rubaiee (2011) refers to it as a psychological notion that is easily understood but difficult to define. These definitions developed through the literature that has been analysed identify patient satisfaction as a multidimensional concept determined by the individual views of patients asked to complete a questionnaire evaluating the adequacy of care services they have received.
Traditionally, patient satisfaction is largely determined by patients’ evaluation of their experiences across key variables, especially outcomes. This view of patient satisfaction is often regarded as a flawed concept if it is based on perceptions of quality of care. More recent research on patient satisfaction is increasingly linked to how they constructed their experiences (Davies et al.2011; Anhang Price et al. 2014). Patient satisfaction is no longer based on patients’ care ratings but on how they have conceptualised it. That is how they have configured their experiences into a belief or idea that their experiences were positive or negative. This construction involves ‘their multiple satisfactions with various objects and encounters that comprise their care’ (Singh, 1989, p. 177). Patient satisfaction is the conceptualisation of their experiences as good or bad, and the extent to which this concept is positive or negative determines their level of satisfaction. Patient satisfaction is distinct from their experiences, although dependent upon those experiences. Patients’ experiences are the encounters with healthcare professionals in a healthcare setting. Satisfaction is the conceptualisation of the totality of their experiences in a healthcare setting, which is influenced, but not determined, by one experience. Patient satisfaction is defined as the evaluation of the conceptualisation of their experiences and the extent to which it has satisfied their needs and delivered the expected outcomes (Jenkinson et al.2002). This working definition is adopted throughout the thesis.
Central to patient satisfaction are patient expectations. Satisfaction in the clinical setting can be defined simply as the desirable outcome of care, while perceived service quality refers to the process where the consumer (in this case, the patient) compares his/her expectations with the service he/she has received, which, in this case, is a subjective measure (Gronroos, 2000). Smith (1992) likewise recognises the subjective nature of patients’ care evaluation, thus illustrating the complex interrelationship between perceived need, expectation of care, and care experience. Indeed, patients’ expectations of care are known to be influenced by several factors, including patient characteristics, prior experience and characteristics of the situation, and environmental factors (Oberst 1984). Expectations predispose a patient to have a positive or a negative experience. Satisfaction levels are related to whether a patient’s expectations are met when they encounter the health care system (Bowling et al. 2013). The degree to which a patient’s expectations are confirmed or disconfirmed is important in constructing their experience in a healthcare setting and upon which they base their level of satisfaction ( Bowling et al. 2013).
Customer and patient satisfaction constructs are similar in that they value the process by which services are delivered. For a patient, service delivery includes medical care and the provision of comfort, emotional support and education (Kupfer and Bond 2012). Also, there is a suggestion that to satisfy patients continuously, there is a need for physicians to incorporate patient perspectives into the clinical decision-making process. Patient satisfaction can be misinterpreted as there is more to it than a health service provider offering high standards of care and ignoring individuals’ perspectives. Good quality health care by itself does not guarantee that patients evaluate their experiences in a positive light. Findings in the literature recognise the need to differentiate between the two concepts of quality health care and patient satisfaction (Cleary 1998; Haddad et al. 2000). Al-Rubaiee (2011) describes satisfaction as a moving target that must be monitored to understand the content of patient expectations and ensure health care providers respond proactively to enhance the standard of care provided to patients. In other words, patient satisfaction should be supported by capabilities and a need for ongoing evaluation of quality of care to identify opportunities for service or care innovations.
Influences
The research suggests that various factors influence patients’ constructions of their experiences in a healthcare setting, although patient satisfaction is generally difficult to isolate from overall clinical outcomes. This section starts by discussing several cultural and demographic influences more generally. Then, it focuses on specific influences found consistently in the patient satisfaction literature: disclosure practices, gender politics, respect for patients’ religious beliefs, the doctor-patient relationship, and the practice of patient-centred care.
The influences on patient satisfaction are difficult to separate from overall clinical outcomes for several reasons. According to Jackson et al. (2001), the psychological determinants that may lead patients to express themselves as being relatively satisfied or dissatisfied remain largely unknown, a point reiterated in the literature reviewed in this section. To attempt to bring some clarity to these important areas, Jackson et al. (2001) set out to establish which characteristics of patients (and physicians) correlate with expressions of satisfaction, what the contribution of the many satisfaction variables identified in previous studies may be, and the extent to which the co-relationships remained constant over time. They found that patients over sixty-five years old are more likely to be generally satisfied; however, the most important predictor of satisfaction, according to them, was the meeting of expectations. This supports the findings of Hall and Dornan (1990), who found that higher satisfaction levels were associated with increased age.
Indeed, considerable research exists indicating older patients tend to be more satisfied with their health care, a phenomenon which is consistent across cultures and nations (Campbell et al. 2001; Crow et al.2002; Jaipaul and Rosenthal, 2003; Sofaer and Firminger, 2005; Moret et al.2007; Quintana et al.2006; Bleich et al. 2009; Rahmqvist and Bara, 2010; Lyratzopoulos et al. 2012). This may arise from older people having lower expectations of the health care system, and therefore, there is less likelihood of their expectations being unmet. However, some researchers maintain that these findings may be flawed and not a true reflection of reality due to an inherent caution and reluctance of older people to voice their dissatisfaction when questioned about the adequacy of their health services as they are in constant need of it (Bowling, 2002; Bowling et al. 2013). Finally, the findings of this review suggest that there has been little research on the demographics and other patient characteristics as determinants of patient satisfaction in KSA oncology settings; this is an area warranting increased attention.
Generally, patients’ construction of their experiences based on their care may involve complex processes. It may be influenced by the values and beliefs of each patient, along with other variables such as health status and socio-economic status. A further factor frequently mentioned in the literature on patient satisfaction is patient-centred care (De Silva, 2014). Within the UK, the need for a patient-centred health system is widely accepted since this approach supports people making informed decisions about their health and care, facilitating appropriate management of their care (De Silva 2014). The need for patient-centred care is also well-recognised globally (IAPO 2006; WHO 2008), and in 2001, the Institute of Medicine (IOM) highlighted it as a major goal for improving health care in the USA. The IOM report defines patient-centeredness as ‘providing care that is respectful of and representative to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions’ (IOM 2001, p. 3). Kupfer and Bond (2012, p. 139) describe patient-centred care as ‘improving health literacy through information and education, coordination and integration of care, physical comfort, emotional support, and personalised care, which encompasses the concept of shared decision making’. It can be argued that achieving a better experience for a patient and, therefore, higher patient satisfaction levels involves good patient-centred care (Krupat et al. 2001; McCormack 2003).
Throughout the literature, strong patient care has been established as a strong indicator of PCC, but there is little to no literature on evidence of PCC in KSA. In the KSA, other influences have also been identified, such as culture and language differences between KSA nationals and health care practitioners, and these have been found to affect the perceived quality of care patients receive. This is largely influenced by the fact that the nursing workforce in the KSA relies mainly on expatriates who are recruited from different countries such as India, the Philippines, South Africa, North America, the United Kingdom, Australia and Middle East countries (Luna 1998; Tumulty 2001; Aboulenien 2002). One study showed that the language and cultural differences of the expatriate nurses may cause Saudi patients to encounter barriers to communication during health care (Al-Dossary 2008). Thus, the challenge for the KSA is to increase the proportion of Saudi nurses in the workforce to deliver culturally sensitive care, further facilitated by all nurses having a command of the Arabic language used by Saudi patients (Al-Dossary 2008). This would enhance patients' experience and allow them to construct their experiences positively. Notably, however, an earlier study argued that language differences between patients and nurses do not impact the satisfaction level of the patient (Ibrahim et al. 2002). These findings call for more research into KSA patient satisfaction, specifically regarding language and cultural differences between patients and nursing staff.
Other variables highlighted as potentially affecting patients’ constructions of their experiences and the subsequent level of their satisfaction with care in the KSA are political-social, age, or educational issues. Patients who are better educated or younger but have poor health have been found in other contexts (such as in Sweden) to be more dissatisfied than those who were less educated and in better health (Rahmgvist 2001). Also, older patients are more satisfied with the service quality than those in their twenties (Hall & Dornan 1991; Cohen 1996). This may be related to the previously mentioned transformation in the economic climate in the KSA. Older people may be more accustomed to living in austere conditions and, therefore, have lower expectations of the healthcare system and appreciate whatever care they receive (Bowling et al., 2013). Rahmqvist and Bara (2010) likewise identified patient characteristics and quality dimensions related to patient evaluations of their experiences in a healthcare setting, namely age, education and health status.
A systematic review of the available literature by Williamson and Harrison (2010) confirms that culture plays a role in how patients experience health care. Failure to determine the cultural needs of individuals receiving care contributes to dissatisfaction with healthcare practices. Williamson and Harrison’s (2010) study can be extrapolated to other countries with cultural differences between healthcare providers and healthcare receivers. In the KSA, there is a cultural belief related to the Islamic faith that patients who have terminal illnesses cope best with their illness at home, surrounded by family members and friends (Younge et al. 1997). This may be a barrier to proper health care provision due to communication issues in such a home-based treatment. For example, whilst doctors and nurses are welcomed into Saudi homes, there may also be a need for drivers, and possibly translators, to accompany them, especially when the patients are women, due to cultural prohibitions related to gender and social interaction (Dein and Stygall 1997; Al-Amri 2010). Moreover, since a large proportion of the nursing workforce is expatriate, while the healthcare receivers are largely Saudi nationals, there is a potential for language and cultural differences, leading to misunderstanding and unsatisfactory encounters between patients and health professionals (Al-Dossary 2008). In contrast, another study (Arora 2003) argued that the language differences between patients and doctors and nurses do not impact patients’ reflections on their experiences. The study noted above by Ibrahim et al. (2002) found that the patients were satisfied with the doctors’ skills and their interpersonal behaviour, even in cases where there were language differences between them. These contrasting findings suggest that more research is needed to determine the effect of and accurately identify communication barriers (between patients, doctors and nurses) on patient satisfaction. Indeed, a better overall understanding of the causes of the positive or negative views by patients on their experience is very much needed.
Disclosure practices
An important cultural issue that may impact patient experiences and their reflections on them is disclosure. Research in Japan by Tanaka et al. (1999) found that patients suffering from terminal cancer wanted clarity on their prognosis so that they could make the best use of their time. The study argued that it is a basic human right of an individual to know about his/her prognosis.
However, in the KSA, patients are often not given the privilege of being treated as independent individuals but are approached as extensions of the family (Aljubran 2010). Al-Ahwal’s (1998) study in the KSA evaluated the awareness of cancer patients of their diagnosis and prognosis from the perspective of a small population of doctors, patients and lay people. The study uncovered a low level of awareness about cancer patients’ prognosis despite a desire that they be made fully aware of their conditions and be treated as autonomous individuals. The doctors largely conceded that they preferred to tell the patients the truth regarding their diagnosis and prognosis. Indeed, it is increasingly being recognised that for KSA doctors to provide suitable treatments for their patients, disclosure and effective communication are important issues (Aljubran, 2010; Younge et al., 1997).
Concealing the diagnosis from cancer patients may lead to poor patient compliance, misinformation about treatment options, and side effects, which could hurt the patient’s survival and remaining quality of life. However, even where disclosure occurs, cultural barriers can exist because of a reluctance to accept a terminal prognosis. This puts healthcare providers in a complex situation, as they are expected to be sensitive toward the patients and their needs and continue the care despite their professional judgment (King et al. 2008). In this regard, it is important to have quality palliative care along with effective coordination between the primary, secondary, and tertiary care services.
Gender politics
One social issue that hinders the quality of care in the KSA is the cultural background relating to women, who still require permission to seek health care from a male guardian and cannot freely communicate their needs to health care professionals, especially regarding reproductive health. This can lead to restrictions on access to health care (Walker 2009). Intervention by the male relatives can mean that healthcare professionals cannot properly investigate the illness of the women (McBride 2008).
For example, McBride (2008) and Elkum et al. (2007) both highlight serious issues relating to breast cancer in the KSA, namely, the cultural stigma associated with the disease and a lack of empirical research on the protocols or techniques involved in its diagnosis and treatment. Breast cancer is the most common type of cancer among Saudi women, yet there is an exceptionally high proportion of young women not being diagnosed (Elkum et al. 2007; Ibrahim et al. 2008). This is largely due to the inherent barriers to screening associated with cultural issues and leads to problems with obtaining accurate and early detection. This, in turn, has negative ramifications on prognosis (Elkum et al. 2007; Ibrahim et al. 2008) and, by extension, with quality of care, which can impact patient satisfaction, which is highly dependent upon meeting expectations.
Respect for religious beliefs
Almuzaini et al. (1998) note that since the 010[KSA is an Islamic nation and that Islam is very influential in healthcare. The provision of religious or spiritual care is often offered in the KSA as a relief mechanism to patients suffering from terminal illnesses (Dein and Stygall 1997). This may be either as an alternative to or alongside palliative medical care. Indeed, Boyles and Nordhaugen (1989) suggest that healthcare activities are at variance with the religious and cultural norms of the nation when one considers that under the pervasive influence of Islam, there is widespread acceptance that one must die and the suffering associated with death is regarded as the show of one’s faith in religion and God. This sentiment is said to help patients cope with cancer better than any other country (Ezzat et al. 1995; Young et al. 1997; Al-Shahri 2002).
Many doctors and nurses are influenced by Western models of care, which are largely secular and strive to provide the best service with a detachment from any religious reasoning of their patients. Clearly, given the issues previously discussed, it could be problematic if doctors lack empathy for such socio-cultural factors during their discussions, prognosis, and treatment of the disease with Saudi patients. This could conceivably create distrust in the health care service and result in patients negatively constructing their experiences.
Doctor-Patient Relationship
Research further suggests that the doctor-patient relationship is an indicator of patient satisfaction. The encounter between practitioner and patient is valuable for defining patient evaluation of quality of care and can be seen as fundamental to the doctor-patient relationship (Ong et al. 1995). Although patient-centred communication is at the heart of such interactions, there are different levels and types of communication. These have been separated into three areas by Ong et al. (1995): (1) the creation of good interpersonal relations between the doctor and the patient, (2) the exchange of information, and (3) the making of decisions which are related to the treatment. Ong et al. (1995) found that the extent and type of communication used by the doctor and the patient's responsiveness will subsequently have a strong impact on the levels of satisfaction derived by the patient from the interaction. Improvements in the doctor-patient relationship will directly influence the quality and levels of patient-centred care and, in the long term, improve patient’s evaluation of their experiences.
In the setting of the KSA, practitioner-patient interactions are mostly characterised by the doctor having authority over the patient (Younge et al. 1997; Elzubier 2002). The problem of high control by doctors was noted by Al-Shahri (2002). It was considered a consequence of the staffing of the Saudi Arabian health system with predominantly non-Saudi health professionals. It has been suggested that such staff might demonstrate low cultural awareness of the Saudi patients and have difficulties with the language. Non-Saudis tend to take a less directive approach to health care, in keeping with the traditional practices taught to them in their countries of origin, which invariably represent Westernised practices. Al-Shahri (2002) believes a shift in perceived quality of care could occur if those health professionals who develop care management plans for Saudi patients are introduced to the Saudi culture. This introduction could help develop more culturally sensitive health professionals, which could positively influence the perceived quality of care by Saudi patients since cultural sensitivity is a key determinant of patients’ constructions of their experience (Bialor et al. 1999).
The particular nature of the doctor-patient interaction in the KSA culture has resulted in a situation where patients may not have autonomy over their healthcare decisions (Younge et al. 1997). Thus, it is evident that information exchange between practitioners and patients tends to be very low, largely due to poor patient participation in decision-making and/or a lack of patient interaction with doctors or nurses (Elzubier 2002; Al-Amri 2010). As a result, patients may not have full knowledge of their condition even though they receive the care and should be perceived as the key participants in the process. However, the KSA health care system is gradually recognising the importance of sharing health care information with patients. There is a new trend in the KSA health system towards encouraging oncology medical staff to keep patients well-informed about their health status. Conceivably, this may enhance patient satisfaction within the KSA (Mobeireek et al., 2008; Aljubran, 2010). As alluded, it is important to recognise how poorly informed patients could create bias in the results and adversely affect the quality of surveys on patient satisfaction.
One way the doctor-patient relationship has been studied is through communication. In his study of communication processes in primary care practice, Roter (2000) endorsed the need for a model which could provide a better understanding of the connection between communication and therapeutic relationships. He discovered a clear link between the provision of information and emotional support by the doctor and positive health outcomes. Roter (2000) implies that there must be a significant paradigm shift in the understanding of the doctor-patient relationship when he states:
“Just as the molecular and chemistry-oriented sciences were adopted as the 20th-century medical paradigm, incorporating the patient’s perspective into a relationship-centred medical paradigm has been suggested as appropriate for the 21st century”. (Roter 2000 p. 5)
Such contentions apply to oncology patient satisfaction in the KSA, where there appears to be a lack of understanding of the relationship between patient-centred communication and therapy and how medical practice influences perceived patient satisfaction (Elzubair 2002). It is suggested by Roter (2000) that the primary challenge to closing this gap is the development of definable and measurable indicators which can represent the conceptual models of the therapeutic relationship, which, in turn, influence patients’ perceptions of their care. It was important to embrace such challenges during the design of the current study the current study.
In a study of women patients with breast cancer and their physicians, McWilliam et al. (2000) attempt to provide evidence of effective approaches to enhancing doctor-patient communication. The study shows that information sharing is intricately related to the relationship between patient and doctor, and this, in turn, affects the patient’s control of the illness. In a further study, Ong et al. (2000) qualitatively analysed relationships between doctor-patient communication and the quality of life and satisfaction of patients. Their findings show that the patient’s perception of their quality of life is largely determined by the affective value of the behaviour of the care-oriented physician during consultation.
Research on doctor-patient communication has also investigated how other information sources may impact communication. Shaw et al. (2007) considered the effects on the doctor-patient relationship of introducing the Internet as an information source. Fundamentally, they aimed to see if the current problems and disparities in doctor-patient relationships could be moderated by the provision of information to women with breast cancer from a source other than doctors. The study showed a statistically significant difference in patients’ perceptions of the doctor-patient relationship after providing high-quality internet-based information. Interestingly, while a negative perception of the doctor-patient relationship was significantly aligned with higher use of the information tool during treatment, in the post-test survey, there was an association between the use of the information tool and a ‘positive appraisal of the doctor-patient relationship’. While this intervention by Shaw et al. (2007) may signal a potential means of improving doctor-patient communication, it lacks the depth needed to establish the extent of the effect. Thus, there is a need for caution in its application, particularly in the KSA.
In a study of how to improve health through communication, Street et al. (2009) identify seven pathways for doing so: (1) increased access to care, (2) greater patient knowledge and shared understanding, (3) higher quality medical decisions, (4) enhanced therapeutic alliances, (5) increased social support, (6) patient agency and empowerment, and (7) better management of emotions. In another study emphasizing the importance of doctor-patient communication, Kenny et al. (2010) state that good communication is essential if the notion of ‘relationship-centred care’ is to be encouraged. Their results show some significant differences between what patients perceive as the communication skills of the doctors and the doctors’ perceptions of those skills. The qualitative research by Jagosh et al. (2011) reveals that doctors’ listening to patients is a critical part of the communication process. These results echo the Institute of Medicine’s (2001) claims about aligning care to the ‘voice of medicine’ as part of the patient-centred care approach.
These studies demonstrate a clear connection between communication and a successful doctor-patient relationship, and there is some evidence that the more the emotions of patients are satisfied by the doctor through effective and considerate communication, the higher the levels of satisfaction generated. However, there is also evidence that the effectiveness of this relationship appears to depend on the severity and associated psychological condition of the patient (McWilliam et al., 2000; Ong et al., 2000; Street et al., 2009; Jagosh et al., 2011). In other words, whilst a correlation seems to exist between communication and patients’ satisfaction levels, the strength of this correlation remains equivocal and is a subject for further study.
During the past four decades, there has been a transition in the doctor-patient relationship from one in which the decisions of doctors were ‘silently complied with’, and any information imparted by the doctor was designed to support his or her opinion of the most suitable course of treatment, to one in which the patient has an expectation of being at the centre of the process and anticipates a greater level of “mutual participation” (Kaba and Sooriakumaran, 2007, p. 57). This shifting relationship reflects not only a change in the socially constructed view of how patients should be empowered but also one which has been encouraged by the ‘social system’. This means that a patient-centred approach has become the predominant model in clinical practice today. However, the KSA is just starting to address the need to improve doctor-patient communication (Aljubran, 2010), and this aspect of research forms an important element of the current study. The next section discusses patient-centred care in greater detail.
Patient-centred care
The ascent of patient-centred care in recent years has been driven by the recognition that care can often be more effective when tailored to specific patients’ needs (Gill, 2013). Patient-centred care in the literature focuses on the individual, the delivery of whole-person care and communication. This form of care encourages the participation of the patient and their family in the decision-making process about treatment. Although researchers disagree on what exactly constitutes patient-centred care, and thus its influence on patient satisfaction has not been firmly established, ample evidence does suggest that patient-centredness leads to patients reflecting upon their experiences in a healthcare setting positively.
Indeed, the literature reveals the existence of several definitions for patient-centred care, and, largely as a result of this, there is a range of approaches available for measuring patient-centred care. Most take a holistic view or measure specific subcomponents such as shared decision-making or communication (De Silva 2014). The systematic review conducted by Mead and Bower (2000) identified five conceptual dimensions of patient-centeredness: (1) bio-psychosocial, (2) patient-as-person, (3) sharing power and responsibility, (4) therapeutic alliance, and (5) doctor-as-person (Mead and Bower 2000, p. 1087). They also identified other influential variables, such as individual characteristics and consultation processes, suggesting that wider and more complex dimensions may be required before any firm conceptual basis of patient-centeredness can be established. A study of this nature has yet to be performed in the KSA.
Patient-centeredness has been suggested to influence physical and psychological outcomes positively; however, Michie et al. (2003) argue that the evidence is inconsistent. They reviewed the effects on the outcome of chronic illness of two concepts in health care communication: one in which the health professional took the perspectives of the patients, and the other where the aim was to ‘activate’ the patient by ensuring they took an active role in their health care. It was discovered that in studies aiming to activate the patients, the results were more consistently associated with good physical health outcomes (Michie et al. 2003, p. 197). Unfortunately, the application of an ‘activation of patient’ approach may be limited within the KSA due to the cultural norms described above, including issues of disclosure, lack of confidentiality of patient’s health status, and poor patient autonomy (Younge et al. 1997; Walker 2009; Aljubran 2010). The proposal of Michie et al. (2003) to activate the patient for improved outcomes would support the need for better communication and a change in the policy on patient information provision and disclosure in the KSA. This would concurrently enhance patients’ understanding of their treatment and allow them to make informed decisions.
Holmstrom and Roing (2010) suggest that because patient-centred approaches seem to be understood differently by different groups within the healthcare profession, a common language should be created to define the contextual and conceptual meanings of patient-centeredness. They were able to differentiate between the terms patient-centred and patient empowerment. Still, they concluded that while the concepts are complementary, patient empowerment has a wider aim, which may place more responsibility on healthcare professionals. On the other hand, patient-centeredness can be seen as the starting point from which patient empowerment can grow. Unfortunately, patients in the KSA generally have little provision for empowerment, given the entrenched cultural and patriarchal norms, which are contrary to a patient-centred care approach (Young et al. 1997; Al-Amri 2010).
McCormack et al. (2011) researched an attempt by an institution in the United States to promote patient-centred care for oncology patients. They pointed out that no comprehensive measure of such care exists. They imply that research on patient satisfaction fails to focus on certain factors, for instance, how patient satisfaction relates to patient evaluation of care expectations. There is no general model that can account for how patients construct the concept of satisfaction, and to address this issue, McCormack et al. (2011) conducted a comprehensive review of the existing literature and undertook interviews with selected patients. The research identified six core concepts which are prevalent in the notion of patient-centred care: (1) exchanging information, (2) fostering healing relationships through focus on affective care, (3) recognising and responding to emotions, (4) managing uncertainty, (5) making decisions, and (6) enabling patient self-management (McCormack et al. 2011).
Similarly, Mead and Bower (2000) emphasise the fact that the delivery of high-quality health care is contingent upon the use of a patient-centred approach. However, the generalizability of their findings is questionable, warranting further research to test this notion in wider settings. Notably, specific socio-cultural contexts may adversely influence patient-centred care, enhancing patient satisfaction. For example, as mentioned previously, in the KSA, patient-centred care does not fit the socio-cultural norm in which doctors are seen as figures of great authority (Mobeeriek et al. 1996; Younge et al. 1997; Elzubier 2002), and attempts to introduce this model may first necessitate a change in the cultural context to support patient satisfaction.
Some studies indicate that patient-centredness has a definite link to patient satisfaction. Studies by Griffin et al. (2004), Bredart et al. (2007), and Rao et al. (2007), which looked at the effectiveness of different approaches aimed at improving doctor-patient communication, demonstrated the evidence of a significant relationship between overall health outcomes and their experience of care and patient satisfaction. Fielding (2009) argued that the perception of patient satisfaction and adopting a patient-centred approach was important since patients are the end-users of healthcare services. The importance of taking a patient-centred approach that recognizes the importance of patient satisfaction is assuming an increasingly prominent role in health care systems worldwide, with the patients’ perspectives being increasingly considered an essential criterion for judging the quality of care (IOM 2001; Mallinger et al. 2005; Wolf et al.2008; Arraras et al. 2009).
Whilst there is evidence that patient satisfaction has a strong connection with the doctor-patient relationship and with the level of positive communication within this relationship (Arrora 2003; Epstein et al. 2005), the connection with patient-centeredness remains ambiguous (Kupfer and Bond 2012; McCormack 2011), although there appears to be some interrelatedness between the two concepts (Jagosh et al. 2011; Bret 2012). Brett and McCullough (2012) argue that patient satisfaction and patient-centred care are not automatically related. The localisation of the concept of patient satisfaction, and hence, localisation of the concept of patient-centred care, means that patient satisfaction would be differently constructed in different locations. As a result, patient-centred care within the context of the KSA may demonstrate variations from the practice of other countries. For example, the construct of optimised, patient-centred communication may differ between cultures.
Kaba and Sooriakumaran (2007) demonstrate that many physicians do not feel an obligation to meet the demands of a patient-centred care approach. Indeed, the concept of personalised care, which assumes that patients are empowered and work together with physicians in determining their care provision and therapeutic options, is rarely seen in the KSA (Elzubier 2002; Walker 2009; Aljubran 2010). Interestingly, it has been suggested that some evidence of high levels of satisfaction may distort the picture, as some physicians may over-order diagnostic tests and prescribe medications to satisfy the emotional needs of patients, which is related to their expectations, even though they would not serve to improve patients’ physical conditions (Kupfer and Bond 2012).
In summary, it can be noted that there is a lack of consensus in terms of defining and fully understanding the underlying meaning of a patient-centred approach and its influence on patient satisfaction. As in other areas of health care, there would appear to be tension between what one group (health professionals) believe is best for patients and that which patients themselves see as important. Nevertheless, despite the lack of a single concept or a common language or standard, it is clear that the notion of a patient-centred approach is considered critical and should be seen as an important element in the care of patients. This is particularly significant given how patient-centred care can positively influence patient experiences. Currently, there is a relatively limited amount of literature on patient-centred care and how it impacts patient-perceived satisfaction (Nichols et al., 2013). This is an area of research that needs to be addressed.
Measurement
Although patient satisfaction measures are widely used to assess quality of care (Jagosh et al. 2011; Batbaatar et al. 2015), researchers lack consensus on how best to measure the construct. This difficulty seems inevitable, given that it is challenging even to define the construct. A patient’s perceptions of their care are difficult to measure. Patient satisfaction is related to their perceptions of hospital care and other items, and certain validated and reliable questionnaires have been developed to measure it. There is no agreed questionnaire or instrument for data collection on the subject. There is also the issue of construct validity, that is, is the researcher able to measure what they claim to be measuring? The problem with measuring patients’ conceptualisations of their experiences is not so much concerned with determining the factors that influence their views. Such factors are well-known and established, as just indicated. The key challenge is to find a way for researchers to measure the patients’ attitudes to these identified factors in a reliable and agreed-upon way. Therefore, in studying the relationship between patient satisfaction and perceptions of quality of care, it is essential to utilise robust, validated, and reliable questionnaires.
In the past, approaches to measuring patient satisfaction were based on a commerce-driven, process-oriented model rather than the patient’s perceptions of care. Some early studies have shown that certain previous satisfaction surveys lack precision and focus more on clinical aspects than patient perspectives (Ware et al. 1983; Pascoe 1983). Kupfer and Bond (2012) argue that this problem has resulted because patient satisfaction surveys have historically had their roots in consumer marketing, where the quality of the service encountered is measured against the customers’ expectations and probability of repeat business. One implication in a medical setting is that patients’ expectations of quality and satisfaction may be inversely related, as their expectations match their perceived needs rather than a realistic appraisal of what care can be supplied (Williams 1994).
Patient satisfaction is thus fundamentally different in healthcare settings compared to consumer marketing constructs, in which service experience approximates expectations. The patient in a clinical setting tends to be indifferent concerning service quality and satisfaction; their focus is mainly on their treatment outcomes. It is only when expectations are not met that the patient is likely to judge the service quality as low (Kupfer and Bond 2012).
Indeed, ‘satisfaction’ must be a difficult concept to measure in any context. Against a background which sees the achievement of patient satisfaction as an important aspect of health care outcomes, Williams (1994) expresses concerns about the extent to which ‘satisfaction’ can be measured, let alone adequately defined. He argues that ‘satisfaction surveys provide only an illusion of consumerism, producing results which tend only to endorse the status quo’ (Williams 1994, p. 809). In effect, he suggests such surveys provide a veneer of patient involvement, which may yield results that fail to reflect reality. For the meaningful experiences and perceptions of patients to be elicited, it is necessary that service providers first identify and isolate factors which provide true satisfaction to patients. In this regard, investigating practitioner skills and how they relate to patient satisfaction is critical for understanding the rationale for delivering good, patient-centred care. The method of the current study has been built upon this assumption.
Some issues of major concern for researchers in this field are the validity and reliability of results arising from satisfaction measurements. DuFrene (2000) suggests a solution to problems with validity and reliability in patient satisfaction measurements, namely, to adopt an extended survey to capture patient's opinions. Merkouris et al. (2004), meanwhile, recommend using mixed methods, as they did in their study conducted in two large Greek hospitals. Interestingly, these two studies came to broadly similar conclusions: the highest levels of satisfaction were related to technical aspects of care, while the lowest had to do with information delivery.
Gill and White (2009) criticise the majority of research performed on patient satisfaction, questioning the validity of instruments used and highlighting associated underlying weaknesses and the subjective nature of patient satisfaction constructs. They indicate that using patient satisfaction as the measure of service quality is a flawed approach, which could hinder effective understanding of the quality of health services from patients’ perspectives. These researchers emphasise the need to focus on perceived service quality, differentiating it from satisfaction and letting this inform the improvement of the delivery process in health care services. However, patient satisfaction measurements are still being used as a proxy for patient assessments of service quality (Turris 2005). For this reason, it is important to conduct further research on how best to define and measure patient satisfaction in healthcare settings.
There are common features of a patient’s experience that are influential in the conceptualisation of their satisfaction, such as outcomes and communication. Patients’ attitudes to these can provide a good indication of how they conceptualise their experiences once the data collection method is reliable and ensures a high degree of construct validity in measuring patient satisfaction. Promising instruments for assessing patient satisfaction have been developed. Whereas earlier studies on patient satisfaction were compromised by the use of invalid approaches to measurement, such as poorly established psychometric testing (William 1998), recent studies have found that certain satisfaction questionnaires/instruments have a well-grounded validity, indicating that developing reliable measures of satisfaction and perceived quality is possible. A good example is the measures of perceived quality described by Rao et al. (2006), which include medicine availability, medical information, staff behaviour, doctor behaviour, and hospital infrastructure. These dimensions provide a direct measurement of the ‘structure’ and ‘process’ of care.
One important issue mentioned earlier regarding the measurement of the satisfaction concept and quality of care is the fact that the evaluation of quality by the patient is difficult, especially with technical competence. For example, a physician who is perceived as action-orientated (e.g. requesting frequent blood or diagnostic tests) may be mistakenly viewed highly favourably (Kupfer and Bond 2012). In the current research, I recognise such limitations of patient satisfaction surveys and recommend adopting appropriate and evidence-based approaches.
A key construct correlated with patient satisfaction is the quality of care the patient receives. Although the two constructs are correlated, however, the dynamic of this relationship is a complex one. In particular, patients are rarely able to judge the technical competency of their care, so reported non-medical criteria influence satisfaction. This supports the notion that any evaluation criteria will be subjective and include non-clinical perspectives. Brady and Cronin (2001) suggest that it is essential to look at three dimensions of quality:
- Outcome quality: the customer’s assessment of the core service,
- Interaction quality: the customer’s assessment of the service delivery process,
- Physical environment quality: the consumer’s evaluation of any tangible aspect related to the service.
Support for this conceptualisation has arisen from testing this approach across different service industries (Brady and Cronin 2001).
In the current research, outcome quality can be related to patient satisfaction measures, that is, rating if their satisfaction concept was generally positive or negative. Interaction quality relates to measures of the process for the delivery of treatment and care (clinical effectiveness of staff and interpersonal aspects of care by doctors and nurses, skills availability, and information on care indicators). Physical environment quality relates to a structure for the delivery of care (i.e. access or service organisation) and whether the patient-rated these favourably and if they confirmed or disconfirmed their expectations.
In summary, there is considerable evidence demonstrating that patient satisfaction measures are being extensively used as indicators of quality of care (Bredart et al., 2007; Jagosh et al., 2011; Kupfer and Bond, 2012). The availability of different constructs of patient satisfaction is evidence of how complicated and challenging patient satisfaction is to measure. Patient satisfaction is very much related to patients’ perceptions of hospital care, and in studying the relationships between these two constructs, it is important to utilise robust, validated, and reliable questionnaires which evaluate such constructs as separate dimensions.
Patient satisfaction in the KSA
This section discusses KSA-based research on patient satisfaction, particularly patients’ satisfaction with the quality of care provided. The present study investigates how structure and process factors impact a specific outcome and lead to the conceptualisation of their satisfaction. To further contextualize and justify the present study, this section of the literature review describes research studies conducted in the KSA on patient satisfaction with quality of care.
The studies discussed in this section are summarized in the table below. After the table, structure and process of care are each discussed in separate sub-sections.
Table 2.1: KSA studies on patient satisfaction and quality of care
| Author-date | Sample | Methods | Key findings | Comments | |||
| 1 | Alaloola & AlBedawi (2008) Patient satisfaction in a Riyadh tertiary care centre. | 1983 inpatients, outpatients and ER patients | Cross-sectional survey Using a self-developed patient satisfaction questionnaire | Patient satisfaction was noted in environmental aspects - room temp—etc. and less found in the interpersonal skills of doctors and phlebotomists as they failed to introduce themselves. | ● The focus of the satisfaction domain was only in the socio-demographic context. ● No focus on specific services such as cancer or medical, which is a limitation ● Although it is valuable for originality, further research is needed in the cancer setting in the KSA | ||
| 2 | Al-Doghaither & Saeed (2000) Consumers' satisfaction with primary health services in Jeddah, Saudi Arabia. | 75 patients aged over 15 years, chosen systematically | Self- administered questionnaire pilot test | Satisfaction scores were higher in those considering all services, while individual service components were scored less. | ● Although high scores for satisfaction were noticed, the service component needs to be monitored and assessed to provide satisfactory services ● | ||
| 3 | Saeed & Mohamad (2002) Satisfaction and correlates of patients' satisfaction with physicians' services in primary health care centres | n=540 patients in 8 PHC, selected randomly in Riyadh | Survey questionnaire, pilot-tested | Service items need to have the correct measure Also, young and adult patients need more attention | ● Other domains like hospital services and nurses’ skills would have an impact on the satisfaction level of patients | ||
| 4 | Al-Ahmadi & Roland, M. (2005) Quality of primary health care in Saudi Arabia: A comprehensive review. | A systematic review of 31 papers met the inclusion | Reviews of literature | There were variations in the quality of primary health care services in the KSA More effort is needed in the organisation of these services | ● Further research is needed to address quality concerns from the patient’s perspective to have better insight into quality care | ||
| 5 | Mahfouz et al. (2004) Primary health care services utilisation and satisfaction among the elderly in Asir region, Saudi Arabia | 253 patients | In 26 PHC in ASIR (6 urban and 20 rural centres), a House-to-house survey was conducted by interviewing an expert health worker and Arabic speaker to answer survey questions. The questionnaire addresses 5 services adopted from Mansour and Al-Osaimi's study in 1993 (continuity of care, humanity, accessibility, thoroughness and information). | Satisfied patients reported 79% dissatisfaction in 3 items: lack of audio-visual for patient education, lack of enough speciality clinics and prolonged waiting time in centres. | ● Emphasis on 5 aspects of lack of reasoning ● More concerns are needed in evaluating different socio-demographic characteristics in elderly patients - results will be significantly different from area to area, so such a comparison would be desirable | ||
| 6 | Akhtar & Nadrah (2005) Assessment of the quality of breast cancer care: A single institutional study from Saudi Arabia | 78 operable breast cancer patient | Retrospective analysis of breast cancer patient charts and histopathology reports from 1995-2000 | Only 37% had triple assessment before surgical procedure radiotherapy not used as per the required standard The overall conclusion is that quality is below international standard | ● No socio-demographic data were retrieved for their sample, which was a limitation that could be addressed in future research | ||
| 7 | Ibrahim et al. (2002) Appraisal of communication skills and patients' satisfaction in cross-language encounters in oncology practice. | 255 patients | Questionnaire “Art of Medicine” used to assess patients' perceptions of clinicians' communication behaviours and patients' global satisfaction. | No difference - means that language doesn’t affect interpersonal skills like communication and patient satisfaction. Patients were equally satisfied in both languages. | ● Interesting finding, but the scale used was not described clearly. | ||
| 8 | Alahwal et al. (1998) “Cancer patients’ awareness of their disease and prognosis”, Annals of Saudi Medicine, Vol. 18 No. 2, pp. 187-9. | 136 (33 cancer patients, 63 doctors, and 40 laypeople) | A questionnaire of 4 questions was developed for this study Distributed in the western region of Saudi Arabia (major hospital providing cancer care) | All patients were in favour of being given full information regarding cancer; this would help them have a better understanding of how to deal with their illness. Doctors, too, favoured that the patients be disclosed about their conditions. | ● Although patient views were taken, the methods would be more useful had qualitative interviews been used as this provides expanded insights into communication issues with patients | ||
| 9 | Younge et al. (1997) Communicating with cancer patients in Saudi Arabia | None | A literature review on communication aspects and factors influencing communication in the KSA | Communication is influenced by many factors, such as cultural and social and health services that lack community care for chronic illness. | ● The number of studies reviewed was not mentioned, and this generalisation potentially limits the findings. | ||
| 10 | Mansour and Al-Osimy (1996) A study of health centres in Saudi Arabia | 300 Consumers | Assessment sheet of centres’ resources regarding quality and availability and consumer satisfaction & a 4-point system Likert scale to measure satisfaction in 5 domains: continuity of care, accessibility, humaneness, information and thoroughness. | A discrepancy of data has been found between centres’ resources evaluation and consumer satisfaction results | ● More studies are needed to evaluate resources and satisfaction through valid measures. ● Studies in hospital resources can provide further insight into patient satisfaction since they focus only on health centres. | ||
| 11 | Almuzaini et al. (1998) The Attitude of Health Care Professionals toward the availability of Hospice Services for Cancer Patients and their Carers in Saudi Arabia | 695 (398 healthcare professionals, 136 cancer patients and 161 informal carers) | A quantitative survey of participants on the quality of healthcare | The Ministry-owned or managed facilities score poorly on patient satisfaction with service organization. | ● Further research is needed using a valid tool to determine which aspects of patient satisfaction are relevant or important to cancer patients while addressing the improvement in government facilities. | ||
| 12 | Brown et al. (2009) Failure to attend appointments and loss to follow-up: a prospective study of patients with malignant lymphoma in Riyadh, Saudi Arabia | A 3-year prospective study of 199 patients with malignant lymphoma in Riyadh | Retrospective analysis of No Shows appointments (No Shows=340 ) | 34% were related to hospital-based communication errors. 17.6 % were related to errors in patient communication with the hospital | ● Based on retrospective analysis, which needs further empirical research to understand communication problems | ||
| 13 | Jazieh, A.R. (2010) Human resources development, ‘Initiative to Improve Cancer Care in the Arab World’ | 12 Experts in health care from across the Arab world and international experts | Interviews, situational analysis | There is a lack of high-quality and well-trained healthcare professionals | ● The research is based on only situational analysis. So, further robust methodology is required to evaluate the needs of human resources in cancer | ||
| 14 | Saghir & Azim (2010) Standards of Care and Guidelines for the Arab World with Limited Resources | 12 experts in health care from across the Arab world | Panel discussions | Lack of standardisation in doctors’ and nurses’ skills leads to varying quality. | ● The research is based on panel discussion and uses no objective methods or criteria. | ||
| 15 | Diab, R. (2010) Access to Cancer Care Facilities, ‘Initiative to Improve Cancer Care in the Arab World’, | 8-panel members made of experts in policy-making, healthcare and scholars (a | Panel discussions (Based on the discussion of panel members about the priority of objectives and available baseline information of accessibility to cancer care) | The panel found that the quality of cancer care suffered from problems like long wait times for the patients, high costs, lack of access to health care and inequality in access for people from rural and marginalised regions. | ● No mention of criteria for evaluating the health care facilities, such as introducing measures or indicators of quality. | ||
| 16 | Shamieh et al. (2010)Access to palliative care | 12 multi-disciplinary experts in palliative care | Panel discussion | Access to cancer care is poor compared to palliative care | ● Discussions purely based on the perception of the experts. Patient views are needed to allow a comprehensive evaluation of the issue | ||
| 17 | Al-Faris et al. (1996). Patients' satisfaction with accessibility and services offered in Riyadh health centres. | 466 randomly selected patients from 6 randomly selected primary health care centres PHCC in Riyadh City | Patient satisfaction and attitude survey | The research found high satisfaction among older housewives and non-Saudi patients. | ● The questionnaire was self-administered, which may add to bias. | ||
| 18 | Al-Sirafy et al. (2009) Hospitalisation pattern in a hospital-based palliative care program: An example from Saudi Arabia. | 759 palliative patient admissions during 4 years (in the absence of sub-acute palliative care models) | A retrospective review of palliative admissions was studied for the reason for hospitalisation, duration of stay and mortality rate. | The research found that quality of life did not improve with palliative care in Saudi Arabia. The quality indicators for palliative care included factors like duration of stay, mortality, and quality of life. | ● While factors like mortality, etc., were easy to understand and calculate, there was no elaboration on factors that may indicate the quality of life improvement. | ||
| 19 | Aljubran, A. (2010) The attitude toward disclosure of bad news to cancer patients in Saudi Arabia. Annual Saudi Med, March April. 2010 | None | Literature review | The researchers highlight the changing trends in patients’ need to understand and know their illnesses. | ● Cultural shift toward considering patient perspective in Saudi culture is evident and warrants further exploration | ||
Few studies were found that focused on the quality of hospital care in the KSA, and most research that deals specifically with the country was shown to be focused on the quality of primary care services (Mansour and Al-Osimy 1996; Alahmadi and Roland 2005; Al-Doghaither and Saeed 2000; Al-Faris et al. 1996; Saeed and Mohammad 2002). Results from these studies demonstrated wide variations in the quality of care in the primary care setting, and all recognised the need for further research.
One study of note assessed patient satisfaction in a tertiary care centre in the KSA (Alaloola and Albedaiwi 2007), and another focused on the quality of cancer care, specifically, assessing the quality of breast cancer care in a KSA health care institution (Akhtar and Nadrah 2005).
Notably, certain studies that used quantitative methods based on patient satisfaction surveys or opinions of healthcare experts appeared to have several flaws. Although the review included the studies assessed as robust, there were some weaknesses in study design or methodology, for example, small sample sizes, retrospective analysis, use of non-validated tools or poor transferability of results (Akhtar and Nadrah 2005; Alaloola and Al Bedawi (2008); Saeed and Mohamad (2002); Mahfouz et al. (2004). Also, there has not been any previous KSA empirical study that has focused specifically on patient satisfaction in oncology settings. It is also worth noting that there has not been any previous qualitative study that has explored the issue of patient satisfaction in KSA.
Despite a paucity of published literature and some flaws in the existing research in the KSA, there is a general, overall trend evident across the published literature. That is, there was evidence that patient satisfaction was adversely affected by (1) poor access to care and treatment availability, (2) poor service coordination between different units and professionals, (3) lack of communication within the multi-disciplinary team required for oncology care, (4) lack of patient communication and awareness, and (5) a general lack of adherence to standardised guidelines related to diagnosis, treatment and monitoring of cancer patients (Akhtar and Nadrah 2005; Al-Doghaither and Saeed 2000; Almuzini et al. 1998; Younge et al.1997; Brown et al. 2009; Diab 2010; Shamieh et al. 2010).
To date, research on patient satisfaction in the KSA suggests that patient satisfaction generally varies according to various factors, in particular, the age of the patient (Al-Faris et al., 1996) and the healthcare providers’ disclosure practices (Al Ahwal et al. 1998; Younge et al. 1997; Aljubran 2010; AlAmri 2009).
For all these reasons, the current study makes an important contribution to patient satisfaction studies, not only in the KSA but internationally and throughout the Middle East because of the KSA’s increasing Westernization and influence in the region. It focuses on all the factors that influence the construction of patients’ concept of satisfaction. The current study can help to fill the knowledge gap in the KSA surrounding patient satisfaction, including the possible impact of doctors’ and nurses’ perceived clinical effectiveness and the perceived accessibility of services. It also contributes to the wider international debates about patient satisfaction since it explores the issue within a particular, non-Western cultural context.
Structure
The structure of care involves how a patient accesses and receives care. How care is provided and structure is important, particularly concerning how patients conceptualise their satisfaction with their experiences in a health setting. A retrospective study by Al-Sirafy et al. (2009) indicated the need to improve access to palliative care services in the KSA. It revealed that patients could not identify evidence of improvement in their quality of life or health. Al-Muzaini et al. (1998) also found that improvements in structure and the manner of delivery are challenged by the lack of knowledge of evidence-based cancer care and by drug shortages. It was concluded that there is a need for an effective framework for palliative care services in the KSA health system.
The recent widespread recognition by Arab countries that the status of palliative care is poor and lacking in structures has given rise to the ICCAW initiative (Initiative to Improve Cancer Care in the Arab World). As part of this initiative, Shamieh et al. (2010) led a panel of experts recommending modifications to the Comprehensive Cancer Network (NCCN) Guidelines. These guidelines made various suggestions for improvements in the structures of palliative care provision. Shamieh et al.’s (2010) report also concluded that there was little research data from the KSA to recommend changes.
Regarding access to services, Diab (2010) was tasked with finding out how to improve access to cancer care facilities to identify key issues, including concerns about excessive waiting times, prevention and screening, diagnosis and treatment, quality of life, and palliation. The findings were clear that there are problems with the structure for the delivery of and access to care in the different Arab countries, including the KSA. The need for an initial assessment to develop a database of baseline information for cancer care facilities was identified.
Lack of satisfaction from a patient’s perspective has been reported in several other KSA studies that evaluated various dimensions of the quality of care. Mansour and Al-Osimy (1996) identified patients’ dissatisfaction with the resources and care provided, whilst Al-Ahmadi and Rolands (2005) identified poor access to adequate chronic disease management programmes and inadequate health education, along with ineffective systems for referral and prescribing. Research in breast cancer tertiary care healthcare institutions also indicated dissatisfaction with the quality of the general standards of cancer care and the significant underuse of radiotherapy; both were recognised as being below internationally accepted standards (Akhtar and Nadrah 2005).
A major study in the KSA, conducted by Alaloola and Albedaiwi (2008), highlighted that patients’ perspectives on service delivery are a core service quality indicator. Their study focused on patient satisfaction or dissatisfaction in a tertiary centre in Riyadh using a cross-sectional survey of 1,983 inpatients, outpatients, and emergency care patients. It was the first report on service quality and patient satisfaction of the KSA healthcare systems to appear in a peer-reviewed journal. One limitation of this otherwise invaluable study was that not every service was studied separately, so the patients’ answers may not represent one hospital setting. The researchers recommended that further studies on patient satisfaction in the KSA are needed.
There is also a need to explore related aspects of cancer treatment within the KSA, including unacceptable side effects (like osteoporosis) caused by current chemotherapy drug use (Al-Amri and Sadat, 2009), and the need to focus on the significant number of patients failing to attend medical appointments (Brown et al., 2009). In the study by Brown et al. (2009) in Riyadh, which involved patients with malignant lymphoma, communication problems were responsible for 34.1% of missed appointments, while another 17.6% were found to result from patient communication errors. One area identified as problematic was the movement of patients with limited access to outpatient appointments and hospital facilities. Addressing such problems represents an essential role of a service organisation.
These studies demonstrate the potential for considerable patient dissatisfaction with certain structural aspects of healthcare in the KSA and, hence, the need to further investigate patient perceptions of a range of specific key indicators of service organisation in the KSA. It should also be emphasised that much of the data presented from the KSA are not derived through primary research but arise from retrospective analyses of data from patient files or records. The need for robust, reliable evidence from empirical research provided a rationale for examining the quality of patient care in oncology wards in the KSA.
Process
Research suggests that the processes by which healthcare is delivered in the KSA are inconsistent in nature and quality, which may give rise to inconsistencies in patient satisfaction. A lack of consistency in the quality of the clinical care processes has been identified in the KSA. Research in Riyadh (Saeed and Mohamed 2002) established that the patients were largely satisfied with the doctors and the nurses; still, this research was undertaken in a context where experienced Muslim physicians and an Arabic-speaking health team were offering free services near patients’ homes. The findings of the current study may not then be generalizable about patients’ conceptualisations of their satisfaction with the KSA.
Several studies have also shown high levels of patient satisfaction in other specialities. The study by Mahfouz et al. (2004) showed that elderly patients were largely satisfied with the doctor's and the healthcare givers’ attitudes and behaviours. Still, patients were generally dissatisfied with long waiting times, lack of speciality care, and lack of information. Al-Faris et al. (1996) studied primary health care centres (PHCC) in Riyadh and found that the satisfaction levels varied according to the factor investigated. Although patients were generally satisfied with the service provided and with the respectfulness of the staff, they were significantly dissatisfied with the interpersonal skills of some healthcare staff and with poorly explained procedures.
The KSA’s Ministry of Health regulates the governmental and private health sectors. The Ministry of Health has the capacity to set standards for national-level strategies for health reforms through change management and allocation of financial resources. Raising the health level of the population is informed by the government’s health research, which is included as a strategy within the National Health Program/Plan. In 2005, Al-Ahmadi and Roland (2005) acknowledged a deficit in the literature on the effectiveness of quality primary care in the KSA, even though the Ministry of Health argued that high quality of care is key to the national health strategy. The available evidence shows that clinical effectiveness in the KSA has historically been considered low.
A study of satisfaction among primary health care patients in the KSA by Mansour and Al-Osimy (1993) indicated low satisfaction with the quality of care of the referral system. More recently, research has shown that patients have developed poor perceptions of the effectiveness of primary health care in the KSA (Al-Ahmadi and Roland 2005). Ineffectiveness and inefficiency in primary care were reported about disease management programmes, prescribing patterns, health education, referral patterns, and some aspects of interpersonal care, including those caused by language barriers. In addition, Al-Ahmadi and Roland (2005, p. 331) also identified other determinants of the ineffectiveness of primary care, such as ‘poor management and organisational factors’, ‘poor implementation of evidence-based practice’, ‘low professional development’, ‘lack of structured approach to use of referrals to secondary care’, and ‘use of healthcare professionals that were not sensitive to the culture of Saudi Arabian patients’.
Hopeful changes are underway in the KSA. Recently, a report by the Ministry of Health (MOH 2010) identified failures in health care in the KSA, which were largely people-related and not technology-related; they were also linked to complexities in managing health information (Ministry of Health, MOH 2010). This led to a Ministry drive to improve primary care practice in several regions. One important and positive change has been adopting an e-health approach as part of the wider KSA focus on e-government, aimed at improving the efficiencies and effectiveness of healthcare. The KSA’s use of e-Health has been identified as a strategic objective for the Ministry, which should not just improve health but enhance how patients perceive the effectiveness of care and availability. The approach involves linking regional health directorates, hospitals, and hospital management centres. The KSA e-Health governance model claims to improve service design by aligning health care with dimensions of quality of care, management of relationships (doctor-patient relationships, nurse-patient relationships), and ensuring delivery of value to patients. However, despite this drive to provide high-quality healthcare services in the KSA, evidence of patients’ perceptions of quality care is lacking, and a gap in the knowledge remains. These findings highlight the need for research on patients’ concepts of satisfaction as one of the key indicators of quality of care from the perspective of clinical effectiveness. Specifically, it would be pertinent to research to investigate how doctors’ or nurses’ skills could be developed to help improve the perceived clinical effectiveness of care and other care processes. The current study will help achieve such objectives.
To determine a practitioner’s clinical effectiveness, evidence-based practice is important. Evidence-based Clinical Practice Guidelines (CPGs) are important tools to help improve patient care and health outcomes. Al-Ansary and Alkhenizan (2004) conducted a review of CPGs and the tools that have been employed in CPGs in Saudi Arabia for the last two decades. Their findings demonstrated the need for good quality, effective CPGs in the KSA to enable alignment with expected standards for quality of care. Ideally, to reduce work and costs, this could be accomplished through local adaptation of good-quality international guidelines. There is a dearth of information in the literature on how CPGs could provide a basis for improving dimensions of care in the KSA. Recent studies have focused on quality measures/indicators known to improve care outcomes. Al-Moajel (2012) showed how improving the effectiveness of quality of care relies on the development of hospital performance indicators in the fields of accreditation or the certification of healthcare structures and processes of care.
One potential problem identified in the KSA is accurately measuring performance indicators. This is in line with the call by Bilimoria et al. (2009) in the US for a framework for policies and procedures to outline the best approach for such measures. In addition, there is a need to implement standardised quality indicators in daily practice through effective strategies to reduce variability and enhance the level of improvement obtained (Vos et al. 2009). Indeed, Al-Moajel (2012) maintains that quality indicators are essential to improve the quality of healthcare services. Al-Moajel’s (2012) study also recommends accreditation of hospital care services as a step towards aligning quality of care dimensions with set standards as part of clinical governance. Despite the clear need for such measures, there is currently no literature on how accreditation and certification systems in the KSA have affected patient satisfaction or impacted clinical effectiveness.
Chapter 3 - Methodology and Methods
Methodology is the research framework guiding the choice of methods for data collection and analysis. Methods are the specific techniques used to gather and analyze data within this framework. The methodology sets the research's theoretical and practical foundations, while methods implement the chosen approach. Together, they ensure a systematic and effective research process.
Introduction
The literature review indicated the need for empirical research on patient satisfaction in the KSA, particularly in oncology wards. As indicated in the review, it is important to address these gaps by exploring, understanding, and interpreting the influential processes in oncology patient satisfaction in the KSA. Studies from outside the KSA offer insights into ways in which patient satisfaction varies in different care settings internationally. However, few studies have explored patient satisfaction in oncology ward settings in the KSA. This indicates that there is a need to consider how, in the cultural context of the KSA, various influencing factors might determine satisfaction with care and why and how a patient is satisfied or dissatisfied with the care provided in the KSA.
By focusing on this important gap in the literature, the following research question was developed:
‘What factors contribute to or hinder patient satisfaction with care in an oncology ward setting in a Saudi Regional Cancer Centre in Riyadh?’
In this chapter, the methodology and research methods selected to answer this research question and to meet the aims of the current study are outlined and discussed. A sequential mixed methods approach was used for this research to answer the research question and to address the aims of the study. The first quantitative phase of the research provided data from questionnaire responses. The results of the analysis of this data were then used to inform the second qualitative phase, which employed semi-structured interviews.
Following this brief introduction, the research question and study aims are considered in more detail before the rationale for the study design is presented. Additionally, the theoretical reasons for using a pragmatically informed, mixed-method design to explore the complex and multifaceted issues of patient satisfaction in the KSA are discussed. The chapter continues by providing a detailed description of how the study was conducted; this includes a description of the study setting, the procedures for recruiting and selecting patients, and the means of data collection and analysis for the two phases. The chapter concludes with an exploration of the ethical issues associated with the current study and a description of how these were addressed.
The Research Question and Study Aims
The primary research question driving the current study was: What factors contribute to or hinder patient satisfaction with care in an oncology ward setting at the Saudi Regional Cancer Centre in Riyadh (SRCC)? This primary question was broken into three more specific sub-questions to be answered during Phase 1:
- Does the clinical effectiveness of health care (doctors’ and nurses’ skills, information provision, availability) influence adult oncology inpatients’ satisfaction with care at the SRCC in Riyadh?
- Does accessibility to health care (service organisation) influence adult oncology inpatients’ satisfaction with care at the SRCC in Riyadh?
- What are the socio-demographic characteristics of adult oncology inpatients at the SRCC in Riyadh?
Informed by the responses in Phase 1, another series of specific questions were asked during Phase 2:
- How do interpersonal aspects of care influence adult oncology inpatients’ satisfaction with care at the SRCC in Riyadh?
- How do socio-cultural communication factors influence adult oncology inpatients’ satisfaction with care at the SRCC in Riyadh?
The specific aims of the study were as follows:
- To determine the likelihood that clinical effectiveness is associated with patient satisfaction in adult oncology ward settings in SRCC.
- To determine how likely the accessibility to health care is associated with patient satisfaction in adult oncology ward settings in SRCC.
- To describe the characteristics of patients in adult oncology ward settings in SRCC.
- To explore the extent to which the interpersonal aspect of care influences patient satisfaction in adult oncology ward settings in SRCC
- To provide recommendations for enhancing patient satisfaction in oncology ward settings in KSA
- To discuss the extent to which and in what ways the qualitative findings help to explain the initial quantitative results of patient satisfaction in oncology settings in KSA
Research Methodology: Overview of Mixed Methods
A mixed-method design enables quantitative and qualitative methods to complement one another and allow for a more thorough analysis of the research problem (Creswell 2003). As the purpose of the current study is to explain the impact of various factors on patients’ satisfaction in oncology wards in KSA, the mixed-methods design is best suited for the research. This sequential mixed methods design was chosen for various reasons, which will be justified throughout the current chapter. Firstly, the research problem is qualitatively oriented; a rational qualitative instrument was used to gain insight into the various factors that may influence patient satisfaction. Secondly, the results of the quantitative research are thought to aid in explaining and gaining insight into the qualitative results (Creswell and Plano-Clark 2011).
Creswell and Plano-Clark (2011) have argued that the use of combining qualitative and quantitative approaches provides a more absolute and complete understanding of the research problem than the use of only a single method. A quantitative method is indeed able to identify the variables that are systematically or statistically correlated. Still, the method fails to provide insight into why the variables are related in the first place. Furthermore, Polit and Beck (2008) state that a qualitative explanation can clarify the imperative ideas that substantiate the findings from the statistical analysis and also provide guidance that helps in the interpretation of results. Therefore, the researcher had chosen to integrate the two methods to provide a more robust understanding of the research problem, as either method would be inadequate to do so alone.
Key issues in mixed methods research
Mixed methods research is where quantitative and qualitative techniques are combined in a research project and the level of interaction between the techniques used. The method is based upon the premise that such a mixture of quantitative and qualitative methods is both practical and compatible. A mixed methods approach can help the researcher to overcome problems in the collection of data and provide reliable findings, as quantitative findings provide concrete statistical facts which are supported through detailed insight provided by qualitative findings (Creswell 2003). The combining of the two research methods, namely, quantitative and qualitative, complement each other, and the data collected can be integrated and also limit the weaknesses in each separate technique as discussed above.
According to Creswell and Tashakkori (2007 p.4), mixed methods research can be described as:
“Research in which the investigator collects and analyses data integrates the findings and draws inferences using qualitative and quantitative approaches or methods in a single study.”
Some researchers claim that MMR results in clarity in understanding the complexities of the social phenomena that are under investigation (Ponterotto and Greiger 1999).
There are several benefits in using a mixed methods approach to research, namely, (1) triangulation (using multiple data collection methods to corroborate findings and to validate these methods); (2) complementarity (elaborating and clarifying the results of one method using another); (3) initiation (uncovering contradictions that lead to re-framing the research question); (4) development (using the findings from one method to inform the other); and (5) expansion (expanding the breadth of research by using different methods at different stages of research) (Greene et al. 1989).
Some of the strengths of mixed methods designs that have been of particular benefit to the current study are that (1) interviews have extended and deepened the survey data, and (2) the conclusions of the study were stronger due to the synthesis of the findings from both methods, thus strengthening the recommendations for improvements to enhance patient satisfaction. There are, however, certain weaknesses in the use of MMR. Different methods can result in different types of answers to a research question. Moreover, a practical limitation is the time required to conduct such a study (Creswell 2009).
The MMR method needs a research paradigm to provide a framework for the research to address the research questions adequately. Creswell and Tashakkori (2007) maintain that a research paradigm represents a belief system or theoretical assumptions and propositions that provide guidelines for answering a research question. Four foundations of research paradigms exist, namely, (1) positivism (built on experimental testing), (2) post-positivism (viewpoint arising from the need for a research context and a recognition of the insufficiency of context-free experimental designs), (3) critical theory (viewpoint that ideas relate to specific ideologies, and biases ought to be articulated; and (4) constructivism (viewpoint that every individual researcher creates his/her independent reality, and therefore, multiple interpretations exist).
According to Sale (2002), ‘one cannot be both a positivist and an interpretivist or constructivist’ (Sale et al. 2002 p.47). Similarly, Hammersley (1996, p.160) argues that:
Quantitative and qualitative methods have been presented as opposing paradigms to be used as and when appropriate, depending on the focus, purposes and circumstances of the research
The primary question of this debate is whether, when using quantitative tools in a mixed methods design, one adopts a positivist interpretation or whether the overall research design remains constructionist or interpretivist. The latter position implies that using quantitative data collection tools is still important to develop conclusions using constructivist approaches.
The logic behind the use of MMR in the current study is driven by practical considerations such as study design, skills and resources as well as theoretical reasoning (i.e. study aims) (Bryman 2006). The primary aim and research question of the current study is to establish a relationship between how the factors uncovered impact patient satisfaction. Considering the primary aim, it is evident that it is necessary to comprehend which major factors influence patient satisfaction, which can be revealed through a quantitative measuring instrument, in this case, a survey. However, to fully comprehend the factors, further insight is needed in understanding patient opinion on the healthcare delivered to them and, ultimately, how that impacted their satisfaction. This is consistent with the perspectives of Snape and Spencer (2003), who argue that ‘quantitative and qualitative methods can and should be seen as part of the social researcher's ‘toolkit’ (p.15). This view echoes work by Feilzer (2010), who maintains that methodological choices should be based on the aim of the study.
While Onwuegbuzie and Leech (2005) and Creswell (2009) stress the importance of pragmatism in MMR, some researchers maintain there is still a lack of clarity on how pragmatism can shape and define the mixed methods approach (Tashakkori and Teddlie 2003). Nevertheless, the consensus in the literature is that some versions of pragmatism represent the most useful philosophy for supporting MMR. For example, Johnson et al. (2007) contend that pragmatism is a suitable philosophy for integrating different perspectives and mixing approaches by applying epistemological justification and logic. According to Johnson et al. (2007), by mixing approaches and methods, the outcome would more readily be able to address and provide tentative answers to one’s research question(s). Similarly, Morgan (2007) provides a holistic view, describing how researchers can vary their approach depending on the research question and draw on pragmatic approaches as a philosophical and practical basis for conducting MMR. This approach enables a multiplicity of perspectives, which enables a deeper understanding of the research problem (Eaves and Walton 2013).
Notably, it has been asserted that neither qualitative nor quantitative methods alone are adequate or robust enough to provide a complete analysis of the complex nature of research in areas such as health care (Sale et al. 2002). This is especially true in this investigation of patient satisfaction in an oncology setting in the KSA since cultural, political and communication problems may all play a role yet may be difficult to explain through a survey or interviews alone. This is at the heart of my decision to use an MMR design, which has already been successfully used to understand patient satisfaction in other studies (Hyrkaas and Paunonen, 2000; Merkouris et al., 2004). Moreover, an important advantage of mixed methods is that it allows triangulation between two or more types of data to assess the same problem so that different perspectives can be corroborated, thus giving weight and validity to the interpretation of the results (Green et al. 1989; Bowling 2007). Converging two or more datasets increases confidence in the results (Bogdan and Biklen 2006). Complementarity uses the results of one research method to elaborate or clarify the results of another, thus achieving a fuller understanding of the phenomenon (May et al. 2000; Sale et al. 2002; Creswell 2003; Bowling 2007). One practical issue of complementarity is the sequencing between the phases and whether the quantitative and qualitative methods are adopted simultaneously or sequentially (Creswell 2009). A common approach suggested by Bryman (2006, pp.106) is that corroboration through the use of qualitative data helps to ‘put meat on the bones of dry quantitative findings’. However, Pope and Mays (1995) emphasise a key point about using qualitative research to corroborate quantitative research in a mixed-method study:
…is not simply joining two techniques or tackling one at the end of a project. Researchers must know the different types of answers derived from different methods (Pope and Mays, 1995, p.44).
An alternative approach to combining data is described by Creswell (2009), namely, the explanatory design. The explanatory design involves two phases where qualitative data helps to explain and expand upon initial quantitative results (Creswell et al. 2003) and is especially useful when such data is needed to explain significant/non-significant results or outlier results (Sale et al. 2002).
The applicability of explanatory mixed methods to this research
The following four key factors were examined as proposed by Creswell (2009) to determine if the MMR methodology was warranted for the study:
Timing
The collection of qualitative and quantitative data may be scheduled and timed so that the data are collected simultaneously or sequentially. As shown in the current research questions, the sequential data collection methods were adopted within both phases. According to McNabb (2012), the strength of a survey is identified with its ability to collect large amounts of responses over a specific period and represent the target population. In the current study, a reliable and validated instrument (phase 1) was combined with an interview session to examine the factors influencing patient satisfaction (phase 2) of cancer patients in SRCC.
Weighting
Weighting refers to the priority and emphasis given to qualitative and quantitative methods. Giving greater emphasis to the quantitative method was necessary to ensure that the maximum amount of data was collected and analysed before seeking an explanation by using interviews in the qualitative phase to keep focus on its application.
Mixing
Mixing involves merging two forms of data into a structure that allows for reliable evidence to be drawn upon about the research question and aims. Mixing in the current study involved analysing the complementary quantitative and qualitative data sets and then combining the findings into the study.
For the current study, mixing was conducted by analysing the qualitative data and then using the conclusions from that data to support the quantitative data. Embedding qualitative data provides a supporting role in the study. The two data sets were complementary and could be combined to provide information on the complex construction of patient satisfaction concepts.
Theorising
Theorising requires considering whether mixed-method research suits the chosen pragmatic paradigm. The MMR methodology was deemed suitable because it could generate much data from different perspectives. It was needed to represent and understand how patients constructed satisfaction with their care.
MMR methodology was deemed appropriate for this research and is justified concerning the ten criteria suggested by the Health Foundation ‘when planning how to measure patients’ experience’, including satisfaction (Health Foundation, 2013, p. 28). The current research meets the Health Foundation criteria as follows:
- The term patient satisfaction was defined in ways that both quantitative and qualitative data can assess.
- The measured patient satisfaction allowed for a good understanding of how patients construct their experience, and it was possible to use data on their responses in this respect to answer the research question.
- It was considered useful to combine both qualitative and quantitative data to maximise the data collected.
- The MMR method was suitable as it enabled samples to be selected rather than all the general population, which was impractical in a study of this size. The MMR approach allowed the researcher to draw from the samples the maximum amount of data possible.
- The MMR method allowed a significant amount of data to be collected within a tight time frame. This helped to address the particular challenge that I faced of a limited period permitted for fieldwork
- The MMR methods used were tested before they were implemented, and they are all well-established and proven data collection instruments used in previous patient satisfaction studies (Hyrkas et al. 2001; Merkouris et al. 2004).
- The data collected by MMR methods could be merged in such a way as to allow the information to be analysed robustly and reliably.
- The MMR methodology was chosen because it could suitably present information for the intended audience.
- The MMR methodology allowed people to express their opinions freely and to feel comfortable providing information to the researcher.
- As there is no single measurement of patient satisfaction, there needs to be several ways of measuring it. Therefore, by providing multiple perspectives, the MMR can provide the data needed to address the research question (Health Foundation, 2013, p. 27).
Summary of the MMR approach taken
The primary research question of the current study focuses on the factors that contribute to or hinder patient satisfaction with care in an oncology ward setting in a Saudi Regional Cancer Centre in Riyadh. The use of a sequential mixed methods design was considered the most appropriate for reaching the aims and objectives of the study and answering the research questions.
Accordingly, in the current study, an explanatory approach was adopted, but with complementarity in mind, whereby the patient satisfaction survey was conducted first and, after analysis of the quantitative data, one-to-one interviews (both by phone and face-to-face) were carried out with oncology patients to provide an assessment of patient satisfaction and assess the relationship between the various variables identified and connected to patient satisfaction. As this method is applicable in both the social and health disciplines, the method was considered most appropriate for assessing the relationships between variables that influence patient satisfaction for patients in oncology wards in KSA (Creswall and Plano-Clark 2011). Integration occurs at the intersection of quantitative phase 1 and qualitative phase 2. The qualitative Phase 2 interviews explore further the quantitative Phase 1 results to provide a deep understanding of patient satisfaction. Figure 3.1 shows the visual model of the explanatory mixed method design used in the current study.
In summary, the sequential explanatory mixed methods approach explained the findings later identified in the quantitative phase by a set of participants using semi-structured interview questions. The data allowed for a richer understanding of the relationship between patient satisfaction, patient experience, quality of care, and healthcare delivery for oncology patients in SRCC, KSA. The findings of the current study are expected to provide a significant contribution to the literature on patient satisfaction and patient experience to improve healthcare service delivery in KSA.
Figure 3.1 The visual model of explanatory mixed methods design used as adapted from Creswell (2009):
| QUAN | → | QUAL | ||||||
| QUAN | QUAN | QUAL | QUAL | Interpretation of Entire Analysis | ||||
| Data | → | Data | → | Data | → | Data | → | |
| Collection | Analysis | Collection | Analysis |
Phase 1: Quantitative Method
Quantitative design: Cross-sectional survey
The first phase of the study comprised a quantitative, cross-sectional survey. According to Hennekens and Buring (1987), a cross-sectional survey examines the relationship between disease or another health state and other variables of interest that exist in a defined population simultaneously. Cross-sectional studies are descriptive. For example, they are used to describe certain population characteristics, such as the prevalence of illness, or they may be used to support inferences of causes and effects (Rothman & Greenland 1998).
Phase 1 of the current study involved a cross-sectional survey of an adult oncology inpatient group. It was administered to determine their satisfaction levels with the care provided to them at the time of their participation. A validated EORTC IN-PATSAT 32 Questionnaire (the inpatient satisfaction quantitative questionnaire, as developed by Bredart et al. (2005), was therefore distributed to adult oncology inpatients in a Saudi Regional Cancer Centre in Riyadh. This questionnaire was deemed a reliable data collection instrument as it has a track record of being used in similar research (Arrora et al. 2010; Obtel et al. 2012), and it has been designed to provide information on patients in an oncology setting, which was the context for the current study. Section 3.4.5 describes the questionnaire in detail.
The setting of the current study was adult male and female oncology wards in one of the main KSA regional referral cancer centres in Riyadh (SRCC). The bed capacity of the oncology wards is a total of 42 beds. This setting was appropriate, as the centres admitted adult male and female patients with varying types of cancer. Geographically, this area included a diverse population from which potential participants of various ages and socio-demographic and cultural backgrounds could be sampled. This sampling was done to ensure that the data collected was not only representative of the inclusion and exclusion criteria detailed below but that it was also generalizable.
Sampling strategy
Population
The population of interest for the current study was all adult male and female inpatients admitted to the SRCC in Riyadh.
Inclusion Criteria
All participants in the research were required to meet the following criteria:
- Had a confirmed diagnosis of cancer
- Was aged 18 years or older
- Had been hospitalised for at least three days (to maximise the number of patients)
- Was mentally fit to answer the questionnaire
- Was aware of their medical condition
Exclusion Criteria
Likewise, those who met the following criteria were excluded from the research.
- Was unaware of their diagnosis
- Was aged less than 18 years old
- Had been hospitalised for less than three days
- Was unaware of their medical condition
- Did not wish to participate
Recruitment procedures
Following ethical approval from the University of Stirling, the School of Health Sciences ethics committee, and the Saudi Regional Cancer Centre (SRCC) ethics committee, I contacted the clinical site in Riyadh. Senior managers, including the oncology nurse managers, head nurses in adult oncology wards, and the medical director, were contacted to provide them with an explanation of the study’s aims and methodologies and to enlist their assistance.
Recruitment and consent took place on the ward by direct contact with oncology ward staff; this personal approach was considered best to secure cooperation and the help of the staff. One nurse educator, in particular, was responsible for distributing the questionnaires and surveys on the researcher’s behalf. Patients were given an information sheet and an invitation to participate (see Appendix 7 for the patient information sheet). They were given time to consider whether they wished to participate and to discuss this with their relatives. Those interested in participating were informed of opportunities to be selected for a follow-up interview for the qualitative phase of the current study
I communicated the criteria for inclusion and exclusion of potential participants to the nurse educator, making her aware of those criteria. Consequently, she determined those eligible to participate and distributed the questionnaire to those who met the criteria.
An invitation letter, along with an information sheet, was distributed to eligible patients with a confirmed diagnosis, and those who wished to participate stated their intention to the ward staff or the nurse educator, depending on who was present in the ward. Patients took one to two days to state their intention to participate. Patients who agreed to answer the questionnaire were asked by the nurse educator to sign the consent form (see Appendix 8 for the patient consent form). Patient information was entered into a recruitment log to maintain the transparency of the research process. The recruitment log included a non-identifiable number for all participants, and the following: age, gender, date of admission and the data collection date were coded. The log facilitated the anonymity and confidentiality of the received data and also managed the time scale for the recruitment process (see Appendix 9 for the recruitment log). The recruitment continued until a target of 100 patients consented to participate was attained.
When the questionnaires were issued, I was passed the details of those willing to be approached to be interviewed. The questionnaire informed the participants of the procedures they needed to undertake if they were interested in participating in the study. A contact number was provided, and the potential participant or someone acting on their behalf could contact me using a number on the questionnaire. This allowed the participant to arrange a second interview for the qualitative phase of the study.
Since I am not a native of KSA, I was very sensitive to the cultural issues in data collection, particularly patients’ cultural expectations. Privacy and respect for their opinions were considered essential, which was deemed necessary to ensure the cooperation of the sample population. Therefore, I went to great lengths to assure the potential participants that their privacy was respected and that their responses would be treated confidentially. To ensure that patients understood the research process and that their participation was kept confidential, it was essential to explain to each of the participating patients the purpose of the study. This included highlighting to patients how their input and opinions can contribute to the study. Furthermore, patients were informed that all information regarding their illness, diagnosis, and other personal information would not be included in the current study, and their participation would be kept confidential.
During the initial data collection phase, certain limitations became apparent. The relatively small sample raised issues over acquiring adequate data to analyse. Also, generalising the conclusion drawn from the data formed another limitation to developing a general theory of patient satisfaction. That is, the question of how (and to what extent) the findings from this location represented the general levels of satisfaction of oncology patients in the KSA receiving such care. There was also the issue that this was the first study of its kind. This meant that there were no previous examples to base the research upon and no way to learn from others’ experiences and, indeed, the limitations of such studies. A further limitation was caused by the restricted time available for conducting the research.
However, the findings are generalizable in the sense that the Saudi system is becoming more westernised, and this means that the findings are more generalizable to oncology patients internationally. Research conducted elsewhere was a useful resource that helped to guide me in the collection and analysis of data.
Sampling methods and response rate
A convenience sample (non-probability sampling) (Teddlie and Yu 2007) was used to select patients for the first quantitative phase of the study. This sampling technique meant that only available people could be surveyed. However, the number of participants would depend on the study setting, including the bed occupancy of the oncology ward settings, research timing, and resources. A limitation of one month (from the end of November 2012 till early January 2013) was placed on data collection for the first phase of the current study. Therefore, convenience sampling was chosen to fit the aims of the current study.
A total of 122 questionnaires were distributed to adult oncology patients in the SRCC in Riyadh, of which 100 completed questionnaires were received. The response rate was high at 82%, even though the recruitment period was time-limited due to the need to adhere to the timeframe, which had been set by my sponsors (Saudi Cultural Bureau office in London), at three months to enable completion within a reasonable period.
Quantitative data collection
Instrumentation
The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group has developed and cross-culturally validated the EORTC IN-PAT-SAT32 questionnaire to assess patients’ perceptions of the quality of hospital-based cancer care (Bredart et al. 2005, Bredart et al. 2007; Arraras 2009). The development of the IN-PATSAT32 was based on existing patient satisfaction questionnaires, as well as interviews with oncology specialists and cancer patients (Bredart et al. 1998). The psychometric properties of this questionnaire have been tested and have been used in different countries (Bredart et al. 1999; Bredart et al. 2003; Arrora et al. 2010; Pishkuhi 2014) and translated into different languages using the EORCT translation guidelines (Cull et al. 2002).
The EORTC IN-PATSAT32 was constructed as comprising eleven multi-item and 3 single-item scales. These include the doctors’ technical skills (items 1–3), interpersonal skills (items 4–6), information provision (items 7–9), availability (items 10, 11) scales; the nurses’ technical skills (items 12–14), interpersonal skills (item 15–17), information provision (items18–20), availability (items 21, 22) scales; the other hospital staff’s interpersonal skills and information provision scale (items 24–26); the exchange of information single-item scale (item 23); the waiting time scale (items27, 28); the hospital access scale (items 29, 30); the comfort single-item scale (item 31); and the general satisfaction single-item scale (item 32) (See Appendix 10 for the IN-PAT SAT32 Questionnaire).
Items are all rated on a five-level Likert scale with the category labels ‘poor’, ‘fair’, ‘good’, ‘very good’ and ‘excellent’. This response scale has been proven to have methodological advantages over other response scales (Ware and Hays 1988). Additionally, the socio-demographic data were collected for each patient, including age, gender, marital status, educational level and place of residency. This survey instrument was justified because it is a well-validated measure of patient satisfaction in the Western context. It still applies to Saudi Arabia’s healthcare system as this method has been used in another dominant Arab country, Morocco (Obtel et al. 2010).
Questionnaire Distribution
For the first phase of the current study, data was collected using the abovementioned EORCT IN-PATSAT32 questionnaire. It took approximately fifteen minutes for each participant to complete it.
The questionnaire distribution was an important part of the data collection process. I was aware of the potential of bias in the distribution that could introduce bias into the data collected. Eligibility was based upon the fact that a person was being treated in an oncology setting and that they could understand the questions being administered. The nurse educator coordinating the questionnaire administration was careful not to coerce or pressurise potential participants. This was done by making clear that participation was not mandatory and there was no effort to persuade or compel a person to take the questionnaire.
The questionnaires were expected to be completed by the patient by themselves and with the help of their family or others if required. This was possibly an issue for those who felt unwell or had poor literacy. The issue of literacy was a potential problem for many older and less educated patients. In practice, some participants needed to receive assistance to complete the questionnaire. This may have introduced a level of bias. Still, as long as the patients gave their views freely to those filling in the questionnaire and they faithfully recorded them, then the possibility of bias was limited.
To further reduce the potential for researcher bias, there was no effort to restrict the questionnaire to any pre-selected group or type of individuals. This limited researcher bias in the selection of participants.
However, there is always some measure of unintentional bias in even the most objective research. How the data was collected could be unintentionally biased. According to Efron (2010), the sample obtained was through convenience sampling; that is, the sample is composed of individuals available for the survey; however, the sampling technique also allowed for voluntary participants. Efron (2010) asserts that such forms of sampling are always biased as they include people who choose to volunteer. Oftentimes, voluntary response samples oversample people who have strong opinions and under-sample individuals who do not care much about the survey topic. The use of this specific method has caused a degree of self-selection bias. The self-selection bias decides causation, which is more difficult to comprehend. For this particular study, the decision to participate may reflect some inherent bias within the characterization or traits of those participating.
For instance, older patients, because of their cultural expectations, may have felt compelled to participate in the study, even though it was made clear to them that participation was voluntary.
There was a concern about overconfidence in patients answering the questionnaires truthfully as nurses collected the questionnaires from them. On a scale of 1-10, with 1 being the lowest confidence and 10 being the highest confidence of patient truthfulness, I rate my confidence as 7. It is possible that patients had not answered the questionnaire truthfully in fear of being scrutinised by the nurse. Then, there is the issue of a patient receiving help from family members, and this could lead to potential distortions in the collection of data. There was always a possibility that a family member could not record a patient’s response to a questionnaire faithfully. This could introduce a measure of bias into the findings.
There is concern that many participants did not have adequate literacy skills to comprehend and answer the questions. There is also a possibility that family members did not possess the needed literacy skills to comprehend and answer the questions. This may have led to distorted results as a clear and concise picture quantitatively is not obtained due to a bias that arises from the non-comprehension of the questionnaire.
The high scoring in the questionnaires could be related to the fact that the nurse educator collected the completed questionnaires. This has been shown in the literature to skew the patients' responses. When nurses collect data, the scoring is usually higher. This limitation in the distribution and collection of data is acknowledged. The completed questionnaires were placed in a sealed envelope by the patients before being handed to the nurse educator. The restricted timeline for the research meant that I could not collect the completed questionnaires in any other way.
Some of the questionnaires were incomplete, and there was some missing data. This could also lead to a bias in the data collected. The responses to the questions, even in the incomplete questionnaires, were accepted and used in the study. There was no need to impute the values, delete a question or reject a questionnaire from the study since the missing data was insufficient to distort the findings. This was because the sample size was sufficiently large. The missing data did not affect the randomness of the data.
Cultural Considerations
It must be acknowledged that the use of a translated questionnaire has the potential to present difficulties. Strauss and Corbin (2008) suggest there are four criteria to consider when using a translated questionnaire: (1) fit, (2) understanding, (3) generality, and (4) control. As IN-PATSAT32 is considered to meet these requirements, the existing Arabic Moroccan version of this questionnaire, first used by Obtel et al. (2012) when assessing Moroccan cancer patient satisfaction, was used. As it had been piloted in Arabic, it was regarded as a validated tool (Serhier et al. 2011) and suitable for use in the current study. Slight adaptations in Arabic were required due to differences between Moroccan and Saudi Arabia, and EORCT has translation guidelines for forward and backward translation (Cull et al. 2002). Any language adaptations were undertaken cautiously with an expert advisor, Dr. Obtel, an oncology doctor.
The Saudi ethics committee chair in the SRCC reviewed the questionnaire. Also, the questionnaire was tested to determine language suitability with Arabic-speaking university students at the University of Stirling before data collection for the current research was conducted. This process helped to identify any cultural barriers and ensure the language used in the questionnaire was fully understandable to Saudi patients.
Quantitative data analysis
The IN-PATSAT32 data were scored according to the available validated scale module (Bredart et al.2005) (See appendix 11 for the Scoring module). Scores for each of the fourteen questionnaire subscales were determined for each patient. All the scores for all items in a particular subscale are summed and then divided by the number of items in that subscale. The scale scores are then linearly transformed to a 0-100 scale, with a high score reflecting a higher level of satisfaction.
The data collected from the questionnaire (INPAT-SAT32) was then entered into a statistical package (SPSS, version 19) for processing and statistical analysis. The statistical analysis resulted in descriptive statistics of the questionnaire items, which are described and presented in chapter four. The information presented includes the percentage of respondents, the means and the standard deviation.
The data from the original Likert scale is also presented, together with that data having been subjected to a linear regression. The original data from the Likert scale presented a range of scores that were analysed. Linear regression involves identifying and determining the relationships between variables. In the data collected in the original Likert-based questionnaire, there were questions related to patients’ satisfaction with their care. The linear regression allows a statistical analysis of the relationships between the various variables (individual responses to the Likert-based questions). This allows the researcher to describe the relationships between the variables in the responses to the Likert questionnaire. Such relationships thus help to describe the samples’ satisfaction with individual issues that are encapsulated in the questions, and in doing so, these allowed me to build up (and then evaluate) an overall picture of patient satisfaction among this sample.
Chapter 4 - Qualitative Findings
Qualitative findings in research encompass non-numerical data, such as textual or visual information, often gathered through methods like interviews, observations, or content analysis. These findings provide insights into the richness and depth of human experiences, attitudes, and behaviours. Researchers use thematic analysis and interpretation to uncover patterns and themes within qualitative data, offering a nuanced understanding of the research subject. Qualitative findings are valuable in exploring complex social phenomena and complement quantitative research to provide a more comprehensive view of a topic.
Introduction
In this chapter, the findings from Phase 2 of the mixed methods study of patient satisfaction at the SRCC in Riyadh are presented. First, the participants’ characteristics are outlined. Second, the findings from the interviews are presented and organised according to the key themes which emerged. Specifically, this qualitative Phase 2 of the research sought a deeper understanding of how interpersonal aspects of care and accessibility to health care influence adult hospitalised oncology patients’ constructions of satisfaction. Furthermore, this phase sought to explore the role of cultural factors in influencing this satisfaction.
To achieve this, each key theme is presented separately, with relevant examples from the translated interview extracts. These interview extracts were selected based on the coding process and also to represent the wide range of participants’ views. Commentary is provided to link these findings with the literature, where appropriate, and also to highlight any similarities and differences between participants’ responses.
The chapter concludes with a summary of the key findings from this second phase of the study. A discussion of the findings presented here, along with those from Phase 1 (chapter 4), is then provided in Chapter 6, where the complementarity of the quantitative and qualitative data is shown. The implications of the findings and considerations for practice and future research are also considered in Chapter 6.
Socio-Demographic Patient Characteristics
In Table 1, the socio-demographic details of the participants, outlining their age, gender, education level, marital status and place of residence, are presented. It should be noted that there was a high number of young people participating in the study. This high proportion of younger people (<45 years) was due to the largely self-selecting aspect of this part of the research since the choice of interviews was based on those who volunteered. This may have made the sample unrepresentative of the general target population since the average median age of the diagnosis of cancer for a man was 58 years of age and 51 for women in 2010 ( Saudi Cancer Registry 2010).
Table 1 - Patient socio-demographic characteristics
| Age | ||||
| 36-45Y | Female | High school | Married | Riyadh |
| 46-55Y | Female | Primary | Married | Riyadh |
| 36-45Y | Female | High school | Married | Riyadh |
| 26-35Y | Female | University | Married | Outside Riyadh |
| 36-45Y | Female | High School | Divorced | Riyadh |
| 36-45Y | Male | Intermediate | Married | Outside Riyadh |
| 18-25Y | Female | Intermediate | Single | Outside Riyadh |
| 26-35Y | Female | High School | Married | Outside Riyadh |
| 36-45Y | Female | Illiterate | Married | Outside Riyadh |
| 36-45Y | Female | High School | Married | Outside Riyadh |
| 66-75Y | Male | Primary | Married | Riyadh |
| 46-55Y | Female | Primary | Widowed | Riyadh |
| 46-55Y | Female | University | Married | Riyadh |
| 56-65Y | Female | Intermediate | Widowed | Riyadh |
| 46-55Y | Male | Intermediate | Married | Riyadh |
| 46-55Y | Female | Intermediate | Married | Outside Riyadh |
| 46-55Y | Female | University | Married | Outside Riyadh |
| 36-45Y | Female | University | Married | Outside Riyadh |
| 26-35Y | Female | High school | Single | Outside Riyadh |
| Above 76Y | Female | Primary | Married | Outside Riyadh |
| 18-25Y | Female | High school | Single | Outside Riyadh |
| 36-45Y | Female | University | Married | Outside Riyadh |
Key Themes Emerging from the Interview Data
The extracts from the semi-structured interviews were translated and then analysed by thematic analysis using coding and theme development. The approach to the analysis was discussed in Chapter 3. The four primary themes identified from interview data are shown in Table 2 and are discussed below.
Table 2 - Themes and Subthemes that Emerged from the Interview Data
| Themes | Subthemes |
| The doctor-patient relationship | Perception of doctor-patient relationship |
| Interpersonal communication | |
| The nurse-patient relationship | The general perception of the nurse-patient relationship |
| Technical aspects of nurses’ skills | |
| Interpersonal aspects of nurses’ skills | |
| KSA cancer contextual factors | Perception of cancer |
| The power dynamic of KSA Doctor | |
| Religious influence | |
| Family influence | |
| Multi-cultural environment–nurses’ effects | |
Organisational factors : service organisation | Perception of a general service organisation |
| Accessibility | |
| Waiting times for services |
The Doctor-Patient Relationship
The analysis of participants’ descriptions of their interactions with their doctors provides insights into the aspects of the doctor-patient relationship that are especially meaningful to the patient and influence their understanding of their experiences and the satisfaction with the care they receive.
The doctor-patient relationship in KSA is somewhat different to the Western model. The family often needs to be consulted concerning the doctor’s disclosure of information to a patient. Doctors must often inform a patient’s family of their treatment and health. This means that the doctor-patient relationship is more complex and that a doctor needs to consider the family in their relationship with their patient. Many patients in the KSA are comfortable with this because of cultural considerations. This had some influence on the
Through interview analysis, four main factors were identified that represent aspects of interpersonal communication between doctors and their patients:
- Listening: listening to and addressing the patients’ questions and concerns
- Information provision: providing adequate information about the patient's conditions and treatments
- Motivation: being encouraging and motivating to the patients
- Care and compassion: caring and compassionate, with attention to the patient’s psychological and medical needs.
These aspects are important to the relationship between patient and doctor despite the requirements for non-
The following section presents the participants’ general perceptions of the doctor-patient relationship in the oncology ward at the SRCC in Riyadh. In the subsequent sections, the four sub-themes are examined in detail.
General Perceptions of the Doctor-Patient Relationship
The current study produced varied views among participants regarding the doctor-patient relationship experience. Many constructed their relationship with their patient satisfyingly, although they were dissatisfied with some aspects.
Fourteen of the twenty-two research participants in the study were positive about their experiences of the doctor-patient relationship. They expressed appreciation and gratitude for their doctors’ personal qualities and interpersonal skills, which contributed to satisfaction with their hospital stay despite the non-disclosure requirements. Those reporting positive experiences described their doctors as comforting, trustworthy, helpful, kind, cooperative and patient. For example, two participants stated the following:-
It was a nice experience. Doctors were very helpful and cooperative. (Participant 15)
However, eight participants were critical of some aspect of the doctor-patient relationship. They commented that, although the doctors’ medical expertise was of a very high standard, they lacked interpersonal skills, including communication skills, kindness, empathy, and compassion. These views may have been in part influenced by their non-disclosure requirements. The following extracts from participants’ narratives illustrate this:
They are professional and skilful in their jobs, but their interpersonal skills need much improvement. (Participant 18)
They are good, but they need development and more time to spend with patients. (Participant 5)
In short, their communication skills need to be improved. (Participant 10)
They told me about chemotherapy and sent me to the health educator to explain the cycles and side effects, which was good. But the doctors here didn’t give the whole treatment plan or plan to clarify things for me. (Participant 3)
In cancer settings especially, suboptimal communication between doctor and patient can increase patient anxiety and distress levels, thereby adversely affecting patient satisfaction with the doctor-patient relationship (Fogarty et al. 1999; Thorne et al. 2013). It is not uncommon for doctors themselves to be unaware of these problems. Researchers argue that there is often a large gap between patients and doctors in their perceptions of the quality of communication between them (Kenny et al. 2010). While the majority of the participants indicated that this communication was of a good standard, the analysis of the perceptions of participants who were dissatisfied with the doctor-patient relationship indicates that some doctors were not adequately aware of, or concerned about, the patient’s concerns and anxieties, or sufficiently willing to address them.
Because many families restrict information disclosure, this prohibits doctors from disclosing information to some patients, especially females. Doctors often need to consult patients’ families on providing information or what should be revealed. This can lead many patients to not being fully informed of their treatment. Many patients are not aware of this family request and the restrictions that are placed upon doctors’ level of communication with their patients, especially about the disclosure of treatment plans. This may cause some patients, especially females, to believe their doctors are poor communicators while only conforming to the family's wishes.
Indeed, there was no indication that doctors avoided contact with these patients. However, in some cases, the doctors’ communications with their patients were not satisfying experiences. Females and males are treated differently under the non-disclosure arrangements. However, several males expressed their opinion that doctors have ‘poor communication’, and this suggests that some patients construct their communications with doctors as being unsatisfactory.
Listening Skills
Participants reported that they often had questions and concerns about their illness or treatment, which, if not answered, caused great anxiety and stress. It was important to them to have adequate opportunities to ask their doctor questions or discuss their concerns and feel comfortable doing so. The fourteen participants who mostly expressed satisfaction with the doctor-patient relationship all indicated that their doctors were frequently available to them, encouraged them to ask questions, and provided all the information needed to address their concerns, as the following extracts demonstrate:
They made me comfortable enough to share my concerns with them and patiently listened to me. They answered each of my queries and cleared my doubts. (Participant 15)
They have been very kind and patient. They listen to my concerns and give complete attention to what I say … They answer all my questions no matter how foolish my questions might sound. (Participant 9)
These data show that the majority of the participants were experiencing high levels of personal attention from their doctors, providing evidence of optimum listening skills in the hospital and indicating that the doctors are addressing the concerns and psychological needs of their patients. This was the case with both males and females and suggested that doctors displayed good communication skills despite the limitations imposed upon them by the non-disclosing cultural attitude. Communication involves issues like ‘listening’, which would not be greatly influenced by any non-disclosure requirements.
In contrast, eight participants reported negative experiences of communicating with their doctors, which they perceived as mainly owing to the doctors’ busy routines and limited time for patient conversations. These participants commented that the doctors seemed unwilling to listen to their questions and concerns or to provide the information being sought. The following extracts demonstrate this and also highlight the power dynamics implicit in these doctor-patient relationships:
I … didn’t have the courage to stop or ask them more as they look busy and talk quickly during rounds. (Participant 5)
This participant’s concerns and emphasis on his/her lack of courage convey a fear of engaging doctors in conversation, which may or may not be related to the doctors’ listening capacity. However, the subsequent observations made by other participants indicate that this listening capacity may be limited in some cases:
My talk with them is usually very brief and one-sided in which all I have to say is ‘yes’ or ‘no’; they tell, and I listen. (Participant 6)
The doctors asked me general questions but were never interested in my concerns. (Participant 21)
These comments suggest a power dynamic that is downward directed from doctor to patient, where the doctor is the one in control of the knowledge that the patients need to allay their anxiety. The fact that this anxiety is not adequately listened to, and the knowledge is not shared highlights an unequal balance of power and control in the patient-doctor relationship here. In particular, the repeated reference to ‘fear’ and ‘courage’ demonstrate the distress some participants felt at not being adequately listened to.
These findings indicate that at least some of the oncology doctors treating the participants in the current study did not give the impression that the participants’ concerns were of interest. Previous research by Jagosh et al. (2011) argues that physician listening has three very important functions: (1) clinical data gathering, (2) healing and therapeutic value, and (3) building the doctor-patient relationship. While it is uncertain from my findings whether or not the doctors were listening to the concerns of their patients, what the study does show is that some felt that they were not being heard. As Ansmann et al. (2013) found, a busy hospital work environment and heavy workload may hinder physicians’ ability to support patients adequately, and they may feel constrained in communicating with patients because of non-disclosure arrangements.
Information Provision
Most participants reported positive experiences of receiving comprehensive information from their doctors and noted the calming and reassuring effects that these had on them. The following extracts illustrate this:
The doctors listened to my queries and clarified my doubts in detail. They took every step to inform me well at the start of treatment and also provided me with relevant information during treatment. (Participant 16)
I even had some misconceptions about radiology, but they clarified the concepts, and now I’m not scared of my treatment. (Participant 11)
These statements would indicate that despite any non-disclosure arrangements, in many cases, doctors are listening to patients and offering them information on their treatment. They can clarify a patient’s treatments in a general way and, in doing so, keep patients somewhat informed. These participants’ statements contrast some of the more negative perceptions of doctors’ listening skills described in the previous section. Of note is the frequent referral of participants due to their lack of clarity regarding their illness and treatments. The responses here, however, certainly suggest some doctors’ efforts to alleviate patients’ anxiety regarding the course of their disease and treatment (even if the prognosis itself may not be positive) through adequate information provision.
It did appear that information provision was problematic for some participants; some reported having to wait too long to receive the information they needed. This was at least partly due to the doctors’ busy schedules and partly due to the hospital protocol arising from policies of the KSA health service, which prevents the nursing staff from providing certain information to patients. As one participant said:
I am waiting longer to get information about results from doctors, while nurses can’t give me this information until the doctors do their rounds. I sometimes can’t tolerate the nurses saying that they are unsure about my treatment, as they have to wait for the results and for the doctor to read the results and inform me about progress. This process makes me feel more worried and anxious about my stay. (Participant 5)
Even though some data showed a positive trend toward taking patient satisfaction into account, participant responses such as these indicate that organisational factors such as hospital policies or procedures can sometimes adversely affect patients' experience and hurt patient well-being (Aljubran, 2010). The following comments highlight this:
It’s worrisome and irritating to wait so long. Especially for cancer patients, it’s even more irritating to wait. I don’t like it when hospital management forgets about the psychological state of their patients. (Participant 13)
I had even requested my oncology team twice to come quickly for the referral visit. They didn’t pay any attention, and I’m still here waiting for my psychologist session. I feel so dissatisfied and depressed. (Participant 10)
The stark contrast between these perceptions and those of the participants who were satisfied with the quality and timing of the information they had received conveys high variability in the level of information provision among different doctors at the hospital. What is apparent from these extracts is that long waiting times to receive information can substantially increase patients’ stress levels. Addressing this issue is important since studies have shown that psychological distress has an impact on cancer mortality (Hamer et al., 2008). For example, those who expressed dissatisfaction with the doctors’ communication skills could be at risk of poorer health outcomes. This would support the view that non-disclosure could be interfering with a patient’s
Motivation
The data from the interviews support the evidence that the nature, as well as the level of communication between doctor and patient, has a significant influence on patient satisfaction and how it is perceived (Mobiereek et al. 1996; Ezubair 2002). It is clear from participants’ statements that doctors potentially play an essential role in raising and maintaining patient morale by being encouraging and positive about their recovery:
They advise me to keep myself hopeful. They tell me that I can get healthy again and I’ll be able to live a normal life. I’m so determined to get rid of my breast cancer, and I’m thankful to my doctors that they have been helping me so much. (Participant 9)
They were supportive of the success of the treatment. They were encouraging and kind. They sounded like they truly wanted me to get well. (Participant 3)
The key elements here are the nurturing of hope, encouragement, and the perception of genuine well-wishing on the doctors’ part. The doctors’ positive attitudes and the nature of patients’ communication with them may reflect, at least in part, the culture of the KSA, in which physicians are traditionally held in high regard and as figures of authority (Mobeireek et al.1996; Younge et al. 1997; Aljubran 2010). However, in contrast to the negative dynamic of power and control, the researcher became aware that those doctors who were perceived as listening inadequately to their patient’s needs were not viewed favourably by patients. The doctor’s ability to listen is described as deeply appreciated and seen as responsibly used, i.e. for the psychological improvement of the patient. Being in the position of authority means that compared to other members of the health care team, doctors have a greater impact, either positive or negative, on the health and well-being of patients. What is evident is that communication and relationships with doctors are significant factors in enhancing patients’ psychological well-being, as attested by other participants:
I didn’t want to stay as I felt depressed, but their motivating words helped me, and I started being hopeful. Now, I can proudly say that if my doctors hadn’t stayed positive and supportive, I wouldn’t have been able to come out of my illness. (Participant 19)
They have inspired me with their attitude and kindness. They are encouraging; it becomes easier to hope for successful treatment … Their supportive words became my strength, and I am ready to go home with a healthy body and mind. (Participant 13)
When doctors are encouraging and motivating, this can have a perceived positive impact on the progression of the patient’s recovery. As previous research has indicated, doctors’ communication in an oncology setting can affect patient satisfaction and influence the patient’s well-being and quality of life (Ong et al., 2000; Wildes et al., 2011).
The practice of non-disclosure could, especially for females, lead to them to their experiences in a negative way, and this, in turn, could impact their health outcomes. The implication of the non-disclosure as a cultural attitude could, therefore, mean that females are more likely to suffer a negative health outcome than males in KSA oncology settings.
Conversely, some participants reported that communication with their doctors had been negative in that their experiences with doctors were not constructed as encouraging or motivating. This is demonstrated by two participants, who explicitly stated how this had disheartened them and weakened their resolve to recover from their illness:
As medical attendants, their behaviour has never been motivating or heartening. (Participant 10)
They have a very casual attitude, which I don’t appreciate much. They don’t fill the patient with motivation and determination to fight against their illness. (Participant 6)
These positive and negative examples show the impact that the physician’s manner may have on the psychological state and even on the physical well-being of the patient. These examples also reflect on the connection between a healthy body and a healthy, positive mind, as ‘hope’ was a keyword emerging in positive descriptions of doctors who were seen as motivating. Previous research argues that a patient’s attitude may positively correlate with doctor behaviours perceived as encouraging and motivating, often resulting in positive medical outcomes such as improved adherence to treatment and self-care (Street et al. 2009). By being motivating and encouraging to the patient, doctors’ communication may have a significant impact on the patient’s state of mind, such as lowering anxiety, and thus, may indirectly influence the overall outcome of the illness episode (Ommen et al. 2010). While it has been argued that an awareness of psychological distress is an essential aspect of patient care, oncology doctors are often unwilling to note the distress in patients and ask questions regarding patients’ psychological health (Cull et al. 1995; Fallowfield et al. 2001).
The interviews provide insights into the overall impact of a trusting and motivational relationship between the doctor and patient on patient satisfaction and well-being, particularly on the patient’s abilities to cope with and fight their illness. Participants’ comments throughout this section tend to support the findings of previous studies that have highlighted the association between a trusting doctor-patient relationship and patients coping with their illness, which may result in improved patient outcomes (Epstein and Street 2007; Arora 2008).
At the beginning of all this, I was scared to death, and every step of my treatment used to frighten me ... But when I talked about this with my doctors, they listened and gave such kind advice and motivation that finally, I started to feel calm. (Participant 4)
The doctors were very friendly and took time to build up my confidence. This provided me with the strength to fight (the) suffering caused by the disease and treatment. I felt comfortable in their presence, and that brought a lot of positive energy to me to receive the treatment with great hope and confidence. (Participant 16)
The interview data show a strong link between hope and trust, reiterating the notion of a positive power dynamic between doctors and patients, where the doctors are respected figures of authority who are seen as crucial to reassuring and encouraging the patient with whom they have built up a good relationship. Other research similarly indicates that having a trusting relationship with one’s doctor can have a positive impact on the patient’s mind, generating a more hopeful attitude towards the condition and thus aiding the overall mental state and self-care, which ultimately improves the patient’s quality of life (Clever et al. 2008). Trust could become an issue as a result of the non-disclosure by doctors of issues related to the patient’s treatment.
Exploring further the connection of trust with patients feeling motivated and encouraged by their doctors, it was found that where there was insufficient trust in the doctor’s genuine interest in the patient’s well-being, feelings of hope and encouragement suffered to the detriment of the patient’s emotional state. For example:
Doctors’ changes in behaviour or attitude can make the patient feel ‘unwanted’. Depression and hopelessness take over his mind, and his hopes to get healthy fade away. Fear, frustration and sadness fill his mind. (Participant 3)
These findings support evidence from other studies regarding the lack of a trusting doctor-patient relationship, which can negatively influence patients’ satisfaction levels (Stewart 1995; Parker et al. 2003). It is evident from my findings that if doctors fail to communicate appropriately with patients, the lack of trust and subsequent lack of motivating and encouraging behaviour may adversely impact the psychological well-being of the patient and potentially the clinical outcome.
My findings are similar to those of Fogarty et al. (1999) and Ommen et al. (2010) but additionally provide a deeper, more meaningful contribution to the hitherto poorly researched field of patient satisfaction from the perspective of the KSA context. It would also indicate that more disclosure of health information is important to enhance the doctor-patient relationship, and this, in turn – based on the evidence that good communication improves patients’ well-being (Aljubran, 2010) – would lead to better health outcomes for those being treated in an oncology setting.
Care and Compassion
The interview data revealed that a further communication aspect that can have a significant influence on patient satisfaction is when doctors show compassion and care. Carmel and Glick define the compassionate behaviour of physicians as ‘strong devotion to the welfare of the patient on two crucial dimensions of patient care: technical and socio-emotional’ (1996, p. 1253). Doctors perceived as caring and compassionate with patients may provide emotional healing, which could be viewed as a determinant of patient satisfaction (Fogarty et al. 1999; Bertakis et al. 1999).
Many participants frequently reported experiences associated with compassion and caring exhibited by their doctors, using terms such as tender, understanding, patient, concerned, and reassuring and indicating a broader definition of care and compassion. For example:
Doctors have been so tender and (re)assuring. (Participant 13)
The doctors were concerned about me and wanted me to recover soon. (Participant 15)
Many also directly alluded to the concepts of compassion, or lack of compassion, when discussing the care they had received from doctors. The absence or presence of compassion impacted the patient’s overall satisfaction with their care. These findings evoke the understanding that an important dimension of patient satisfaction is the ability of the doctor to relate to and engage with the patient as an individual or, as highlighted in the 2001 IOM definition of the patient-centred approach, to be concerned with the ‘needs, and values [of the patient], and ensure that patient values guide all clinical decisions’ (IOM 2001, p. 40).
The perceived lack of compassion may have been attributable to doctors’ avoiding close engagement with some patients due to the above-noted stipulations regarding disclosing certain health information to families rather than patients. Another possible explanation is that expatriate doctors for whom Arabic is a second language experience difficulty verbally expressing care and compassion to Saudi patients. These expatriate doctors may feel in particular constrained about communicating with patients in the context of the requirements regarding the non-disclosure of information to patients.
My findings indicated that some participants had experienced compassion and caring from their doctors according to these terms, which in turn helped them to feel more comfortable in discussing their concerns with the doctor; this also made them feel the doctor was truly interested in their recovery. The following extracts illustrate this:
The doctors understood my need for a sitter[1] and sent me a social worker to facilitate that during my stay. (Participant 20)
The doctors were compassionate enough to give me a few minutes (out of) of their busy routine and listen to my concerns. (Participant 10)
These extracts convey that compassion and care were shown towards these patients by showing that the doctors understood and responded well to their circumstances, paying attention to their concerns and preferences.
In contrast, other participants commented that the doctors showed inadequate compassion in communicating with them and appeared uninterested in their well-being. Thus, these patients felt discouraged from asking questions, and this constraint reportedly made it more difficult for them to cope with their illness:
They don’t have time to talk to patients, and everything is so routine that they don’t have compassion towards the patient. They ask routine questions and provide general reassurance. I am suffering so much of it without any psychological support from doctors. It is really difficult for me to cope. (Participant 19)
The doctors are not compassionate at all. They just asked a few questions about our illness but never appeared concerned with our psychological state. (Participant 21)
Two main findings emerge about compassion and the doctor-patient relationship. First, there is a link made between compassion and coping (psychologically), with the implication being that an absence of compassion impacts negatively on the ability to cope. Second, the appearance of a lack of concern on the doctors’ part is a common idea. ‘Concern’ is here distinguished from basic communication, the implication being that it is more than just asking questions; rather, it requires a ‘patient-centred’ attitude that balances meeting the patient’s clinical and psychological needs.
As noted, expatriate doctors for whom Arabic is a second language may be hindered in expressing care and compassion by the language barrier between themselves and Saudi patients. The language barrier may mean they appear detached from their patients and not appear as empathic, especially as they may also lack cultural sensitivity. My findings agree with previous research that indicates the positive impact of doctors’ compassion on decreasing the level of anxiety in cancer patients, which in turn increases the level of patient satisfaction and results in improved medical outcomes (Fogarty et al. 1999).
Patient satisfaction in an oncology setting was related to the important role that the doctor plays in all aspects of their recovery. It highlighted the need for excellent interpersonal skills for them to fulfil this role effectively:
To me, doctors aren’t only diagnosticians but also a ray of hope. Their behaviour, words and facial expressions are important to me, and how I judge the chances of getting well. (Participant 3)
By interpersonal skills, I mean communication skills and compassion. They need to have more kindness and empathy. Here, doctors are good — I don’t say they are bad — but in these skills and characteristics, a lot is lacking. (Participant 18)
A comment from one of the participants summed up the importance of the interpersonal aspects of the doctor-patient role, which appear at times to be disregarded by the medical profession but are often the standards by which patients judge doctors:
The patients classify doctors on an additional criterion, which is ‘behaviour’. The doctor who’s good at his job but not so supportive or caring is designated as a bad doctor. At the same time, hospitals select doctors based on their abilities and experience. (Participant 3)
These findings suggest that it is not only doctors’ medical expertise that is valued but also their interpersonal communication skills and the level of trust, compassion and ‘felt’ concern that they bring to their relationships with patients. It also suggests a disagreement between what patients value in a doctor and those attributes and values doctors consider important to the organisation. Non-disclosure and language barriers may all interfere with the doctor’s expression of care and make them appear as remote figures who show ‘detached concern’, rather than empathy. This may factor in patients constructing their experiences when negatively interacting with doctors.
The nurse-patient relationship
Findings in this area can broadly be divided into two elements, which interplay to varying degrees and show varying experiences of the nurse-patient relationship. The first is technical competence, relating to nurses’ professional skills in administering medication and other treatments. The second is nurses’ perceived interpersonal skills, encompassing a caring attitude, showing compassion, and being available to respond to patients’ needs. Beginning with an overview of participants’ overall impressions and general perception of the nurse-patient relationship, the following sections outline these key areas, analysing their interplay.
General perceptions of the nurse-patient relationship
The majority of participants recognised the importance of the nurses’ roles and were appreciative of their help and attitudes. Those reporting positive experiences when describing their relationship with nurses used words such as ‘kindness’, ‘supportiveness’, ‘accuracy’, ‘responsiveness’, ‘trustworthiness’, and ‘understanding’, as the following extracts show:
They are always willing to help us. It’s so inspiring that despite their busy routine, they like to wear a kind and reassuring smile. (Participant 13)
The nursing staff was very dedicated. They provided a great deal of help and support. They attended to each patient with a smile and performed their work diligently. They made my stay comfortable. (Participant 16)
These comments convey the impact of the nurses’ positive interpersonal attitudes (i.e. being kind and reassuring), as well as their professional qualities and competencies (performing their work diligently), on patient satisfaction.
In contrast, a few participants reported that nurses did not have supportive attitudes and were sometimes too busy for positive communication. The most noteworthy aspects of dissatisfaction related to issues such as inadequate attention to individual patient's needs and a lack of psychological support:
Generally, nurses are good but need to recognise the psychological status of the patient by allowing more time to spend with cancer patients when asking questions. (Participant 5)
The nursing staff is good, but there’s a lot of need for further development. They cannot adapt to patients of different mindsets having a generalised attitude, which isn’t insufficient. And that’s the reason I’m not satisfied. (Participant 7)
The findings also indicate that, to deliver improvements regarding the nurse-patient relationship, there is a need to address organisational constraints. These include the low number of nurses at the hospital, which strains their capacity and/or capability. It seems that there is a need to increase the number of nurses and enhance their efficiency so that they can devote more time to effective communication with their patients, as illustrated by the responses of two participants:-
They are good, but they are very busy, and there is a real staff shortage. (Participant 1)
The number of nurses is a drawback, as they are limited. Therefore, sometimes I didn’t want to bother them to get assistance for the bathroom, so I asked them to teach me how to disconnect the IV plug, and then it was easier for me to help myself. But of course, when I need them, they are around and respond well to my calls. (Participant 18)
The last excerpt highlights the awareness that, while nurses’ capacity may be limited, this is not owing to any technical incompetency or lack of care but is rather an issue of resources. The positive opinions towards the end of the extract indicate that, despite constraints, nurses make themselves available to help patients with urgent needs. However, some of the participants mentioned a lack of psychological support rather than technical assistance as being the key feature that defined their relationship with nurses:
Nurses need to be specifically trained to deal with cancer patients. They should be aware of our psychological state, and their attitude should provide confidence to patients as we sometimes have many questions or are worried about the next appointment or discharge. They should welcome questions and comfort us with patience and kindness. (Participant 21)
This extract gives the impression that the nurses did not fulfil their role appropriately and failed to offer psychological support, which is important for a patient-centred approach to nursing. Moreover, this participant felt nurses should focus more on communication and relationship building. Overall, it was apparent that a nurse not having sufficient time to interact and communicate with patients determined patient satisfaction with the nurse/patient relationship. These findings concur with those of Shattell (2004) and Rachiadia (2009), who indicate that patients want approachable, available, empathic and willing to talk with them and nurses who are not rushed because of their workload and responsibilities.
Phase 2: Qualitative Method
3.6.1 Qualitative design: Semi-structured interviews
Data was gathered through interviews with the participants selected from those who had answered the questionnaire used in Phase 1 and had agreed to be interviewed. It was also important to test the interview schedule in the initial interviews through a pilot interview between the researcher and nurse educator (Ritchie and Lewis 2003). Interviews are deemed suitable to explore attitudes and beliefs (Gordon 1975), and they can be structured, unstructured (open), or semi-structured (Mason 2006; Walliman 2005).
Semi-structured interviews were used in the current study for the following reasons: (1) to elicit the participants’ perspectives on what areas were deemed deficient, satisfactory, or excellent regarding the care they had received or to fill in the gaps that had been highlighted following analysis of the questionnaires; and (2) for complementarity. Some researchers argue that the credibility of research is often affected when it is based on semi-structured interviews (Creswell, 1998; Patton, 2002), for example, because the meaning or wording of questions may be interpreted differently by the respondents. However, other researchers (Barribal and While 1994; Opie 2004) support using semi-structured interviews. Careful consideration was taken throughout the research to keep both perspectives in mind. The questions were developed keeping in mind the comprehension level of participants can vary, so very layman words were used, and no particular jargon was used. During the pilot phase of interview testing, the questions were securitized to ensure that participants concluded a single interpretation. Semi-structured interview questions in a healthcare setting are not uncommon, but for this particular study, many factors and concerns influenced them. Therefore, during the pilot phase of interviewing, all questions were scrutinised, and discussions from the questions were closely monitored to ensure that participants were comprehending them.
Participant recruitment
Participants who responded to the questionnaire during Phase 1 were invited to participate in follow-up interviews. Participation was invited after the quantitative questionnaire by asking patients to indicate if they were interested in a follow-up interview. I contacted those who agreed to interview by telephone to arrange an appointment and obtain verbal consent (see Appendix 8 for the interview consent form). Patient information and contact details were entered into the interview recruitment log to manage the research recruitment process (see Appendix 9 for the interview recruitment log).
Sampling methods
The sampling approach for Phase 2 was based on the results from Phase 1 but also relied on the participant's agreement to be interviewed. Thus, the sample selection for the interviews was largely based on convenience sampling. That is, the selection was based on those who were most readily accessible when conducting the study (Burns and Grove 2007). Such convenience sampling uses non-probability sampling techniques based on accessibility and ease of access to participants (Marshal 1996).
Throughout the study, convenience sampling was used because of issues of access and time. These restraints meant that the researcher could only identify a sample based on those whom she could conveniently approach in the oncology ward and those who were willing to participate. The convenience sampling method was also used since participation was based on the patients who had already completed Phase 1. That is, only those who had previous access to the questionnaire were included in the sampling.
Of those who completed the quantitative questionnaire, 100 were invited to participate in follow-up qualitative interviews. Of these, 38 expressed their interest, with 23 subsequently leaving contact details and one person dropping out because of personal reasons, making a total of 22 participants for the interviews. This is a relatively small sample but representative, as discussed later in chapter five. It was sufficient to gather rich data so that it became common in the later interviews to be presented with views and experiences similar to those already reported.
The development of the interview schedule
The aim of Phase 2 of the mixed methods study was exploratory to help gain a deeper understanding of patient satisfaction in the KSA. The interview design was informed by several practical considerations, including ensuring each interview took no more than 30-45 minutes to avoid tiring the patients (Rhemtulla and Little 2012). An interview schedule was prepared to elicit the participants’ perceptions of patient satisfaction. The interview schedule included a brief discussion on an outline of issues, a list of topics and subtopics relevant to the research, and the primary research question (Green and Thorogood 2009); the questions were adapted and refined based on the results of Phase 1.
It is important to recognise that researchers should use interview schedules cautiously, as they can challenge the exploratory aim of qualitative research (Arthur and Nazroo, 2003). Accordingly, the interview schedule was derived from the quantitative phase by identifying several key issues. The areas of interest coherent with the research question were selected based on the INPATSAT 32 results. It was anticipated that the broad areas of interest would be evaluated and explored in the interviews, for example, clinical effectiveness and accessibility to health care.
These broad areas were then broken down into more specific and manageable concepts to facilitate further exploration. For example, the doctors’ skills, nurses’ skills, information exchange, service organisation/accessibility, and general satisfaction were identified as the specific areas of interest that were essential to be covered during the interviews. This led to a semi-structured interview schedule built around the results from Phase 1, but the actual interview used open-ended questions to allow scope for the patients to present their views and provide answers in their own words (Bryman 2004). The interview questions in the schedule were checked and approved by my supervisors, ensuring the questions were not leading questions focused towards generating responses that reflected my opinions.
Following approval, the English version of the interview schedule was then agreed upon by my supervisors and prepared for translation to Arabic. As mentioned previously, translation was an important step as there was a need to ensure that the questions and wording were consistent with cultural considerations. It was also important to test the interview schedule in the initial interviews (Ritchie and Lewis 2003). Therefore, in the first couple of interviews, it was possible to assess how well the interview schedule worked according to the data types I was generating and whether these data met the study aims. The prepared interview schedule can be found in Appendix 20.
Qualitative data collection
A majority of the interviews conducted were through telephone rather than face-to-face. The use of telephonic interviews came about for various reasons. Firstly, there was a need to adhere to a specific timeframe for completing fieldwork for the current study. Also, many of the oncology patients who were discharged after the survey was completed gave rise to difficulties in transport as face-to-face interviews meant travelling a great distance. It was also observed that most participants felt more comfortable with telephonic interviews, particularly male participants, due to cultural restrictions in speaking with a female researcher face-to-face. The face-to-face interview conducted within the oncology ward provided a great deal of insight into the participant's behaviours during the interview, which clarified patient satisfaction to a great extent from observing non-verbal gestures and cues.
Telephone Interviews
Telephone interviews were administered to oncology patients who could not be reached for face-to-face interviews due to distance or because of the patient’s preference for a telephone interview. It is noteworthy that problems with recruiting participants for face-to-face interviews (even for practice interviews) are common (Mann and Stewart, 2000). Telephone interviews have been previously used successfully for qualitative semi-structured interviews (Bowman et al. 1994; Barriball et al. 1996). However, one advantage of telephone interviewing is that it extends access to participants (Mann and Stewart, 2000).
Telephone interviews are considered to be a credible and robust method, although the researcher is unable to see non-verbal and social cues such as body language (Novick 2008). This lack of visual cues is considered a minimal loss in the context of the patients under study, as they were all familiar with the issues raised (Opdenakker 2006). Indeed, there are other social cues available in telephone interviews, such as voice and intonation (Opdenakker 2006). In addition, the patients seemed more relaxed, reflective and able to freely discuss sensitive topics during telephone interviews (Sturges and Hanrahan 2004; Irvine et al. 2013). For example, participants were very comfortable discussing their doctor’s attitude towards them and openly spoke of the lack of compassion exerted by doctors on their patients. The telephone interviews, arranged over the phone, especially suited the cultural context where privacy is valued. A total of 20 telephone interviews were conducted.
Face-To-Face Interviews
Face-to-face interviews were conducted with two patients in the oncology ward setting of the SRCC in Riyadh. Face-to-face interviews provided a basis for determining changes in patients’ moods and tone and voice inflexion about their satisfaction with the dimensions of care offered by the oncology department (Pop et al.2002). The interview process is described in more detail in the following section.
Interview process
Although face-to-face interviews were desirable, in practice, for most patients, it was not possible to agree on a mutually convenient time for interviewing in the hospital before their discharge. This was because most of the patients had been already discharged from the hospital oncology ward and so had returned to their families. In such contexts, they were often not free to speak because of cultural restrictions. Additionally, most patients resided outside of Riyadh, making visiting them post-discharge difficult, not only in terms of distance but also because it was time-consuming and costly.
In a sequential mixed method study, it is important to maintain a short time interval between the first and second phases, and the use of telephone interviews managed this. This increases the likelihood of aligning the quantitative questionnaire with the interview schedule (Harris and Brown, 2010). A short interval between the phases was therefore chosen to maximise patients’ recollections of the underlying reasons behind their responses to the quantitative questionnaire (Cronoholm and Hjalarsson 2011).
Follow-up hospital appointments for these patients were six to eight weeks post-discharge, meaning they were interviewed between discharge from the hospital and their next appointment. There was also a possibility that patients’ conditions might deteriorate over time, which could have made participation at a later date highly unlikely. Accordingly, under the circumstances, to extend access to discharged patients and maximise recruitment for the qualitative phase without compromising the quality of the information, telephone interviews were performed with these patients at a mutually convenient time.
Although it was originally planned to record interviews, this was not possible since the ethical committee of the SCCR in Riyadh insisted on a separate patient agreement if audio was to be used. Since interviews were not recorded, this emphasised effective note-taking to capture all participants’ responses accurately. Good notes must preserve interview information by providing an accurate account of the verbal responses and dialogue. A potential disadvantage to note-taking over tape recording or videotaping is the possible inability to capture all relevant details (Muswazi and Nhamo, 2013).
Additionally, the writing process can mean long gaps or pauses in the interview, plus the interviewer may find it rather challenging to combine concurrent note-taking with guiding the conversation (Beebe 2001). Similarly, Muswazi and Nhamo (2013) describe how note-taking disrupts communication effectiveness between the interviewer and the respondent. Conversely, an advantage of note-taking is that it can facilitate data analysis since the interviewer may already have classified the information into appropriate response categories (Burnett et al.1998). To guard against potential problems, I undertook practice interviews with Arabic students at the University of Stirling and note-taking before conducting real ones. The first interview was conducted on the 6th of March 2013, and the last on the 24th of April 2013.
Each interview started with introducing myself to the participant as a research student and healthcare professional not associated with their care. Before starting an interview, a brief review of the study's aims was performed to remind the participant. This further highlighted to the patients the importance of their participation in generating valuable research data, helping improve the quality of health care in the future. The fact that the study information would be made anonymous and kept strictly confidential was also emphasised at the outset. I tried to make the participant as comfortable as possible by consciously attempting to establish an informal atmosphere and rapport with the participant. I also reminded the participants of the voluntary nature of participating in the study and that they could withdraw at any time. I also encouraged them to ask for clarification if they did not fully understand the questions. I emphasised that they should not feel embarrassed to refuse to answer any question should they feel uneasy.
Several areas of concern became evident during the interview, which initially appeared to affect the openness of the participants’ responses. Anonymity was one of these since participants were concerned that any negative perspective they voiced might filter back to the healthcare professionals caring for them, thus affecting any future care they might receive in the hospital. All participants were, therefore, assured of anonymity many times. I also sometimes sensed nervousness and hesitation and a tendency towards formality in the way the participants responded to my questions. This was understandable given Saudi culture; Saudis tend to be reserved and respectful, granting considerable authority to healthcare workers and holding them in high regard. Moreover, in the KSA, strong family ties and the hierarchical structure within the family unit mean women might feel inhibited about criticising people in authority. Indeed, some Saudi women must seek permission from a male guardian before openly communicating their needs and wishes to healthcare professionals (Walker 2009). It was, therefore, not surprising that some people initially felt uneasy about describing negative healthcare experiences or raising concerns and voicing dissatisfaction over their doctors.
I became increasingly sensitive to these potential barriers and soon learned to adapt my interview techniques to encourage informality and transparency. In particular, this meant respecting the patients’ cultural choices, ensuring an informal ethos, and treating them as individuals to minimise stress. Thus, to encourage participants to continue talking and elaborate on particular issues of interest, I used verbal prompts such as, ‘Tell me more about’, ‘please explain’, and ‘Why do you think that?’ I also followed recommendations made by Fontana and Frey (1994) and ensured I was courteous, friendly and pleasant. As the interviews proceeded, participants appeared increasingly relaxed and tended to open up more.
During the beginning of some interviews, patients made many positive comments, which might have been interpreted as having considerable satisfaction with their hospital care. However, as the interviews progressed, participants started voicing concerns over their care, making several negative comments and pointing to areas where they thought improvement could be made. This honesty is consistent with an emotional shift as the interview-interviewee relationship evolves, and a rapport develops (King and Horrocks 2010). Nevertheless, the extent to which the participants’ culture adversely affected the transparency of the answers they provided remains unknown. There was an awareness that culture was a potential factor that needed to be addressed in the discussion. The context of the findings needs to be accounted for when discussing them. It was important to make clear that the participants were from the KSA, and what they expressed was based on how its culture influenced their responses. Any findings derived from these responses are, therefore, a reflection of these cultural influences. Introducing the issue of culture as a variable in the discussion of the findings ensured that it was at the least acknowledged.
My training in communication as a nurse and my professional skills led to an awareness of these constraints and limitations and was important when analysing and interpreting the data. I understood the difficulties and challenges involved for a patient and how this could have influenced their views. My experience as a nurse in KSA was also helpful as it provided me with an insight into the cultural assumptions of my patients. My communication training allowed me to interact with people and, to an extent, allowed me to overcome any cultural barriers. This and an awareness of the influence of culture allowed for a fuller and more complete discussion of the findings. To a certain extent, it was a bit difficult to separate roles as a researcher and nurse, particularly in developing a rapport that maintains the limit of a researcher. Rapport building as a nurse is more focused on building relationships with patients to ensure the quality of care and comfort throughout the delivery of healthcare services. However, as a researcher, it is essential to only divulge in communication building to the extent that it provides appropriate information to the researcher. Also, as a researcher, it is essential to abstain from bias by favouring specific participants over others. As a researcher, it was essential to refrain from emotional attachments; this is also true for a nurse but to an extent. Therefore, a middle ground was struck, which ensured that participants that I valued their input without becoming too emotionally attached to them.
Qualitative data preparation
Generally, interviews create a large amount of data in audio or textual format (Pope et al. 2000). Whilst translating the transcribed interviews from Arabic to English, problems were encountered. Literal (word-for-word) translation can often be inappropriate and lose the actual meaning behind the original narrative (Rubin and Rubin, 1995). The bias inherent in transcript translation in qualitative research has been extensively discussed in previous publications (Brislin et al. 1973; Rubin and Rubin 1995; Temple 1997).
A noted primary methodological dilemma is to use literal translation, or ‘free’ translation, that changes the wording to improve the readability and understanding of direct participant quotes. Two risks of free translation are the potential loss of information about the participant, and the possibility of misinterpreting the meaning of their words (Rubin and Rubin 1995). To reduce these risks, I used literal translations as far as possible, but with minor modifications to improve grammar and enhance understanding of their meaning in English. It should be noted the extracts drawn from patients’ interview narratives and presented in Chapter 5 should not be regarded as verbatim translations. All extracts represented by translated notes taken during interviews were then imported to NVIVO 10 software, which is an electronic package for qualitative data designed to manage data and assist data organisation (Bazeley and Jackson 2013).
Qualitative data analysis
In qualitative research, there are diverse approaches for analysing qualitative data. However, it is argued that qualitative data analysis should be aligned with the research aims and theoretical framework that underpins the research (Pope and Mays 1995). I chose thematic analysis, which allowed the themes present in the data to merge both from the quantitative and qualitative was helpful (Fereday and Muir-Cochrane 2006). Thematic analysis is defined as a search for themes that emerge as being important to the description of the phenomenon (Daly et al. 1997). Thematic analysis helps to describe and organise the content of interviews through coding and categorisation of data into themes and sub-themes (Creswell 1998). By taking a hybrid approach, it is possible to facilitate both inductive and deductive development of coding, which means a combination of the data-driven inductive approach (Boyatzis 1998) and the deductive a priori code template, as described in the next section (Crabtree and Miller 1999). Accordingly, it fits the research questions by allowing the phenomenon of patient satisfaction to be fundamental to the deductive thematic analysis whilst also allowing for themes to emerge from the data by inductive coding. Additionally, it is aligned with the mixed methods framework of the current study, as connecting theory and data by moving back and forth between theories and data (quantitative and qualitative) is an essential part of creating a theoretical understanding (Morgan 2007).
Thematic Analysis Using Coding
Six major stages are identified by Fereday and Muir-Cochrane (2006) in the use of a process thematic analysis: (1) development of the coding manual; (2) testing for coding reliability; (3) identifying the preliminary themes which have emerged from the data; (4) applying templates of codes and additional coding; (5) connecting the codes and identifying themes; and (6) corroborating the identified themes by the process of confirming the findings. The coding process was carried out based on these stages, as described next.
Stage1: Developing the coding manual
A coding manual is important because it helps a researcher to recognise the textual data from the transcribed interviews (Crabtree and Miller 1999). In addition, it enables the researcher to divide the textual data into segments, to label each identified segment, and to assess further the developed interview segments for evidence of reoccurring themes (Miles and Huberman 1994; Janesick 2003).
I developed the coding manual based on the research questions and the results from Phase 1 compared to the qualitative data received in Phase 2. For example, coding was categorised into three components. The codes were identified as those factors that were influential in determining a patient’s level of satisfaction with their care based on the Donabedian (1980) quality of care model. The coding was based on the findings, and the emerging themes differed somewhat from the initial expectations. This is a common feature of research, and it is an expected part of the research process. About clinical effectiveness, the analysis clarified the measure of clinical effectiveness for the study.
The themes that emerged were (1) clinical effectiveness, (2) structure of care (accessibility to health care), and (3) outcomes of care (patient satisfaction). Within the domain of the three main codes, five sub-codes were identified: (1) doctor skills as a process of care, (2) nurse skills as a process, (3) information exchange as a process, (4) service organisation as the structure of care, and (5) general patient satisfaction as an outcome of care.
However, it is argued that a credible code must capture the qualitative richness of the phenomena (Boyatiz 1998). Therefore, codes were identified by label, definition of the theme, and a description of when the themes occurred. Table 1 provides an example of the coding manual that was developed.
Table 1 - Example of a Priori Coding Developed from Templates of Codes Related to Patient Satisfaction
| Code 1 | Definition | Description |
| Label: Process of Care | Clinical effectiveness | doctors’/nurses’ interpersonal skills technical skills information provision availability information exchange |
| Code 2 | Definition | Description |
| Label: Structure of Care | Accessibility to healthcare service organisations | hospital environment access to department medical personnel attitudes lab services admission services |
| Code 3 | Definition | Description |
| Label: Outcome of Care | Patient Satisfaction | general patient satisfaction during hospital stay |
Applying an NVIVO computer-assisted method in qualitative data analysis, I coded the interview data based on initial key topics in the coding manual. NVIVO was used because it is easy to use and it is easy to import data from the MS Word processing package (Morrison and Moir 1998; Richards 1999). Further use of NVIVO makes it possible to determine coding stripes from the document's margins, an aspect that made it possible to determine which code had been used at which point.
However, computer-based data analysis and coding were implemented with full knowledge of the limitations of computer-assisted coding methods (Bourdon 2002). For example, some concerns using computer-assisted methods may result in ‘guiding’ the researcher only in a particular direction. This disadvantage occurs due to the capacity of computer-assisted methods to create a sense of detachment from the actual data (Bazeley and Jackson, 2013). Despite these limitations and critiques, computer-assisted methods promote accuracy and transparency in the data organisation processes.
Within the NVIVO software, the creation of codes is achieved through the use of free nodes present in the navigation view window or by using the ‘create and analyse’ tab that is located in the ribbon of commands (Richards 2009). For example, interview data related to clinical effectiveness generated 32 free nodes. If a new code was identified, I re-read the annotated extracts from interviews to ensure the new codes were appropriate to textual data. Thus, I repeatedly reviewed and refined the coding manual before I generated the final coding framework.
Stage 2: Testing codes reliability
To achieve coding reliability, it is recommended that two or more researchers individually code an interview transcript rather than relying on a single researcher (Stewart et al. 2007). Therefore, I checked the coding framework with my supervisors and compared it with the interview data. Overall, agreement on coding was high, and a few minor issues were discussed and resolved before proceeding to the analysis.
Stage 3: Summarising data and identifying initial themes
Summarising the data was achieved through repeatedly reading and re-reading the raw data and outlining key points about the questions I asked during interviews. Table 2 demonstrates the process of summarising data.
Table 2 - Example of the Process of Summarising Data
| Research Question | Summary of Responses |
| Doctor communication aspects | listening, psychological support, kindness, information about illness progress, understanding and responsiveness were important aspects of communication with participants |
Stage 4: Applying the template of codes and additional coding
The template of codes was applied to facilitate the template analytic technique, as suggested by (Crabtree and Miller 1999). The coding manual was used to ensure systemic application and to identify the important sections in the text. All the codes from the coding manual were entered into the NVIVO software as free nodes. From this basic structure, the free nodes were organised and categorised according to four groups of data: (1) clinical effectiveness of doctors, (2) clinical effectiveness of nurses, (3) accessibility to health care, and (4) patient satisfaction as an outcome of care. Table 3 demonstrates the method of coding three data sets by applying codes from the coding manual.
Table 3 - Deductive Coding Using Codes From The Coding Manual
| Name of theory-driven code | Care Assessment Based Model: (Donabedian 1982) |
| Explanation of Code | process of care (clinical effectiveness of doctors and nurses), structure of care (accessibility), outcomes of care (patient satisfaction) |
| Clinical Effectiveness (Doctors’ Skills ) | psychological support, availability, and information regarding illness prognosis |
| Clinical Effectiveness (Nurses’ Skills ) | caring, technical skills, patient-centred care |
| Accessibility of Health Care (Service Organisation) | friendly hospital environment preferred, waiting times for admission need to be considered |
| Outcome of care (general satisfaction) | Generally, patients were satisfied with care while simultaneously having concerns regarding provided care |
Data analysis was not only guided by the coding manual but also involved inductive coding from annotated extracts that identified new themes (Boyatzis 1998). For example, the power dynamics of doctors that affect patient satisfaction emerged from data during the coding of the clinical effectiveness (doctor skills). An example of this is provided in Table 4.
Table 4 - Example of Inductive Coding from Data
| Name of data-driven code | the power dynamic in doctor communication |
| Explanation of code | the perception of doctors as ultimate figures of authority over health in the KSA |
| Perception of doctors | perceived as too busy or rushed, unapproachable and as failing to consider the psychological status of the patient |
Stage 5: Connecting the codes and identifying themes
The process of connecting codes is critical for discovering themes which identify a pattern in the data to describe the observations and then interpret features of the phenomena (Boyatzis 1998; Crabtree and Miller 1999). By connecting similar free nodes, themes were identified, and similarities and differences between sets of data were found at this stage, which indicated areas of relevance to the research questions. Additionally, themes started to cluster within the differences identified between participants' views regarding varying situations. For example, Table 5 shows connecting the codes and identifying themes.
Table 5 - The Process of Connecting the Codes and Identifying Themes
| Clinical Effectiveness (Doctors/Nurses) | Factors related to doctor skills: Psychological support by doctors Information provision about illness | Factor related to nurse's skills Time devoted by nurses Nurses’ language barriers Psychological support provided by nurses |
| Accessibility | Impact of settings (single versus shared room) on patient satisfaction Delay in admission services affects patient satisfaction | |
| General Satisfaction | Patients are generally satisfied with the provided care | |
| Contextual Factors | The power dynamic in doctor-patient communication Multicultural environment (effects of nurses) Role of religion in affecting patient satisfaction Role of family in affecting patient satisfaction | |
Stage 6: Corroborating and legitimating coded themes
In this final stage, it was important to confirm the findings by ensuring that the themes identified were representative of the original data (Crabtree and Miller 1999; Fereday and Muir-Cochrane 2006). Before the analysis moved to the interpretative stage, in which the themes were connected to the explanatory framework, the clustered themes identified from the previous stage were reviewed to check if they captured key aspects of the phenomena. Also, re-reading the text from the original extracts helped to illuminate agreements and disagreements in views between segments of data. Further, the analysis tools in NVIVO, such as queries, text searches, and models, were used to develop the analytical process. Thus, the patterns of meaning, similarities, and differences could be explored and set out. Lastly, core themes that captured the phenomena of patient satisfaction in an oncology ward setting in the KSA were identified. The qualitative findings, including all identified core themes related to the aspects of patient satisfaction as a phenomenon, are presented in Chapter 5.
Ethical Considerations
Informed consent
It was essential that patients understood that participation in the study was voluntary and that declining to participate did not mean that they would be disadvantaged in any way regarding their healthcare provision (Parahoo 2006). All willing patients were asked by the oncology nurse educator to sign an informed consent form (see Appendix 8). They were provided with an explanation of the study and a participant information sheet (see Appendix 7) to enable them to make an informed choice about participation. Informed consent was also required from those patients willing to participate in the follow-up interview. I contacted participants by phone to apprise them of the possibility of the interview and to discuss it with them.
Anonymity and confidentiality
The identity of participants was protected in the current study through complete data anonymity and confidentiality (Polit and Hungler 2001). Patients and their associated results were assigned study identification numbers, and participants’ answers, records, notes of interviews, and completed questionnaires were kept confidential in a locked cabinet during the study. Data was only shared with my PhD supervisors, and participants were not identifiable at any stage.
Data protection
To ensure adherence to legal requirements (Data Protection Act 1998) and ethical guidelines, I protected data by keeping all data in a secured cabinet. Following completion of the current study, these will be stored in the Archive Section of the University of Stirling for ten years.
Cultural and Linguistic Barriers
Sand et al. (2007) note that it is important that the researcher be fully aware of the barriers that can affect their research and, where possible, take preventative actions. One important potential barrier in this research was the form of Arabic used in the KSA. All correspondence, including the patient consent form, information sheet, and letter of approval from the University of Stirling, was translated into Arabic, reviewed by the authorities at the SRCC in Riyadh, and the translation was officially verified. This approval process took some weeks to complete, was longer than anticipated, and had a bearing on the timings of the study.
An important cultural barrier to consider is that some women who are diagnosed with cancer in the KSA may be influenced by the involvement of a male guardian, as discussed previously. Obtaining consent from such women (Rashad et al. 2004; Walker 2009) required fully explaining the study to the male guardian, which could have affected the woman’s decision to participate. The implications of these socio-cultural issues conflicted ethically with, and would be contrary to, the UK guidelines on good clinical research practice (GCRP) (Medical Research Council, 1998). A further problem in this regard was the inconvenience of having to ensure the availability of a suitable male guardian.
Potential Distress
Mcllfatrick et al. (2006) point out that non-malfeasance, justice, and respect for human dignity are the guiding principles for interacting with the vulnerable and that a researcher’s well-developed sense of reflectivity should go some way to mitigate problems arising. For this reason, consideration was given to the health status of patients throughout the study. For example, those who participated in Phase 1 of the study were first judged well enough by gatekeepers and checked by the nurse educator and ward staff before being asked to proceed with the interview in Phase 2. I was fortunate in being able to liaise with the oncology staff and the attending physician because this helped to inform my decisions regarding patient vulnerability. I was also vigilant to detect any sign of patient distress becoming apparent during the study participation. Had this happened, I would have immediately considered withdrawing patients to protect them from any exacerbation of their already poor health. In practice, during the study, there were no instances of patient distress and no evidence of any adverse impact of the research on any participant; hence, there was no need to consider any withdrawal.
Researcher Skills and Resources
Appropriate skills for implementing both quantitative and qualitative data collection and analysis were required in the current study; thus, I attended a wide range of university courses during my PhD studies. Further training in the use of SPSS software was also undertaken. For the qualitative phase of the current study, I attended the University of Stirling NVIVO training program. Other skills I developed during the current research years included managing electronic databases and English being my second language; I tried to improve my academic writing. Workshops in these areas were attended during the current study.
As a native Arab, I had a good understanding of potential socio-cultural barriers which might arise during interviews. I could also communicate with the patients in their mother tongue as it was convenient and practical. These positive aspects of my skills helped me build a rapport with the patients and also helped enhance their trust in me and their willingness to share their views. Potential negative aspects were related to my inexperience in conducting formal interviews. However, certainly, my experience as a nurse helped me develop skills for interviewing patients, which would be transferable to the more formal research setting. To overcome any potential difficulties and to address my novice interviewer status, I practised my interview technique through workshops and guidance and encouragement from my supervisors, from whom I learned techniques for ensuring there was a consistent focus on relevant areas of enquiry. Developing an interview schedule also kept me focused.
As I was an oncology nurse before beginning my PhD, I was more comfortable in the oncology setting than someone who had no experience in such an environment. This allowed me to interact and communicate successfully with patients when seeking a sample. It also helped to secure the informed consent of participants, and it allowed me to create an informal and relaxed atmosphere for the interviews. I had previously worked in this setting, and this familiarity was helpful in the distribution of questionnaires, which was useful for the collection of reliable data.
However, interacting with cancer patients as a former nurse differs from studying them. In the interviews, it could be argued that I interacted with them as much in my familiar role as a nurse as I was acting as a detached researcher. This could have led to potential bias in the data collected. However, in many respects, the model of the fully objective and detached researcher is not sustainable in the context of informal and semi-structured qualitative interviews. Furthermore, despite having previously worked as a nurse and having considerable experience in dealing with cancer patients, it did not help to establish a rapport with a patient. I had to work hard to establish a rapport with the participants despite my previous experience. In sum, I would argue that my previous experience as an oncology nurse did not harm the validity of the research but contributed to its reliability.
Chapter Summary
This chapter has provided an overview of the research design employed in the current study and a theoretical rationale for its use. The major aim of the study was to assess factors influencing patient satisfaction in an oncology ward in the KSA. Specifically, the study first sought to identify what factors contribute to or hinder adult oncology inpatient satisfaction with care at the SRCC in Riyadh. Second, it explored why and how these factors influence adult oncology patient satisfaction.
The study employed a mixed methods approach in the form of an explanatory sequential design to complement the quantitative and qualitative nature of the research aims.
The research was divided into two phases: Phase 1 used a quantitative method, which involved conducting a cross-sectional survey of the satisfaction levels of adult oncology inpatients in the SRCC at Riyadh. Phase 2 focused on the qualitative aspects of the study, including the semi-structured interviews with adult oncology inpatients who had answered the initial questionnaire.
The chapter also identified patient recruitment issues and data collection methods, including the sampling technique and data analysis used for each phase. It also highlighted the ethical issues behind the current study.
The findings for both phases of this mixed methods study are presented in the following two chapters.
Chapter 5- Discussion and Conclusion
The discussion section interprets findings and relates them to existing literature, while the conclusion summarizes key points, highlights significance, acknowledges limitations, and suggests future research directions.
Introduction
In this chapter, the quantitative findings from Phase 1 and qualitative findings from Phase 2 are presented together and discussed about the research question: ‘What factors contribute to or hinder patient satisfaction with care in an oncology ward setting in a Saudi Regional Cancer Centre in Riyadh?’
Based on this analysis, my main conclusion is that patient satisfaction is influenced by the key domains of structure and process of care, including doctors’/nurses’ interpersonal relationships, organizational efficiency and cultural factors. These are discussed in turn in sections 6.4, 6.5, and 6.6. The findings are compared and contrasted with the existing literature on patient satisfaction. In addition, the implications of the study findings for patients, nursing practice, and policy reforms are identified. The main contributions that the research in the current study makes, together with some of its limitations, are then considered. Further research within the context of the KSA is also discussed and considered.
Therefore, in this chapter, I will first present The research findings from the discussions of the main themes that emerged from the coding categories of ‘process of care’ (clinical effectiveness), ‘structure of care’ (accessibility to health care), and ‘outcomes of care’ (patient satisfaction), based on Donabedian’s model are discussed first.
Second, the results are discussed in detail according to the themes of doctor-patient relationships, nurse-patient relationships, contextual factors relevant to cancer in the KSA, and organisational factors impacting patient satisfaction. The findings are examined about the research questions and compared and contrasted with current evidence from the literature review to provide a more complete understanding of patient satisfaction in the KSA.
The thesis concludes with a discussion of the contribution and implications of this research in the following areas: (1) patients, (2) for practice, and (3).
Overview of Results
It is clear from this research that several key determinants influence the degree of patient satisfaction in oncology ward settings in the KSA. The quantitative results provided evidence that the clinical effectiveness of doctors and nurses, accessibility and socio-demographic factors significantly influence patients’ satisfaction levels. The qualitative data facilitated further exploration of these determinants and gave rise to several additional emergent themes related to these areas of care. For example, it emerged that doctor-patient relationships, nurse shortages, and language barriers are areas where changes could be made to improve care, thereby enhancing patient satisfaction. These findings contribute important new insights into the interpersonal aspects of care in light of the underlying social and cultural contextual factors regarding patient satisfaction in the KSA. These themes are explored in greater depth in the next section.
This literature review has illustrated the context and contribution of the present study of patient satisfaction as an indicator of healthcare quality in oncology wards in the KSA. Using the narrative synthesis method, this literature review presented literature on (a) quality of care and the use of the Donabedian model to define it; (b) patient satisfaction, which is a measure of healthcare quality; and (c) the assessment of patient satisfaction and quality of care in the KSA. Overall, this review has demonstrated the difficulty of defining and measuring quality of care and patient satisfaction. The review also demonstrated the gaps in current scholarship on patient satisfaction in the KSA.
A key element of this discussion has been the relationship between patient-centred care and patient satisfaction. Research has shown that patient satisfaction is affected by the model of patient-centred care adopted (Brown et al. 1999; Mead and Bower 2000), and evidence has suggested that the underlying notion of what patient-centred care means has implications for patient satisfaction (Michie et al. 2003; McCormack et al. 2011; Kupfer and Bond 2012). However, there is a dearth of literature on patient-centred care in the KSA. The literature that does exist suggests that the adoption of patient-centred care in the KSA can help bridge the gaps related to information provision resulting from cultural beliefs (Younge et al. 1997; Al-Ahwal 1998; Aljubran 2010).
Other major issues identified by patients as barriers to achieving quality in primary care included (1) poor interpersonal skills of health care providers, (2) lack of continuity of care and accessibility, (3) hospital overcrowding, (4) transportation limitations, (5) lack of efficiency in appointment systems, (6) inadequate drug supply and laboratory services, (7) long waiting times, and (8) short consultation times (Al-Faris et al. 1996). Another notable fact brought to light through the literature review is that the KSA suffers from a lack of healthcare professionals with the necessary language skills to interact meaningfully with Saudi nationals.
There is a need to improve the quality and quantity of healthcare professionals in the country (Al-Ahmadi and Roland, 2005). A further issue is how cultural, language, religious, and social barriers make it difficult to reach out to patients directly and deliver quality, patient-centred care to oncology patients. This is partially due to the standards typically adopted by the largely non-Saudi healthcare workforce in the KSA (Young et al. 1997; Ezzat et al. 1995). Finally, whilst there are many international studies available on patient satisfaction as a quality indicator for health care, this review has identified a lack of consensus on how it can be measured effectively.
There have been some positive changes in socio-cultural and communication factors in the KSA, for example, an evident change in attitudes towards disclosure to cancer patients and the need to deliver care that demonstrates patient-centeredness (Aljubran 2010). However, there remain gaps in the literature regarding perceptions of KSA patient satisfaction from the perspective of relationships between structure/access (service organisation) and process of care (clinical effectiveness of staff and interpersonal aspects of care, doctors’ and nurses’ skills, availability of equipment, information provision) and outcomes of care (patient satisfaction). There also appears to be a lack of evidence about the quality of health care in the KSA. These gaps are evident in the literature covering the last three decades. It is noteworthy that changes in the standards of quality of care about access to care (structure of care), effectiveness of care and availability (processes of care) and outcomes of care (satisfaction) have been identified as having happened largely during this period.
This review has evaluated the knowledge base of patient satisfaction, focusing on the oncology care setting in the KSA. By expanding the understanding and knowledge base of patient satisfaction in the KSA, this review has identified significant gaps in the research. This review has consequently justified the current research and given rise to the following research question:
What factors contribute to or hinder patient satisfaction with care in an oncology ward setting in a Saudi Regional Cancer Centre in Riyadh?
The identified gaps in knowledge highlighted in this review can be addressed by effectively interpreting the relationship between patient experience/satisfaction and quality of care while focusing on oncology patient satisfaction in the KSA. The ultimate intention of my study is to contribute knowledge to a hitherto under-researched area.
Interpersonal Aspects of Care: The Doctor-Patient Relationship
The regression analysis of the quantitative Phase 1 found that, in particular, the following factors were important to patients’ satisfaction: doctors’ willingness to listen, support, availability, and provision of adequate information on an illness. To better understand this aspect of patient satisfaction, during the qualitative Phase 2, participants were questioned on their satisfaction with different aspects of care. One of the key themes arising from this research stage was the doctor-patient relationship. This process demonstrates the complementarity of the quantitative and qualitative data, enhancing the validity of the results.
In recent years, the nature of the doctor-patient relationship has been extensively reviewed in the literature, and it is recognised as being one of the most important factors influencing patient satisfaction (Little et al. 2001; Mallinger et al. 2005), as well as being associated with other positive patient outcomes such as greater adherence to treatment and improved self-care (Ware et al. 1983; Cecil and Killeen 1997; Street et al. 2009). My results affirm this contention in the KSA context and provide greater insight into this important aspect of patient satisfaction. Notably, when questioned about doctor-patient relationships, it was evident that participants emphasised the interpersonal aspects of care. Many participants believed doctors should understand and respond appropriately to patients’ emotional and psychological well-being and physical needs.
This concept of the need for support for oncology patients is not new (Merckaert et al. 2010; Nicols et al. 2013). However, in the cultural context of the KSA, the family and the Islamic faith are pivotal to patients’ experience of care and generally provide the patient with the necessary emotional and psychological support during their illness (Al-Shahri 2002). During the interviews, many participants voiced their underlying fears and anxieties regarding their condition. These findings, where patients look to doctors for psychological and emotional support, may be related to an apparent shift in patients’ perceptions of their requirements from health care in the KSA. Through their responses, the participants seemed to question the commonly accepted paternalistic medical model of care, where doctors are figures of authority and encourage an imbalance of power and authoritarian-type relationship with their patients. My findings illustrate a desire for a more patient-centred approach to care and for patients’ personal needs to be taken into account, particularly within the cultural and religious context of the KSA.
To fully understand, four key elements arise: (1) doctors’ listening skills, (2) information provision, (3) the extent to which patients felt motivated and encouraged, and (4) the extent of compassion doctors showed towards patients.
A strong link was found between doctors having a motivating and encouraging attitude and building greater trust with patients. Participants who noted that doctors had a casual or uncaring attitude expressed distress with their situation. In other words, a strong emphasis was placed on psychological and physical needs, with many patients highlighting that a doctor should understand and respond compassionately and empathically to their psychological state. Arguably, if doctors consistently practised such patient-centred care, there would be increased levels of patients.
Moreover, reducing patients’ psychological distress would undoubtedly serve to improve medical outcomes since studies have shown that psychological distress hurts cancer mortality (Hamer et al. 2008). Previous research also suggests that the patient-centred approach is required to meet oncology patients’ needs and improve the quality of care provided in the KSA (Nichols et al. 2013). This is also confirmed by the findings of the current study, where several patients emphasised their desire for a patient-centred approach in which the healthcare professionals prioritized their needs. However, the current study’s findings showed that despite the need for a patient-centred approach from doctors, the degree to which this trait was evident in the doctors in the current study was variable, with some doctors appearing to lack the ability to deal with their patients as individuals, and with consideration. This lack of a person-centred approach hurt the level of patient satisfaction. One particular issue was the policy of non-disclosure of information to patients, and this in itself may be a significant factor in doctors failing to appear sympathetic and
The implication from these findings is that implementing a patient-centred approach in the KSA health care system through policy reform and other initiatives could enhance the quality of care and hence improve patients’ constructions of (and overall satisfaction with) their experiences of their health care.
The Nurse-Patient Relationship
As described in the previous section, the quantitative results provided evidence that nurses’ interpersonal skills and nurses’ information provision were important to patient satisfaction. A deeper understanding of this aspect of patient satisfaction was obtained during the qualitative phase by questioning participants on their satisfaction with different aspects of nursing care. One of the main sub-themes arising was the nurse-patient relationship.
The quality of nursing care has been identified as a key determinant of patient satisfaction in hospitals in different contexts by several researchers (Wagner and Bear, 2009; Findik et al., 2010). Indeed, it has similarly been postulated by Johansson et al. (2002) that patient satisfaction can be affected by the nature of the nurse-patient relationship, which is often viewed as being interactive and participatory to meet patients’ needs. In a related manner, research by Ervine (2006) indicates that the nurse-patient relationship is important if patients are to be satisfied with the kind of medical intervention they receive. The stronger the relationship, the more motivated the nurse will be to help the patient and the patients to cooperate with their nurse. For example, nurses must understand the patient’s needs, whilst the patient should follow the nurse’s requests, such as compliance with medication administration. This mutually respectful and compliant relationship would help optimise the treatment process, promote positive outcomes, and, hence, increase patient satisfaction.
The findings of the current study contribute to the international literature by adding that patients in oncology ward settings in the KSA seek prompt and attentive care from their nurses. The patients require a good interpersonal relationship with their nurse as part of their care. Nurses are not merely to be dispensers of medicine but rather are there to support the patient. In the qualitative phase of the current study, I probed deeper to investigate what the participants considered important concerning nursing care. Two areas of concern were identified: (1) technical competence and (2) interpersonal skills. Technical competence related to nurses’ professional skills in administering medication and other treatments; overall, patients had positive attitudes towards such skills. Moreover, it appeared that acknowledging nurses’ expertise conveyed an element of trust. However, some concerns were mentioned, such as inadequate knowledge regarding the nature and dose of chemotherapy treatment being administered; this may partly explain why some patients conceived of their care as less than satisfactory.
Regarding interpersonal skills, participants strongly wanted to develop a supportive and trusting relationship with nurses. To do so, nurses must show care and compassion and support patients by listening to their needs. As previously mentioned, doctors were considered facilitators of a patient’s progress towards recovery by providing them with motivation and encouragement. A similar picture emerged with nurses. There were several participants requiring all health care providers to pay attention to their psychological as well as medical or physical needs.
The study’s result would seem to indicate that patients in the KSA are seeking a holistic approach to their care. This is a recurrent theme frequently appearing throughout the current study. These are also traits that Rchaidia et al. (2009) highlight in their cross-cultural studies, which investigated cancer patients’ perceptions of the ‘good nurse’. Interestingly, this phenomenon appears to be universal, as it is evident across both Western and Eastern cultures. The study of Rchaidia et al. (2009) described the need for nurses to ‘be present’ both physically and mentally to support their patients adequately. My findings add that despite the particular culture of the KSA, it begins to conform to the international pattern whereby nurses are expected to provide strong interpersonal care along with technical competence.
My findings suggest that increasing workloads can act as a barrier to achieving such patient-centred care. Other researchers have also shown how high nursing workloads can adversely influence the quality of health care (Haberfelde et al. 2005; Lankshear et al. 2005). The findings of the current research agree with this contention in the KSA context since ‘availability’, or the lack of time available for patient care due to nurses’ busy work schedules, created dissatisfaction for several participants. The feeling was that lack of time negatively impacted nurses’ communication with patients, creating a sense of being undervalued by the patients. It is clear that a shortage of nurses negatively affects patient satisfaction.
A perceived shortage of nurses in health care systems is universally evident within the literature. Still, this is especially the case in the KSA, where the employment of non-Saudi nurses is a common practice to fill the gap in the workforce (Al-Dossary 2008). Even with the KSA government’s Saudisation programme, the fact that expatriate nurses still dominate the KSA health care system indicates a need for better policies to encourage Saudis to train as health care professionals. Indeed, this contention is supported by Al-Dogaither (2000) and Atallah et al. (2013), who emphasise that KSA hospitals need to consider implementing strategies to manage this problem better, especially since the expatriate nurse force may not have the appropriate cultural and language skill set to attain high-quality care. This was also an issue raised in the current study: many of the patients were concerned that the nurses from different cultures might not fully understand their particular needs, and this could be a factor influencing patients’ sense of satisfaction or their dissatisfaction with the quality of care that they receive in oncology ward settings.
In the current study, nurses were believed to be acting in ways that were construed as supportive and understanding, and patients were generally satisfied with the nursing care they received; the exceptions being with some issues of interpersonal care, which were often due not to poor nursing but rather to cultural and language problems. Despite the nurse's workload, the patients were found to be more concerned with the different cultural backgrounds of many of their nurses. Cultural differences have often hindered the understanding between nurses and patients and can lead to poor communication (Luna 1998; Tumulty 2001; Aboulenien 2002). This has implications for a patient-centred approach in KSA, possibly indicating inadequate training of the recruited expatriate nurses, with many possibly lacking specialist knowledge in oncology.
Conceivably, the recruitment of nurses lacking specialist knowledge of oncology could also result in inadequate or unsatisfactory patient care. This could, in turn, represent a significant factor in reducing patients’ conceptions of their level of satisfaction with the quality of care provided (Al-Dossary 2008). The research has shown that specialist nurses can improve cancer patients’ experiences of care (Griffith et al.2013).
The current study also found that patients’ concerns over nurses of different cultures could lead to problems in interpersonal relationships. In particular, differences in language were an issue that impeded the desired interpersonal relationship between patients and nurses. This is a factor in patients’ quality of care, indicating that more locally recruited nurses could improve patient satisfaction in oncology wards.
Language issues between patients and their carers could be a factor in explaining why patients with a lower level or an average education have generally lower levels of patient satisfaction in the findings. This group is less likely to be familiar with English and may have fewer opportunities to speak to their often foreign-born nurses (who do not speak Arabic). This could result in them having fewer opportunities to communicate with health professionals. As English is the most common language employed by expatriate health professionals, this may mean that the less educated patients (who generally do not speak English) will, therefore, have unsatisfactory interpersonal relationships with many of their nurses, and this impacts negatively on their perceptions of satisfaction. In contrast, the better-educated patients, often educated in a second language, can communicate with expatriate nurses. This may result in them having a better interpersonal relationship with the health care professionals in the oncology ward setting and, therefore, having a better level of satisfaction.
The Cultural Dimension of Interpersonal Aspects of Care
While healthcare systems vary across cultures, several studies have highlighted the significance of contextual factors in healthcare delivery for patients’ constructions of their experiences as satisfactory. In particular, the nature of the health care delivery has a direct impact on patient’s perceptions of their treatment and the quality of the care they receive (Tzeng et al., 2002; Scott et al., 2003; Siorouni et al., 2012; Al-Harbi et al. 2012; Jacobs et al. 2013).
My findings highlighted so far in this chapter have illustrated a relationship between the quality and nature of the patient’s relationships with medical staff and their overall perceptions of the care being provided, which, in turn, impacts their levels of satisfaction. However, other qualitative issues also emerged as important to these areas, which may be specific to KSA. One issue in particular worth noting is the culturally endorsed power dynamics regarding the doctor-patient relationship. According to my findings, it is evident that cultural perceptions of the doctor as a figure of authority about one’s health often engender an imbalanced power dynamic in which patients feel constrained and reluctant to ask questions or interact with their doctors. This negatively impacts on the level of patient satisfaction. The findings of the current study indicate the need for a more balanced dynamic of trust and a greater rapport.
Saudi culture has traditionally been hierarchic, but when it comes to patients’ reflections on their satisfaction with their care, they want doctors to respect their needs and respond to their requests. Patients wanted a more personal approach from their doctors. There was evidence to suggest that there is an increasing tendency for some doctors to share information with the patients themselves rather than with their families. There appears to be a shift in some doctors’ approach to patient care from the traditional approach to one that is more patient-centred. This finding contributes to the body of evidence relating to the health care of patients in Middle Eastern countries.
Historically, studies have largely portrayed patients in the KSA as being viewed as fragile and vulnerable, with little capacity to cope with their illness (Younge et al. 1997). It is for such reasons that doctors frequently confide in patients’ relatives regarding life-threatening conditions rather than speaking with the patients themselves (Younge et al. 1997). There is a wealth of past evidence indicating a lack of effective communication between physicians and patients with serious illness (Mobeireek et al. 1996; Elzubier 2002). The findings of the current study are highly informative, as they provide evidence of a major cultural shift, one in which patients in the KSA are increasingly being afforded full disclosure of their diagnosis and prognosis.
The study found that culture is a factor in patient satisfaction. Health professionals’ failure to recognize the cultural needs of a patient is a factor in their level of satisfaction. An underlying subtheme which emerged during the qualitative phase related to the impact of the multicultural hospital environment on patient satisfaction. Although culture per se was not a significantly dominant theme that emerged in the results of the quantitative phase of the study, the qualitative phase did highlight a significant impact of the multi-cultural hospital environment on patient satisfaction, particularly concerns about language and communication difficulties.
Many patients’ perceptions of the care they received were based on how their religious views and needs were respected. Given the importance of religion in the KSA, the fact that the majority of the expatriate staff originated from non-Muslim countries and were not practising Muslims was a cause for concern for many patients. Religion is especially important for seriously ill patients, such as the patient population in the current study. Therefore, cancer patients tend to be particularly strict in their religious observances, fearing that they may soon die and face God’s judgment (Al Shahri 2002). This may sensitise them to the fact that non-Muslims are caring for them, and they may be worried that non-Muslim staff might not understand or appreciate how their wishes need to be consistent with the teachings of Islam. For example, patients may fear that non-Muslim patients may not respect the modesty, dignity and cleanliness expected of a devout Muslim or appreciate the gender considerations of a Muslim woman (Al Shahri, 2002).
My findings raise the issue of cultural considerations in patients’ satisfaction with their care. There is anxiety among some patients that the multicultural context of a KSA oncology setting could detract from the quality of care that they demand. To enhance patients’ satisfaction further, there is a need for nurses to employ greater sensitivity to the particular characteristics and backgrounds of individual patients and tailor their communication accordingly. In other words, the findings convey the need for a tailored, individualised approach towards patients rather than assuming a standardised Western approach, which the expat nurses were seen as routinely delivering. Staff in oncology settings need to be aware of the cultural considerations when providing care in oncology wards in the KSA. Failure to do so will result in their failure to deliver true patient-centred care.
A further cultural issue that emerged during interviews was the stigma associated with cancer. The potential impact this has on prognosis due to stigma acting as a barrier to screening is especially concerning (Younge et al.1997; Elkum et al. 2007; Al-Amri 2010). This deep-seated cultural notion will take great effort and time to change. A further theme was how, within the KSA, cancer diagnosis extends beyond stigma and is perceived by some as a death sentence, instilling great fear and a sense of doom. This highlights how healthcare workers in the KSA must develop good interpersonal and communication skills to support cancer patients. Improving medical knowledge and prognosis, hence, survival rates should help alleviate such fears. However, in the KSA context, there is an inevitable cultural barrier to overcome before these issues can be properly addressed.
Key Issues of Patient Satisfaction in an Oncology Setting in the KSA
To summarise, patients perceived the interpersonal skills of both doctors and nurses as being significant contributors to satisfaction with their care. Additionally, patients felt these healthcare professionals should ensure that they relate well to their patients and provide the best patient-centred care possible to minimise distress and anxiety. This should, in turn, optimise patient outcomes. It was also evident that expatriate nurses could potentially exert a negative impact on patient satisfaction, largely arising from the language barrier. Notably, although patient-centred care is a statutory requirement for registered doctors and nurses in the UK (NMC 2010), this is a relatively new care perspective in Middle Eastern countries. The current study has revealed evidence to suggest that, at least in the oncology setting investigated, patient-centred care is assuming an increasingly prominent role in the KSA. However, there are still areas of concern over cultural issues among patients.
KSA authorities should be willing to address such issues in the care of oncology patients through policy reform, in particular by developing strategies that will help healthcare professionals deliver patient-centred care practices.
Implications for Practice Organisation and Structure
The results of the quantitative survey indicated that certain aspects of services and care organisations adversely affect levels of patient satisfaction. Thus, accessibility, such as ease of movement of patients from one facility to another, and availability of services, such as screening and testing, were important considerations in this regard. Additionally, attitudes of health care personnel (showing kindness and being helpful), provision of information, and waiting times were other key issues. Considerable variation in responses was especially evident regarding satisfaction with waiting times for performing medical tests/treatment. To better understand this aspect of patient care, and in keeping with the mixed method design, the qualitative phase included questions on organisational efficiency and how it affected participants.
Although it is encouraging that when questioned about the healthcare system, most participants gave positive responses, there were also some negative responses concerning the accessibility to healthcare facilities. Thus, discussions with participants regarding organisational issues exposed several failings; poor accessibility about waiting times was particularly concerning to many participants, especially given the perceived ‘life-limiting’ nature of cancer. The slow pace at which care and information were given also heightened patients’ anxieties. The lack of availability of single rooms was a further concern, as several participants felt sharing a room with several others was detrimental to their psychological and physical well-being. If they are in a crowded room, the patients tend to feel undervalued and even neglected, and this could lead to them having a poor sense of satisfaction with their care.
It is widely accepted that quality of care relates closely to the organisation of health care delivery, including structure and process (Donabedian 1980; Campbell et al. 2000; Donabedian 2005; Fenny et al. 2014). It is therefore not surprising that the organisational inefficiencies identified here would adversely influence the cancer patients’ perceptions of the care being provided, hence resulting in lower levels of satisfaction (Stizia and Wood 1997). Pascoe’s (1983) early conception of patient satisfaction identified it as a combination of personal healthcare experience and evaluations of healthcare services in general.
This was the case in the current study, where the lack of single rooms, overcrowding, staff shortages, and lack of organisational efficiency in the oncology ward where the study was conducted impacted patient satisfaction. This would indicate that authorities should seek to create an environment in an oncology setting that makes a patient feel comfortable, and this will have a positive impact on their sense of well-being. This would also increase patients’ confidence that they are in a setting which can cater for their needs and fulfil their goal of restoring them to health and wellbeing. This confidence will allow them to reflect positively upon their treatment and raise their satisfaction. In particular, there needs to be enough staff to enable them to spend time on the needs of patients. The presence of more staff on the ward would help to reassure patients, who are often distressed and anxious. Furthermore, the extra staff would be able to provide more time in caring for patients and allowing them the opportunity to treat them as individuals.
Implications for Policies
Policy and medical reforms are paramount in the KSA, with evidence-informed policy development being a vital part of improving patient care (Snilstveit et al. 2012). There is a clear need for local policymakers and, more widely, for the Saudi Ministry of Health to confront the failings of the KSA healthcare system highlighted by the current study. Policy-making authorities must recognise that there are currently several unacceptable standards; they must embrace the challenges of improving patient satisfaction in oncology settings by taking appropriate steps. The findings of the current research provide valuable evidence to guide policy reforms so that new healthcare service policies can focus on improving the key aspects of patient care that patients are most dissatisfied with.
To enable patients to feel that they are receiving a good level of care, there needs to be a definite policy to promote communication between staff and patients. This means that the authorities should seek to support nurses and doctors in providing a patient-centred approach to patients. Although there has already been a significant shift in the non-disclosure policy for patients, this can remain a problem for several patients, particularly female patients. There is also a need to ensure sufficient recruitment of Saudi medical staff in line with the KSA’s existing policy of Saudisation. Finally, there are changes in the organisation of health care in this context that also need to be addressed.
Moving From Physician-Centred To Patient-Centred Models of Care
One of the most prominent findings is the fact that many oncology patients in the KSA appear to be rejecting the paternalistic medical model of care commonly practised in the region, preferring instead a more holistic, patient-centred approach, which takes account of their psychological as well as their physical needs. This would suggest a need for healthcare professionals and policymakers to recognise that the imbalanced, authoritarian relationship doctors have previously had with their patients is unproductive and potentially detrimental to patient outcomes. Instead, policymakers should consider introducing initiatives and methods to educate healthcare professionals in patient-centred rather than physician-centred care.
Patient-centred care enables patients to feel part of the treatment process and as part of the decision-making process. Communication is crucial for any patient-centred approach. Nurses and doctors need to be able to give patients information and establish a rapport with them as part of the process of providing patient-centred care for a patient. The authorities could help the many expatriate nurses and doctors by providing them with information and training on communicating with Saudi patients. This may include an overview of specific cultural issues, along with aspects of patients’ cultural values and expectations that may impede effective communication with patients if they are not recognised.
Furthermore, expatriate nurses and doctors should be encouraged to try at least to communicate with patients with simple phrases. If the medical staff try to engage with patients routinely, this could lead them to construct their experiences in oncology ward settings positively.
Implementing a Policy of Disclosure: Fostering Patient-Centered Care in KSA
A further implication arising from the current study relates to policies regarding the disclosure of diagnosis and prognosis and the provision of patient information. In the past, patient nondisclosure regarding life-threatening or terminal illnesses was universally common (Field and Copp, 1999). In contrast, nowadays, requests for nondisclosure increasingly represent a departure from the norms of clinical practice, certainly in Western societies (Field and Copp, 1999).
The current study suggested that the old authoritarian approach by doctors is still influential among some doctors, who may not, therefore, see disclosure as relevant or important for a patient. There is a pressing need for healthcare providers and policymakers in the KSA to embrace the idea that doctors should be compelled to tell patients the truth and that disclosing diagnoses to patients is their moral and professional duty. Failure to fully disclose information on a patient’s condition could lead to an irretrievable relationship breakdown between doctor and patient.
Achieving this would require formulating guidelines outlining a systematic process for breaking bad news. To this end, doctors could be advised to follow an approach involving effective communication and negotiation skills, for example, by adopting the model developed by Hallenbeck and Arnold (2007), which has already been highly applicable to the KSA setting. Aljubran (2010) suggests this approach should be formally developed and taught in medical schools, as well as being part of postgraduate training to promote doctor-patient communications. This is essential if doctors are to develop good interpersonal relationships with patients, which is necessary for a patient-centred approach.
Encouraging More Saudis To Train As Health Care Professionals
All of the previous failings that have been highlighted, namely, patient nondisclosure, poor patient information provision, and physician-centred care, have doctor-patient communication at the heart of the problem. However, a breakdown in some aspects of nurse-patient communications was also a feature identified as problematic in the current study, largely relating to the language problems of expatriate nursing staff.
The results of the current study fully support the Saudi government’s Saudisation programme to encourage more Saudis to train as health care professionals, hence, to progressively replace non-Saudis with Saudi workers in the KSA health care system (Al-Dossary 2008). It is evident from the findings that this approach is vital, not just to address the shortage of healthcare workers but equally important to tackle the general lack of cultural awareness and the poor language skill set of non-Saudi or expatriate nurses.
Unfortunately, the Saudisation process is progressing very slowly in the healthcare sector. It is hampered by the fact that nursing in the KSA is not viewed highly as a profession for women (Miller-Rosser 2006). This rests primarily on the fact that women are expected to meet the demands and needs of their families first and foremost (Maben et al. 2010). It would seem that not enough is being done to address this issue, and there needs to be education and social policies that allow women to train and work as nurses and also meet the needs of their families.
To expedite the Saudisation process, robust local and national policies are needed to implement strategies in hospitals to encourage women and educators to develop a more positive view of nursing as a career. So, supporting this cultural change could enhance perceptions and the value of nursing and thus facilitate the education and career development of several Saudi women.
In short, the Ministry of Health has an obligation to provide the health care system, and in particular, oncology settings, with a greater number of linguistically and culturally competent doctors and nurses who are familiar with implementing patient-centred care and supporting patient autonomy. This will enhance patient satisfaction, as those from the same culture will not only be able to communicate with patients in Arabic, but they will also be more likely to develop good interpersonal relationships and allay patients’ anxieties over cultural and religious differences with expatriate staff members. This could also raise patient satisfaction in an oncology ward setting.
Need For Improved Service Organisation
Lastly, the failings identified in organisational efficiency in service provision also serve to inform healthcare providers and policymakers. The need for improved service organisation through the design and implementation of more effective and efficient systems and processes to better meet patients’ operational expectations is clear. The approach should target specific areas, including the need for an enhanced care environment, for example, by making available sufficient numbers of single rooms in oncology wards and improving ease of access to care through reduced waiting times for oncology patients.
Moreover, the exchange of information, information on discharge, ease of parking, and cleanliness were further significant areas of service organization that were indicated as needing improvement. These quantitative results could mean that effectiveness affects satisfaction more than kindness. The qualitative findings underscored the need for addressing the issue of waiting time, as it was found that accessibility to health care and waiting times were closely linked and greatly lowered their levels of satisfaction with the services offered.
In summary, it appears that the government needs more effort towards encouraging a change of attitude in healthcare professionals and the public of KSA to facilitate patient-centred care and patient autonomy. The current study found that patients wanted more consultation with doctors and a conscious effort by healthcare providers to develop interpersonal relations with patients to enhance their ability to communicate their needs and desires, especially about information on their condition.
If these issues are addressed, patients’ autonomy would be more advanced in an oncology ward setting in KSA. This is particularly important given the ethical principles and Islamic values which underpin the legal and moral aspects of society and public opinion in the KSA. It is also important that hospital management teams formulate local policies and guidance to support aspects of care valued by the patients. This would facilitate a more balanced, trust-based relationship between healthcare professionals and patients and ultimately improve patient satisfaction.
Contribution of this Research: Advancing Knowledge and Understanding
The current study has provided useful evidence concerning patient satisfaction in oncology ward settings in the KSA. It makes an international contribution since it provides a case study of patient satisfaction in a non-Western context, in which values of health care and particularly patient satisfaction are measured in the local Saudi cultural context (which can impact both the policy and provision of health care and patients’ expectations). Health care in the KSA is becoming increasingly westernised, whilst there is a parallel process of the Saudisation programme currently being implemented in the KSA health service. Therefore, an exploration of patient satisfaction and experience makes a very.
The current study has provided, in particular, valuable new insights into the meanings and descriptions of factors which underpin and influence patient satisfaction in the oncology ward setting in the KSA. These factors include interpersonal relationships, disclosure and cultural issues. The study has significantly contributed to the body of knowledge available in this field, generating fresh evidence of significant potential for policymakers and hospital management teams wanting to improve the care of the population studied. It is also conceivable that the results may be cautiously generalised to other patients receiving care in hospital settings in other Middle Eastern health systems (and other developing world contexts) and who are suffering from life-threatening or terminal illnesses.
The study has also offered a framework for analysis of the theory of patient satisfaction based on its particular context of findings from the KSA and, in doing so, makes a potential contribution to the theory of patient satisfaction in general.
A primary contribution of the study lies in its sequential explanatory mixed methods design, which allowed for the research question to be answered effectively. A mixed methods approach is widely recognised as offering a greater likelihood of answering research questions, particularly when there is a limited amount of existing research on the topic under investigation, as was the case here (Johnson and Onwuegbuzie, 2004;3; Health Foundation, 2013). It, therefore, facilitated the acquisition of a rich data set to assess the level of patient satisfaction with care processes, the structure of care, and the outcomes of care in a KSA setting.
The Donabedian model also allowed a deeper understanding of cultural patient satisfaction issues (Donabedian, 1980). Moreover, adopting an initial quantitative investigation, followed by a qualitative second phase, provided deeper insight into these categories by allowing an intensive dissection of the underlying themes behind the initial quantitative responses.
The mixed method approach has allowed for various perspectives to be examined about patient satisfaction in KSA oncology wards. This approach has also helped deepen the understanding of the factors influencing patient satisfaction with the quality of care provided in the study setting. By utilising the findings of this research to guide further research and/or inform policymakers during their design and implementation of reforms, there could be improved patient satisfaction.
Another benefit of combining data from two different research paradigms in the manner adopted here is that it provides complementarity or explanatory power. The former has been described as when the results of one research method are used to elaborate or clarify the results of another, thus achieving a fuller understanding of the phenomenon (May et al. 2000; Sale et al. 2002; Creswell 2003; Bowling 2007). The latter is defined as involving two phases where qualitative data helps to explain and expand upon initial quantitative results (Creswell et al. 2003). Complementarity has, therefore, served to enhance the credibility of the findings. To facilitate a sequential explanatory mixed methods design, the semi-structured interviews in the qualitative Phase 2 synthesised a general explanation of the factors that influenced oncology inpatients’ satisfaction with the quality of their care.
The fact that I began analysis of the first quantitative phase as soon as data was collected proved advantageous. This allowed me to start to code the data early and develop a coding manual, hence paving the way for the qualitative phase and ensuring that the interview questions were appropriately focused on the research question. Moreover, using a hybrid approach of inductive and deductive coding was appropriate during the analysis of the qualitative data. It resulted in a more deliberate and rigorous analytical method, strengthening the results obtained (Fereday and Muir-Cochrane 2006).
Limitations
While the study has achieved its main aims, some limitations are associated. There were limitations to the study, particularly constraints due to official policy that restricted the sampling, recruitment and the length of time available to conduct the research in oncology ward settings that could have made the sample unrepresentative and therefore made the findings not generalisable. These constraints were overcome in part by...
Also, the collection of qualitative narratives drawn from the questionnaires focused exclusively on findings identified from the analysis carried out in the quantitative Phase 1. This could have hampered a full exploration of factors affecting patient satisfaction, thereby potentially affecting the reliability of the data. The translation of the interviews from Arabic to English was not verbatim, which meant that there was a possibility that there was a risk of losing the meaning of particular responses. However, this was avoided by …
An important limitation of the study was the limited time for the fieldwork subject to KSA governance. The research site was restricted to only one hospital to ensure the research complied with KSA regulations. Had additional sites been used, this could have facilitated the capture of more diverse opinions. Although the use of one study site could limit the generalisability of the results to other populations, the findings may still be transferable to other settings that have similar characteristics and populations as those in the current study.
A further limitation was the potential to introduce sample bias using convenience sampling during the quantitative phase. Conceivably, those individuals willing to participate may have been individuals who were largely satisfied with the system, or the converse could be true; this would then give an imbalanced view. In addition, the purposive sampling for the qualitative phase was not adequately stratified. Arguably, stratified purposive sampling, wherein a purposive subsample is chosen within a purposive sample, would have been a superior approach (Patton, 2002); it delivers maximum variation in characteristics and enables quality data to emerge due to this variation. Furthermore, the sample size was restricted because of longitudinal limits and may not have been large enough to reveal some significant patterns, themes and relationships.
Satisfaction is highly subjective and means different things to different people. Therefore, another potential limitation was that there was no measurement of satisfaction. Instead, satisfaction was assessed qualitatively. The multidimensional concepts of satisfaction illustrated during this process would benefit from further qualitative studies to explore the reason for and the extent of patient satisfaction or dissatisfaction.
A further aspect that may have limited the quality of the information collected from the participants was that the qualitative phase was self-reported, with no opportunity to verify participants’ responses independently. Self-reported information can be unreliable, biased or exaggerated due, for example, to participants’ situations or moods or due to poor understanding of the
Therefore, as with any such research based on a small sample size, the conclusions of this research have a limited amount of generalisability. This is further underlined by the various limitations of the research itself, including sampling, circumstances of recruitment, and timelines of research. The analysis and conclusions indicate certain important factors of patient satisfaction, some of which are specific to the local context of the oncology ward in the KSA (such as the non-disclosure policy), whilst others can be extended into other, much wider contexts.
As noted in the previous section, this research indicates several issues and factors that help to advance the theory of assessing patient experiences by assessing patient satisfaction.
In the current study, patient satisfaction is examined as an aspect of patient experience indicator of the quality of care among adult cancer patients in oncology wards in the Kingdom of Saudi Arabia (KSA). The research aimed to identify and analyse key issues in establishing the quality of healthcare provision in this context, as measured through its corollary of patient satisfaction.
In particular, the findings advance theory and understanding of issues of patient satisfaction within the particular context of the KSA.
Recommendations for Future Areas of Research
Based on the strengths of the study and the limitations discussed previously, a series of recommendations are provided about the research directions and future research.
Research Directions
The research strategy employed in the current study can be further developed to understand better patient satisfaction in oncology ward settings and other inpatient settings in the KSA. To build on the findings presented here, further research regarding patient satisfaction in the KSA is needed. Future investigations should be multi-centred and recruit larger numbers of participants from a more diverse population. In doing so, it would be prudent to draw up culturally sensitive quantitative tools and qualitative methods for use in the KSA, which would allow for even greater collection of relevant data about patients’ satisfaction with their care and their levels of satisfaction. Research into the possibility of developing standardised tools to be used by researchers to collect data on patient satisfaction with quality of care in various inpatient settings in the KSA should be encouraged. This would allow for a deeper understanding of patient satisfaction with care nationally and over time and enable health service providers to adjust their care to provide greater patient satisfaction.
During such studies, it would be beneficial to examine and measure the specific impact of patient-centred care as a domain in patient satisfaction, plus incorporate a quality-of-life measure, which can be linked to satisfaction levels. The quality-of-life measure should consider the specific cultural needs of Saudi patients and not just take account of their sense of physical and mental well-being. Any further research on quality-of-life measures should be adapted to reflect the specific contexts of Saudi cultural and religious values and how these impact medical staff, patients, and the running of hospitals.
In addition, further research could investigate culture in greater depth, for example, by developing a greater understanding of how to enhance culturally competent communication between patients and healthcare professionals from different backgrounds and also exploring the extent to which culture positively or negatively influences patient care and satisfaction in the context of the power dynamic in doctor-patient relationships in the KSA. A deeper understanding of the cultural factors that impact patients’ relationships with their nurses and doctors could inform policymakers and potentially improve patient outcomes.
Future Research
The current research has identified areas that need further investigation to improve patient satisfaction in the KSA and beyond based on evidence. Another very important research topic which could be pursued is the impact of the Saudisation process on patient satisfaction and the factors behind the rather limited success of the Saudisation programme. There needs to be more research on how Saudisation can enhance levels of patient satisfaction, with particular attention to nurse-patient and doctor-patient communication and the cultural sensitivity of healthcare staff. Further, the shift to Saudisation in KSA oncology settings could ensure greater patient satisfaction at the cultural level and lead to an improvement in communication between patients and healthcare professionals but result in improved patient satisfaction with their care. Saudisation should not only be seen as an economic necessity but also as a strategy to improve the quality of care in oncology ward settings.
Patients’ relationships with their nurses or doctors are critical for successful health outcomes for patients. The current research has shown that there were occasionally problems in these relationships due to cultural differences between the mainly Saudi patients and the mainly expatriate medical/nursing staff. There needs to be a greater understanding of how cultural barriers can be overcome to ensure effective relationships between nurses, doctors and patients. There needs to be research on how to provide models for the relationship between expatriate health professionals and Saudi patients and models to exemplify how expatriate doctors and nurses can interact in ways that could improve communication with patients, as this is critical to a therapeutic person focused. There would also be a need to consider how such models could be implemented within hospital oncology ward settings in the KSA and beyond.
Conclusion
My research was concerned with investigating the factors that influenced patient satisfaction with their quality of care in an oncology ward setting in the KSA. It is clear from the findings that levels of patient satisfaction were based both on patients’ physical treatment and upon expectations as to the standard of care they hoped to receive. Not only was patients’ satisfaction with the quality of their care shaped by the nature, speed and efficiency of their treatment and the environment in which it takes place, but it was also influenced by the sense that their psychological needs were being addressed and their physical health needs. Patients sought a caring and sensitive approach from their nurses and doctors, and their satisfaction depended on strong interpersonal and individualised care. Patients also sought a patient-centred approach from both nurses and doctors.
Of particular importance is that overall, patients wished to be informed of their prognosis and treatments. This is contrary to the generally accepted traditional practice in the KSA, where physicians provide information about serious illnesses and treatments to family members first and seek approval before informing the patient.
Patients see Doctors, nurses and healthcare organisations as providing not only physical care but also psychological support. This suggests the need for developing strong doctor/nurse-patient relations and for healthcare providers in oncology ward settings to deliver a patient-centred approach. It is evident that many emergent themes related to the patients’ needs to feel secure and have confidence in their nurses, doctors and health care setting. Therefore, patients’ views must be considered if improvements in patient satisfaction and high-quality care are to be attained.
It would be pertinent to extend this research to a wider setting in a larger population to gain an even better understanding of the needs of patients, especially about their relationship with doctors and nurses in a multicultural setting. This examination of how to improve interpersonal relationships could then inform policymakers and ultimately lead to not only improved perceptions of the quality of their care but could also conceivably lead to real improvements in patient outcomes.
The current study has added valuable knowledge to the previously under-examined field of patient satisfaction with care in oncology ward settings in the KSA. It has highlighted factors that influence patients’ satisfaction with the quality of their care. In particular, it has provided evidence of a need for healthcare professionals in the oncology KSA health system to develop strong interpersonal relations with their patients and practice a patient-centred approach. The new theories and fresh evidence this research provides will be of substantial significance to policymakers and hospital management teams in the KSA wanting to improve the care of their patients in oncology wards.
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World Health Organization (WHO) (2009). Towards a strategy for cancer control in the Eastern Mediterranean region. Available online from: <http://www.emro.who.int/dsaf/dsa1002.pdf>. [Accessed 20 September, 2011].
World Health Organization, WHO (2008).The World Health Report 2008: primary health care - now more than ever. Geneva
World Population Review (2014). Available online from: <http://worldpopulationreview.com/countries/saudi-arabia-population/>.
Younge, D., Moreau, P., Ezzat, A., Gray, A. (1997). Communicating with cancer patients in Saudi Arabia. Annals of New York Academy of Science. 809 (1), pp. 309–316.
Zahl, P. H., Maehlen, J. and Welch, H. G. (2008). The natural history of invasive breast cancers detected by screening mammography. Archives of Internal Medicine. 168 (21), pp. 2311-6.
Zhao, S. H., Akkadechanunt, T. and Xue, X. L. ( 2009). Quality nursing care as perceived by nurses and patients in a Chinese hospital. Journal of Clinical Nursing. 18(12), pp. 1722-1728.
Appendices
Appendix1: Percentage Distribution of Cancer Incidence among Saudis by Sex according to Age Group, 2010 (Saudi Cancer Registry 2010)
Appendix 2: Search and screening process
Databases search date: 07-01-2014
| Databases | Search terms | Results |
Science Direct Limiters: ● Published Date: 1980 -2014 ● English Language Boolean operator AND, OR | patient satisfaction, quality of care patient satisfaction, Saudi Saudi patient satisfaction, quality of care Saudi Cancer, patient satisfaction, quality care quality health care, Saudi communication, Saudi, quality of care | 4969 papers returned 100 papers returned 38 papers returned 467 papers returned 177 papers returned 219 papers returned |
CINAHL Limiters FOR CINAHL : ● Published Date: 1980 -2014 ● English Language ● Peer Reviewed ● Language: English ● Inpatients Boolean operator: AND, OR | patient satisfaction, quality of health care patient satisfaction, Saudi quality of health care, Saudi doctor communication skills, Saudi | 38 papers returned 1 paper returned 29 papers returned 53 papers returned |
Web of Science (including Medline) Limiters: ● Published Date: 1980 -2014 ● English Language Boolean operator: AND, OR | patient satisfaction, Saudi communication, Saudi cancer care patient satisfaction, Saudi hospital quality care cancer patient satisfaction, Saudi | 163 papers returned 14 papers returned 36 papers returned 5 paper returned |
Google Scholar Limiters: · Published date: 1980-2014 · English language Boolean operator: AND, OR | patient satisfaction, Saudi, quality care, patient-centred care, oncology, hospitals, doctor-patient communication | 2500 papers returned |
Appendix 2 (continued) - Screening process
Appendix 3: Inclusion and exclusion criteria of the literature search strategy
| Inclusion criteria | Exclusion criteria |
| 1. Research papers found in peer-reviewed journals or referenced government/non-government publications were included. | 1. Papers limited to the outcomes of cancer treatment drugs or symptom management were excluded. |
| 2. Studies based on KSA that had investigated the quality of hospital care for patients in general and cancer care patients in particular were included. Only adult cancer patient studies were included as the focus of this review. | 2. Studies that investigated the quality of hospital care for non-adult patients with or without cancer were excluded. |
| 3. Those studies that had used review, qualitative, quantitative or mixed approaches were included. | 3. Studies not supported by peer-reviewed journals were excluded. |
| 4. Studies conducted between 1980 and 2014 were included. | |
| 5. Some research that was on patient satisfaction concepts, measurement and other factors ( patient-centred care, doctor-patient relationship and socio-cultural issues) that impact patient satisfaction was also included to assist the theoretical background of the study even when their research was not based on the KSA |
Appendix 4: Criteria for quality appraisal of chosen studies in literature review
Quality appraisal criteria by Dixon-Woods et al. (2005)
- Are the aims and objectives of the research clearly stated?
- Is the research design specified and appropriate for the aims and objectives of the research?
- Do the researchers provide a clear account of the process by which their findings were produced?
- Do the researchers display enough data to support their interpretation and conclusions?
- Is the method of analysis appropriate and adequately explicated?
One point was given for each of the above, and studies that conformed to 3 out of 5 were selected for review.
Appendix 5: Table of included studies
| Author-date | Sample | Methods | Key findings | Comments | |
| 1 | Alaloola & AlBedawi (2008) Patient satisfaction in a Riyadh tertiary care centre. International Journal of Health Care Quality Assurance. vol. 21, no7, 2008 | 1983 inpatients, outpatients and ER patients | Cross-sectional survey Using a self-developed patient satisfaction questionnaire | Patient satisfaction was noted in environmental aspects - room temp—etc. and less found in the interpersonal skills of doctors in phlebotomies, as they failed to introduce themselves. | · Lack of clarity in describing the tool they used –like question areas. · The focus of the satisfaction domain was only in the socio-demographic context. · No focus on specific services such as cancer or medical, which is a limitation · Although it is valuable for originality, further research is needed in the cancer setting in the KSA |
| 2 | Al-Doghaither & Saeed A. A. (2000) Consumers' satisfaction with primary health services in the city of Jeddah, Saudi Arabia. | 75 patients aged over 15 years, chosen systematically | Self- administered questionnaire pilot test | Satisfaction scores were higher in those considering all services, while individual service components were scored less. | · Although high scores for satisfaction were noticed, the service component needs to be monitored and assessed to provide satisfactory services |
| 3 | Saeed & Mohamad (2002) Satisfaction and correlates of patients' satisfaction with physicians' services in primary health care centres By Saudi Medical Journal | n=540 patients in 8 PHC, selected randomly in Riyadh | Survey questionnaire, pilot-tested | Service items need to have the correct measure Also, young and adult patients need more attention | · No clear description of recruitment and methods -Other domains like hospital services nurses’ skills would have an impact on the satisfaction level of patients |
| 4 | Al-Ahmadi & Roland, M. (2005) Quality of primary health care in Saudi Arabia: A comprehensive review. | A systematic review of 31 papers met the inclusion | Reviews of literature | There were variations in the quality of primary health care services in the KSA More effort is needed in the management and organisation of these services | · Further research is needed to address quality concerns from the patient’s perspective to have better insight into quality care |
| 5 | Mahfouz et al. (2004) Primary health care services utilisation and satisfaction among the elderly in Asir region, Saudi Arabia | 253 patients | In 26 PHC in ASIR (6 urban and 20 rural centres), a House-to-house survey was conducted by an interview with an expert health worker Arabic speaker to answer survey questions. The questionnaire addresses 5 services adopted from Mansour and Al-Osaimi's study in 1993 (continuity of care, humanity, accessibility, thoroughness and information). | Satisfied patients reported 79% dissatisfaction in 3 items: lack of audio-visual for patient education, lack of enough speciality clinics and prolonged waiting time in centres. | · More information is needed regarding the tools used · Emphasis on 5 aspects of lack of reasoning · More concerns are needed in evaluating different socio-demographic characteristics in elderly patients - results will be significantly different from area to area, so such a comparison would be desirable |
| 6 | Akhtar & Nadrah (2005) Assessment of the quality of breast cancer care: A single institutional study from Saudi Arabia | 78 operable breast cancer patient | Retrospective analysis of breast cancer patient charts and histopathology reports from 1995-2000 | Only 37% had triple assessment before surgical procedure radiotherapy not used as per the required standard The overall conclusion is that quality is below international standard |
|
| 7 | Ibrahim et al. (2002) Appraisal of communication skills and patients' satisfaction in cross-language encounters in oncology practice. | 255 patients | Questionnaire “Art of Medicine” used to assess patients' perceptions of clinicians' communication behaviours and patients' global satisfaction. | No difference - means that language doesn’t affect interpersonal skills like communication and patient satisfaction. Patients were equally satisfied in both languages. | · Interesting finding, but the scale used was not described clearly. · Further research is needed to evidence that cross-language communication is not a barrier to patient satisfaction within the multi-dimensional needs of cancer patients and cultural differences |
| 8 | Alahwal et al. (1998) “Cancer patients’ awareness of their disease and prognosis”, Annals of Saudi Medicine, Vol. 18 No. 2, pp. 187-9. | 136 (33 cancer patients, 63 doctors, and 40 laypeople) | A questionnaire of 4 questions was developed for this study Distributed in the western region of Saudi Arabia (major hospital providing cancer care) | All patients were in favour of being given full information regarding cancer; this would help them have a better understanding of how to deal with their illness. Doctors, too, favoured that the patients be disclosed about their conditions. | · Although patient views were taken, the methods would be more useful had qualitative interviews been used as this provides expanded insights into communication issues with patients |
| 9 | Younge et al. (1997) Communicating with cancer patients in Saudi Arabia | None | A literature review on communication aspects and factors influencing communication in the KSA | Communication is influenced by many factors, such as cultural and social and health services that lack community care for chronic illness. | · Although valuable information was obtained, there was no clear methodology mentioned, and several studies reviewed were not mentioned, and this generalisation potentially limits the findings. |
10 | Mansour and Al-Osimy (1996) A study of health centres in Saudi Arabia | 300 Consumers | Via assessment sheet of centres’ resources regarding quality and availability and consumer satisfaction & a 4-point Likert scale to measure satisfaction in 5 domains: continuity of care, accessibility, humaneness, information and thoroughness. | A discrepancy of data has been found between centres’ resources evaluation and consumer satisfaction results | · More studies are needed to evaluate resources and satisfaction through valid measures. · Studies in hospital resources can provide further insight into patient satisfaction since they focus only on health centres. |
| 11 Sweden | Rahmqvist and Bara (2010) Patient characteristics and quality dimensions related to patient satisfaction. | 7425 patients in all medical centres in Sweden | Questionnaire concerned with the perceived quality of healthcare | Older patients with good health status were satisfied with 90% Interestingly, educated patients with poor health status were dissatisfied in comparison to less-educated patients with better health status |
|
| 12 | Williamson, M.J. & Harrison, L. (2010) Providing culturally appropriate care: A literature review International Journal of Nursing Studies, vol. 47, no. 6, pp. 761-769. | None | Literature review through multiple databases search | Cultural factors found to impact on health The focus was on the cognitive aspect of culture, values & beliefs; thus, there was a failure to identify specific mechanisms that culture has as a negative health mechanism |
|
| 13 | Walston et al. (2008) The changing face of health care in Saudi Arabia | None | Review of literature | The complexity of changing the health care system in the KSA is a continuous challenge, and private health care needs to be reformed to augment the needs of healthcare |
|
| 14 | Almuzaini et al. (1998) The Attitude of Health Care Professionals toward the availability of Hospice Services for Cancer Patients and their Carers in Saudi Arabia | 695 (398 healthcare professionals, 136 cancer patients and 161 informal carers) | A quantitative survey of participants on the quality of healthcare | There is a lack of consistency in the health care quality in KSA. The Ministry-owned or managed facilities score poorly on patient satisfaction with a service organisation. The university and the military facilities do slightly better than the government-managed facilities on patient satisfaction. |
|
| 15 | Elkum et al. (2007) Being 40 or younger is an independent risk factor for relapse inoperable breast cancer patients: The Saudi Arabia experience | 867 breast cancer patient data at King Faisal Specialist Hospital and Research Centre (KFSH&RC) from 1986 to 2002 were reviewed | The researchers used hospital patients’ records for collecting data. They employed statistical techniques to establish the correlation between age and breast cancer prognosis. | The research established that women under 40 were more prone to having a terminal prognosis and complexities. It also found that the treatment protocols in KSA were the same as in the USA, and hence, the quality of care was good. |
|
| 16 | Amri and Sadat (2009) Cancer chemotherapy-induced osteoporosis: How common is it among Saudi Arabian cancer survivors | 71 patients who received chemotherapy in Saudi Arabia were examined for osteoporosis through bone scans. | 71 patients | The main findings indicated that there was a high level of risk for osteoporosis for patients treated with chemotherapy. There was a lack of standard BMD (Bone Mineral Density) testing that could lead to early detection. There was also a scarcity of drugs that could help prevent the condition. |
|
| 17 | Brown et al. (2009) Failure to attend appointments and loss to follow-up: a prospective study of patients with malignant lymphoma in Riyadh, Saudi Arabia | A 3-year prospective study of 199 patients with malignant lymphoma in Riyadh | Retrospective analysis of No Shows appointments (No Shows=340 ) | 34% were related to hospital-based communication errors. 17.6 % were related to errors in patient communication with the hospital |
|
| 18 | Jazieh, A.R. (2010) Human resources development, ‘Initiative to Improve Cancer Care in the Arab World’ | 12 Experts in health care from across the Arab world and international experts | Interviews, situational analysis | There is a lack of high-quality and well-trained healthcare professionals |
|
| 19 | Saghir & Azim (2010) Standards of Care and Guidelines for the Arab World with Limited Resources | 12 experts in health care from across the Arab world | Panel discussions | Lack of standardisation in doctors’ and nurses’ skills leads to varying quality. |
|
| 20 | Diab, R. (2010) Access to Cancer Care Facilities, ‘Initiative to Improve Cancer Care in the Arab World’, | 8-panel members made of experts in policy-making, healthcare and scholars (a | Panel discussions (Based on the discussion of panel members about the priority of objectives and available baseline information of accessibility to cancer care) | The panel found that the quality of cancer care suffered from problems like long wait times for the patients, high costs, lack of access to health care and inequality in access for people from rural and marginalised regions. |
|
| 21 | Shamieh et al. (2010)Access to palliative care | 12 multi-disciplinary experts in palliative care | Panel discussion | Access to cancer care is poor compared to palliative care |
|
| 22 | Cornell, B. et al. (2009) Measuring the quality of hospital care: an inventory of indicators. Internal Medicine Journal, 39 (6), pp. 352-360. | None | Literature review | The literature review revealed that the quality indicators for measuring healthcare quality were varied and non-standardised. The researchers found over 300 indicators of quality used in the available literature. |
|
| 23 | Walker (2009) The right to health in Saudi Arabia | None | Review of available international and regional human development reports, independent research and newspaper articles | Social issues like the low position of women in society and lack of social and political freedom impact access to quality care. |
|
| 24 | Dein & Stygall (1997) Does being religious help or hinder coping with chronic illness? A critical literature review. | None | Literature review | The researchers found a correlation between spiritual beliefs, religious practices and psychological prognosis and made recommendations for integrating religious empathy in health care |
|
| 25 | Al-Faris, E.A., Khoja, T., Falouda, M. and Saeed, A.A.W., (1996). Patients' satisfaction with accessibility and services offered in Riyadh health centres. Saudi Medical Journal, 17(1), pp. 11-17. | 466 randomly selected patients from 6 randomly selected primary health care centres PHCC in Riyadh City | Patient satisfaction and attitude survey | The research found a high level of satisfaction among older patients, housewives and non-Saudi patients. |
|
| 26 | Al-Sirafy, S.A., Hassan, A.A. and Al-Shahri, M.Z. (2009) Hospitalisation pattern in a hospital-based palliative care program: An example from Saudi Arabia. American Journal of Hospice and Palliative Medicine, 26(1), pp. 52-56. | 759 palliative patient admissions during 4 years (in the absence of sub-acute palliative care models) | A retrospective review of palliative admissions was studied for the reason for hospitalisation, duration of stay and mortality rate. | The research found that quality of life did not improve with palliative care in Saudi Arabia. The quality indicators for palliative care included factors like duration of stay, mortality and quality of life. |
|
| 27 | Groene, O. et al. (2008) An international review of projects on hospital performance assessment. Int J Qual Health Care 20: 162–71. | None | Literature review, expert interviews, and performance assessment tool for hospital quality improvement (PATH). | The research found a substantial lack of standardisation in terms of quality indicators. The research could identify only 11 hospital performance measurement projects that contained standardised methodology and showed robust design. |
|
| 28 | Mainz J. (2003) Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care, 15: pp.523–30. | None | Literature review | A review of available literature on quality indicators for health care highlighted that quality is divided into structural, process-related and outcome-related. |
|
29 Japan | Tanaka, A, et al. (1999) Thoughts and feelings of in-patients with advanced terminal cancer: Implications for terminal care improvement. Nursing & health sciences, 1(3), pp.189-193. | Eight terminally ill patients with cancer | Semi-structured Interviews | The research found that the patients wanted solutions for pain control, needed family support, and wanted to live their lives ordinarily as much as possible. The desire to do their best with what they have led them to have a positive attitude and improve their illness management. |
|
| 30 | McBride, D. (2008). Blood Test for Breast Cancer Introduced in the Middle East.ONS Connect, 23(6), 9. | None | Article based on independent research by the author, who is a nurse at the Kaiser Permanente Oakland Medical Centre and a faculty member at Samuel Merritt College in Oakland, CA | The article discusses the introduction of blood tests in the Middle East to improve breast cancer detection |
|
| 31 | Aljubran, A. (2010) The attitude toward disclosure of bad news to cancer patients in Saudi Arabia. Annual Saudi Med, March April. 2010 | None | Literature review | The researchers highlight the changing trends in patients’ need to understand and know their illnesses. |
|
| 32 | Bredart et al. (2007) Determinants of patient satisfaction in oncology settings from European and Asian countries: Preliminary results from the EORTC IN-PATSAT32 questionnaire. European Journal of Cancer, 43(2), 323-330. | 647 cancer patients from hospitals in the EU and Asia | EORTC INPATSAT32 Questionnaire; quality of life of the patients and socio-demographic data; institutional data. | Quality indicators included the number of nurses and doctors per bed, hospital size, ward setting, geo-cultural origin, patient awareness, global health status, and education level. |
|
| 33 | Linder Pelz Towards a theory of Patient satisfaction. Social Science and Medicine, 6 (1982), 577-82. | None | Review of literature | Defining and conceptualising what is patient satisfaction |
|
| 34 | Pascoe. (1983) Patient satisfaction in primary health care; a literature review. Evaluation and program planning, 6 3-4, 85-210. | None | Review of literature | An interpretive and reflexive review of literature on access to healthcare |
|
| 35 | Keith. R. (1998) Patient satisfaction and rehabilitation service. Arch Physical Medical Rehabilitation Journal.1998 (79), 1112-8 | None | Discussion about patient satisfaction in rehabilitation services. | High level of satisfaction with rehabilitation services |
|
| 36 | Ware et al. (1983) Defining and measuring patient satisfaction with medical care. Evaluation and Planning Program Care Journal, 6 3-4, 246-253. | 55 Likert-type survey measuring patient satisfaction analysed | Describe the patient satisfaction questionnaire and test validity and reliability | Measured variables of customer care |
|
| 37 | Kupfer and Bond.(2012) Patient Satisfaction and Patient-Centered Care Necessary but Not Equal JAMA (2012), 3, 8, 139-40 | None | Viewpoint | States that patient satisfaction is not the same as patient-centred care. Suggest patient satisfaction is not always guaranteed by patient-centred care. |
|
| 38 | William’s (1994) Is patient satisfaction a valid concept? Social Science and Medicine, 3, 516-23. | None | Review of literature | Presents satisfaction as a complex concept as the extent to be measured depends on the extent to be defined |
|
| 39 | Turris,(2005) Unpacking a patient’s concept of satisfaction- a feminist perspective. Journal of Advanced Nursing 50, 3, 293-298 | None | Review of literature | A feminist critique of patient satisfaction |
|
| 40 | Kaba and Soronkabium, (2007) The evolution of the doctor-patient relationship. International Journal Surgery, 4, 44-67. | None | Literature review | The need for ever-great progress toward a patient-centred approach |
|
| 41 | Rao et al.(2006) Toward patient-centred care in India- a scale to measure patients’ perception of quality. International Journal for the Quality of Care, 414-21. | 1869 Outpatients and 611 Inpatients were sampled from 4 different healthcare facilities in India | Cross-sectional survey | Measures of Perceived quality included medicine availability, medical information, staff behaviour, doctor behaviour, and hospital infrastructure. |
|
| 42 | McCormack et al. (2011), Measuring patient-centred communication in cancer care: A literature review and the development of a systematic approach, Social Science & Medicine, Vol. 72, pp 1085-1095 | None | Literature review | Identified Six core concepts related to Patient-clinician communication as a critical element of patient-centred care |
|
| 43 | Jagosh et al. (2011), The importance of physician listening from the patients’ perspective: Enhancing diagnosis, healing, and the doctor-patient relationship, Patient Education and Counselling, Vol. 85, pp 369–374 | 58 Patients from McGill University Health Centre in Canada | Qualitative interpretive study | Three main themes were identified on why doctor listening is important to patients:) an essential component of clinical data gathering, 2) listening as a healing and therapeutic agent,3) fostering the doctor-patient relationship |
|
| 44 | Jackson et al. (2001), Predictors of patient satisfaction, Social Science and Medicine, Vol. 52, pp 609-620 | A patient survey of their satisfaction. A sample of 500 adults with physical symptoms attended a general medicine clinic in the USA. | Cohort study | Personal characteristics influence satisfaction, and by the time frame immediately reported after the clinic visit, 52% were satisfied, while those 2 weeks after the visit, 59 % were satisfied, and 3 months after the visit, 65 % were satisfied |
|
| 45 | Ong et al. (1995) Doctor-Patient Communication: A literature review. Social Science and Medicine, 40, 903-918. | None | Literature review | Synthesis of the existing literature on patient-doctor communication. It is central to a good relationship and health outcome |
|
| 46 | Holmström and Roing (2010). The relation between patient-centeredness and patient empowerment: A discussion on concepts. Patient Education and Counselling. 79(2), pp.167-172. | Concept analysis approach compared to literature review | Patient-centredness and empowerment are complementary to each other. Patient empowerment can also be achieved by patient-centredness |
|
| 47 | Roter (2000). The enduring and evolving nature of the patient-physician relationship. Patient Education and Counselling. 39, pp. 5-15 | NONE | Review of literature | Exploring relationship-centred medical paradigm on the nature of doctor-patient relationship. Thus, it suggested a framework Linking therapeutics relationship to communication in the doctor-patient relationship |
|
| 48 | McWilliam et al. (2000), Breast cancer patients’ experiences of patient-doctor communication: a working relationship, Patient Education and Counselling, Vol. 39, pp 191-204 | 11 Women with breast cancer interviewed | Qualitative phenomenological study | Identify the importance of a patient-centred working relationship. Effective communication as affective, behavioural and instrumental was linked to positive experiences of women with breast cancer |
|
| 49 | Shaw et al. (2007), Doctor-patient relationship as motivation and outcome: Examining uses of an Interactive Cancer Communication System, International Journal of Medical Informatics, Vol. 76, pp 274-282 | 231 breast cancer patients given computer and access to internet information resources | Survey data collected pre-test and 4 months post the use of information system through the internet | Positive perception of doctor-patient relationship post-test. It is evident that information resources through the Internet do improve patient satisfaction |
|
| 50 | Kenny et al. (2010), Interpersonal perception in the context of doctor-patient relationships: A dyadic analysis of doctor-patient communication, Social Science & Medicine, Vol. 70, pp 763-768 | 91 doctors and 1749 patients in Canada | Cross-sectional study Doctors and patients independently completed questions on doctor communication skills after consultation visit | Doctors and patients had different views and perspectives on communication held during the consultation |
|
| 51 | Michie et al. (2003), Patient-centeredness in chronic illness: what is it and does it matter? Patient Education and Counselling, Vol 51, pp 197-206 | None | Review of literature They review 2 types of communication in chronic illness: patient activation and taking patient perspective and if it affects health outcomes. | Activation of patients results in good physical health outcomes more than taking only patient perspective. Therefore, different types of patient-centred communication result in different health outcomes. |
|
| 52 | Donabedian, (1980). Explorations in quality assessment and monitoring. Vol. 1. The definition of quality and approaches to its assessment. Ann Arbor, Mich.: Health Administration Press | None | Review | A proposed model to determine patient satisfaction with quality of care. Three domains, structure, process and outcome, can be used to define quality |
|
| 53 | Khamis, & Njau (2014).Patients' level of satisfaction with the quality of health care at Mwananyamala Hospital in Dar es Salaam, Tanzania. BMC health services research, 14(1), pp. 400-407 | a SEQUAL Questionnaire was used to collect data from 420 patients in an outpatient clinic in Tanzania | Cross-sectional survey study | The use of the Donabedian model to assess the level of patient satisfaction with quality of care proves useful Poor satisfaction among patients generally because of a lack of communication |
|
| 54 | DuFrene R., (2000), An evaluation of a patient satisfaction survey: validity and reliability, Evaluation and Program Planning, Vol. 23, pp 293-300 | None | Comparative analysis | Testing the validity of external patient satisfaction surveys. They were often unreliable because of issues of poor design |
|
| 55 | Street et al. (2009). How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counselling. 74(3), pp. 295-301. | None | Literature review | Identified Seven pathways of communication to improve health | · The results imply the need for taking a patient-centred approach in communication to improve health as proposed by the Institute of Medicine's definition of patient-centredness |
| 56 | Mead and Bower, (2000). Patient-centeredness: A conceptual framework and review of the empirical literature. Social Science and Medicine. 51(7), pp 1087-1110. | None | Literature review | Five conceptual dimensions were identified to support the patient-centred model in doctor-patient relationships | · The findings cannot be generalized as patient-centred care depends mainly on sociocultural aspects of the setting, and the applicability of the 5 dimensions identified needs to be tested in another cultural setting like KSA |
| 57 | Merkouris et al. (2004). Evaluation of patient satisfaction with nursing care: Quantitative or qualitative approach? International Journal of Nursing Studies. 41(4), pp. 355-367. | 200 Inpatients from 2 large hospitals in Greek | Mixed methods study (Quantitative and Qualitative methods concurrently for Triangulation ) | Patient satisfaction with nursing care was highly scored for technical competence, while low scores were associated with information provision. Interpersonal aspects were central to the patient experience |
|
| 58 | Oberst (1983) ‘Patients perceptions of care’. Measurement of satisfaction. Cancer, 53, 2333-2337 | None | Discussion Paper on the nature of patient satisfaction in an Oncology setting. | Philosophical problems of subjective feeling of satisfaction |
|
Appendix 6: Participant information sheet (patients)
Study Title: Patient Satisfaction in Oncology Ward Settings in Saudi Arabia: A Mixed Methods Study
Project Investigator: Manal Banaser Contact Number: (number given)
Dear Participants
I want to invite you to participate in a research study. Before you agree to participate, it is important for you to understand the reason for the current study and what it will involve to make an effective contribution to the study field. Please read the information below about the study. Feel free to ask about any of the information, and if you need even more information, you can contact me any time at the above-given contact number.
The study is a postgraduate research student project supervised by Dr Kathleen Stoddart and Dr Nicola Cunningam at the Department of Nursing, Midwifery and Health at the University of Stirling in the United Kingdom. The King Fahd Medical City Scholarships department in Riyadh funds this project.
Project Aim: The project is aimed to help understand the experience of adult hospitalised cancer patients with the received care by taking patient perspectives on doctors’ and nurses’ technical skills, information provision, availability and services organisation to make recommendations for improvement. The research study will be conducted in two phases. First, a questionnaire on patient satisfaction with care will be distributed to adult hospitalised cancer patients in a Saudi Regional Cancer Centre in Riyadh. Second, 6 participants of those who completed the questionnaire will be invited voluntarily to attend an individual interview with the research investigator to expand our knowledge of optimising satisfaction with care or making recommendations for areas of improvement in quality of care.
Advantages of taking part in the current study:
Your expectations and opinions for the received care in an oncology setting are an important aspect in ensuring the quality of care. Your satisfaction scores will help healthcare providers to identify areas for improvement, as well as to maintain the quality of care in the future. By giving reasons for either satisfaction or dissatisfaction with care within the interviews, healthcare providers can have an understanding of your experiences with hospital care. Eventually, they will make an effort to contribute to delivering effective, high-quality cancer services in Saudi Arabia.
In the first phase, you must complete the questionnaire by rating the aspects of care given in the hospital and then return it to the investigator. In the second phase, you will be invited to attend an interview with the researcher. You will be asked about the reasons for your satisfaction with care or if you are unsatisfied. It will use open-ended questions, which might be recorded if you agree to maintain the accuracy of the results.
Participation in both phases of this project is voluntary. You may withdraw at any time with no consequences. Please note if you are interested in joining an interview for the second phase of the current study, you can contact me as early as possible.
Confidentiality
Confidentiality will be maintained by providing identification numbers rather than participant names for questionnaires and interview records or notes. This will enhance the confidentiality of provided information. For all records, notes of interviews, and answers, the researcher will keep questionnaires in a secure place during the study period. Once the data have been analysed and the study completed, the information will be destroyed. Two supervisors will monitor the study, and the findings will be written as a Ph.D. thesis. You will not be identified at any stage of the written report or the thesis. All information will be kept anonymous, known only to the researcher and supervisors. This project has been cleared by the University of Stirling Ethics Committee, as well as approved by the Ethics Committee of the Saudi Regional Cancer Centre in Riyadh.
Thank you for taking the time to read this information sheet and thinking about participation in the study.
Researcher Name: Manal Banaser Contact Number: (number provided)
Principal Supervisor: Dr. Kathleen Stoddart
Appendix 7: Patient consent form
Study Phase:
Participant identification number:
Study Title: Patient Satisfaction in Oncology Ward Settings in Saudi Arabia: A Mixed Methods Study
Researcher Name: Manal Banaser
I have read and understand the study information sheet and this consent form. I have had an opportunity to ask questions about my participation.
I understand that I am under no obligation to take part in the current study.
I understand that I have the right to withdraw from the current study at any stage without giving any reason.
I agree to participate in the current study.
Name of Participant:
Signature of Participant:
Signature of Researcher:
Date:
Contact details of the researcher
Name: Manal Banaser
Address: (address given)
Telephone Number: (number given)
Email: (address given)
Reference:
University of Stirling Research Ethics Committee. Informed consent. Available from: http://www.goodresearchpractice.stir.ac.uk/documents/Chapter6.pdf
Appendix 8: Recruitment log for patients
Study Title: Patient Satisfaction in oncology ward settings in Saudi Arabia: A mixed methods study
Name of Researcher: Manal Banaser
| Patient ID | Age | Gender | Date of admission | Yes/No to study | Reason for admission | Date recruited | Date of data collection |
Appendix 9: EORCT inpatient satisfaction questionnaire EORTC IN-PATSAT32
We are interested in some things about you and your experience of the care received during your hospital stay. Please answer all the questions by circling the number that best applies to you. There are no 'right' or 'wrong' answers. The information that you provide will remain strictly confidential.
During your hospital stay, how would you rate doctors in terms of:
Poor, Fair, Good, Very good, Excellent
| Questionnaire Item | Poor | Fair | Good | Very good | Excellent |
| 1. Their knowledge and experience of your illness? | 1 | 2 | 3 | 4 | 5 |
| 2. What treatment and medical follow-up do they provide? | 1 | 2 | 3 | 4 | 5 |
| 3. The attention they paid to your physical problems? | 1 | 2 | 3 | 4 | 5 |
| 4. Their willingness to listen to all of your concerns? | 1 | 2 | 3 | 4 | 5 |
| 5. The interest they showed in you? | 1 | 2 | 3 | 4 | 5 |
| 6. The comfort and support they gave you? | 1 | 2 | 3 | 4 | 5 |
| 7. The information they gave you about your illness? | 1 | 2 | 3 | 4 | 5 |
| 8. The information they gave you about your medical tests? | 1 | 2 | 3 | 4 | 5 |
| 9. The information they gave you about your treatment? | 1 | 2 | 3 | 4 | 5 |
| 10. What is the frequency of their visits/consultations? | 1 | 2 | 3 | 4 | 5 |
| 11. The time they devoted to you during visits/consultations? | 1 | 2 | 3 | 4 | 5 |
During your hospital stay, how would you rate nurses in terms of:
Poor, Fair, Good, Very good, Excellent
| Questionnaire Item | Poor | Fair | Good | Very good | Excellent |
| 12. The way they carried out your physical examination (took your temperature, felt your pulse, etc.)? | 1 | 2 | 3 | 4 | 5 |
| 13. The way they handled your care (gave your medicines, performed injections, etc.)? | 1 | 2 | 3 | 4 | 5 |
| 14. The attention they paid to your physical comfort? | 1 | 2 | 3 | 4 | 5 |
| 15. The interest they showed in you? | 1 | 2 | 3 | 4 | 5 |
| 16. The comfort and support they gave you? | 1 | 2 | 3 | 4 | 5 |
Please go on to the next page
During your hospital stay, how would you rate nurses in terms of:
Poor, Fair Good, Very Good, Excellent
| Questionnaire Item | Poor | Fair | Good | Very good | Excellent |
17 Their human qualities (politeness, respect, Sensitivity, kindness, patience,…)? | 1 | 2 | 3 | 4 | 5 |
| 18. The information they gave you about your medical tests? | 1 | 2 | 3 | 4 | 5 |
| 19. The information they gave you about your care? | 1 | 2 | 3 | 4 | 5 |
| 20. The information they gave you about your treatment? | 1 | 2 | 3 | 4 | 5 |
| 21. Their promptness in answering your buzzer calls? | 1 | 2 | 3 | 4 | 5 |
| 22. The time they devoted to you? | 1 | 2 | 3 | 4 | 5 |
During your hospital stay, how would you rate services and care organisation in terms of Poor, Fair, Good, Very good, Excellent
| Questionnaire Item | Poor | Fair | Good | Very good | Excellent |
| 23. The exchange of information between caregivers? | 1 | 2 | 3 | 4 | 5 |
| 24. The kindness and helpfulness of the technical, reception, and laboratory personnel? | 1 | 2 | 3 | 4 | 5 |
| 25. The information provided on your admission to the hospital? | 1 | 2 | 3 | 4 | 5 |
| 26. The information provided on your discharge from the hospital? | 1 | 2 | 3 | 4 | 5 |
| 27. What is the waiting time for obtaining the results of medical tests? | 1 | 2 | 3 | 4 | 5 |
| 28. What is the speed of implementing medical tests and/or treatments? | 1 | 2 | 3 | 4 | 5 |
| 29. The ease of access (parking, means of transport…)? | 1 | 2 | 3 | 4 | 5 |
| 30. The ease of finding one’s way to the different departments? | 1 | 2 | 3 | 4 | 5 |
| 31. The environment of the building (cleanliness, calmness….)? | 1 | 2 | 3 | 4 | 5 |
In general
| Questionnaire Item | Poor | Fair | Good | Very good | Excellent |
| 32. How would you rate the care received during your hospital stay? | 1 | 2 | 3 | 4 | 5 |
© QLQ-IN-PATSAT32 Copyright 2001 EORTC Quality of life Group. All rights reserved. Permission granted through EORCT email
DEMOGRAPHIC QUESTIONNAIRE ( Quantitative Phase 1 )
- Age
- From 18-25Years old
- From 26-35 Years old
- From 36-45 Years old
- From 46-55 Years old
- From 56-65 Years old
- From 66-75 Years old
- Above 76 Years old
- Gender
- Male
- Female ¨
- Marital status
- Single ¨
- Married ¨
- Divorced ¨
- Widowed ¨
- Education level
- Primary ¨
- Intermediate ¨
- High ¨
- University degree – above ¨
- Illiterate ¨
- Place of Residence
- Riyadh ¨
- Outside Riyadh ¨
Appendix 10: A Scoring Manual for In-patient Satisfaction Questionnaire
Scoring Procedure for the EORTC IN-PATSAT32
[Reference: Brédart et al, EJC, 41 (2005) 2120-2131]
The international field-testing study of the EORTC cancer in-patient satisfaction with care measure (EORTCIN-PATSAT32) has confirmed the hypothetical structure of the questionnaire. This questionnaire should thus be scored as follows:
1) Content of the questionnaire
Multi-item scales
- Doctors
Interpersonal skills (items 4-6)
Technical skills (items 1-3)
Information provision (items 7-9)
Availability (items 10, 11)
- Nurses
Interpersonal skills (items 15-17)
Technical skills (items 12-14)
Information provision (items 18-20)
Availability (items 21, 22)
- Other hospital personnel kindness and helpfulness, and information giving (24-26)
- Waiting time (performing medical tests/treatment, receiving medical test results) (items 27, 28)
- Access (items 29, 30)
Single item scale
- Exchange of information (item 23)
- Comfort/cleanness (item 31)
- General satisfaction (item 32)
2) Format of the questionnaire
Period of reference: Refer to interactions with health care providers and services in the oncology hospital during hospital stay.
How would you rate it? Poor (1)/Fair (2)/Good (3)/Very Good (4)/Excellent (5)
Number of items: 32
3) Scoring procedure
All multi-item or single-item scales are all constructed similarly: (1) the raw scores for the individual items within a scale are first summed, and then, for the multi-item scales, divided by the number of items in the scale; and (2) these scale scores are then linearly transformed such that all scales range from 0 to 100, with a
higher scale score representing a higher level of satisfaction with care.
Scoring details
In the 32-item questionnaire, each response is given a numerical equivalent (poor=1, excellent=5). Scores for each of the fourteen questionnaire subscales will first be determined for each patient. All the scores for all items in a particular subscale are summed and then divided by the number of items in that subscale. For example, for doctors’ technical skills, the patients’ responses on items 1, 2 and 3 are added together and then divided by 3. The scale scores are then linearly transformed to a 0-100 scale, with a high score reflecting a higher level of satisfaction. So, for example, the items relating to satisfaction with doctors’ technical skills are questions 1, 2 and 3. If a participant answered with a rating of 3, 4, and 4 for those questions, the scores would be summed (=11), then divided by 3 (=3.67). To linearly transform the data to a scale ranging from 0-100, that score will be divided by 5 (highest possible score) and multiplied by 100 (in this case, 3.67/5 = .7333 * 100 = 73.33)
[1] Sitters are commonly relatives of the patients who, at their request, accompany them during their hospitalisation, offering moral and practical support. Typically, patients must ask their doctor’s permission to have a sitter stay with them overnight.
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